Could I have saved my doctor?

image stethoscopeThe first thing 22-year-old Casey ever said to me was, “How is your day going, Doctor?”

While not the most unusual opening line of a first-time patient, there was something about the way she said it that rang a vague alarm bell.  Casey had complex physical and mental health needs, and over the following six months I saw her numerous times.  She had survived childhood leukaemia, but her type 1 diabetes and Crohn’s disease were making daily life difficult.

Regardless of what she was going through, Casey always spent at least a minute or two each consult enquiring about my well-being. I initially thought that her questions may just have been merely social pleasantries. I didn’t think too much about her commenting that I looked tired or asking if I was overdoing things – perhaps because my friends and family were doing likewise. I smiled sweetly when she gave me beauty tips and fashion advice. But when she started asking me particularly personal questions about my relationships, health and resilience levels, and not accepting my brush-offs, I knew things had gone too far.

Casey is certainly not the first patient who has asked me unduly personal questions. I usually find such intrusiveness quite easy to deflect, and for the boundaries between myself and an inquisitive patient to be maintained without the need for explicit definition. There was, however, something different about Casey’s approach: a desperation, a need, something raw. I did not get any sexual vibes, or even overtones of seeking friendship, just a sense that my being happy and healthy was of tremendous importance to her.  It felt like she genuinely cared about me – I just couldn’t work out why.  Something about it did not sit well, so I decided to address and gently explore this with her.

It didn’t take much probing.

“Twelve months ago our family GP killed herself.”

Casey’s face contorted with the effort of trying to hold back the floodgates of intense emotion.

“Dr Sara looked after me since the day I was born.  She found my leukaemia and my diabetes, and was there for me and my family through all of it. And then she suddenly wasn’t.”

She paused, taking the offered tissue and loudly blowing her nose.

“One day I rang the surgery and the receptionist told me she’d left the practice. I asked when was returning. The receptionist said ‘Never’. I didn’t understand. I’d only seen Dr Sara the week before and she didn’t say anything about leaving. I found out later that she’d taken an overdose.

“I had no idea she was suffering. And then I realised that I’d never asked. She cared about my health so deeply and yet I had never even considered hers.  I feel so ashamed.

“No one at the surgery ever talked about what happened. They took her name off the door and the website within days, and made out like she had never existed. My new GP said things like ‘Let’s focus on the here and now’ or ‘We are here to talk about you, not Sara’ when I tried to bring it up. Everyone knew what happened; there was no point trying to hide it. So why did they remove every trace of her?”

Casey looked to me, puzzled and angry.

“I don’t know,” I admitted. “I guess it was how they dealt with their grief.”

” I kept thinking of all the years she gave to them… and to us, her patients. All gone. I couldn’t stand it any longer. That’s why I started coming here and seeing you. .”

The depth of her grief and guilt took several consults to reveal. Over time she came to understand and accept that it was not her role or responsibility to safeguard her doctors’ health, or to worry about any emotional burden which may result from the provision of care.

Her questions of me became less personal and insistent, but she continued to ask how I was going. I thought of poor Dr Sara each time, and always answered Casey sincerely and honestly, grateful that my answers were able to provide reassurance.

(names and identifying details have been changed)

First published in Medical Observer, 25th July 2014

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Physician Don’t Heal Thyself

One reason why I chose to do medicine was that I didn’t always trust doctors – another image stethoscopebeing access to an endless supply of jelly beans.  My mistrust stemmed from my family’s unfortunate collection of medical misadventures: Grandpa’s misdiagnosed and ultimately fatal cryptococcal meningitis, my brother’s missed L4/L5 fracture,  Dad’s iatrogenic brachial plexus injury and the stuffing-up of my radius and ulna fractures, to name a few.

I had this naïve idea that my becoming a doctor would allow me to be more in charge of the health of myself and my family. When I discovered that doctors were actively discouraged from treating themselves, their loved ones and their mothers-in-law, and that a medical degree did not come with a lifetime supply of free jelly beans, I felt cheated.   I got over the jelly bean disappointment quickly – after all, the allure of artificially coloured and flavoured gelatinous sugar lumps was far less strong at age 25 than it was at age 5 – but the Medical Board’s position regarding self-treatment took a lot longer to swallow.

Over the years I’ve come to understand why guidelines exist regarding treating oneself and one’s family, as well as close colleagues, staff and friends.  Lack of objectivity is not the only problem. Often these types of consults occur in informal settings and do not involve adequate history taking, examination or note-making.  They can start innocently enough but have the potential to run into serious ethical and legal minefields.  I’ve come to realise that, like having an affair with your boss or lending your unreliable friend thousands of dollars to buy a car, treating family, friends and staff is a pitfall best avoided.

Although we’ve all heard that “A physician who treats himself has an idiot for a doctor and a fool for a patient”, large numbers of us still self-treat.  I recently conducted a self-care session with about thirty very experienced GP supervisors whose average age was around fifty. When asked for a show of hands as to how many had his/her own doctor, about half the group confidently raised their hands. I then asked these to lower their hands if their nominated doctor was a spouse, parent, practice partner or themselves. At least half the hands went down. When asked if they’d seek medical attention if they were significantly unwell, several of the remainder said, “I don’t get sick,” and one said, “Of course I’d see a doctor – I’d look in the mirror.”

Us girls are a bit more likely to seek medical assistance than the blokes (after all, it is pretty difficult to do your own PAP smear – believe me, I’ve tried), but neither gender group can be held up as a shining example of responsible, compliant patients. It seems very much a case of “Do as I say, not do as I do”.   I wonder how much of this is due to the rigorous “breed ’em tough” campaigns we’ve been endured from the earliest days of our medical careers.  I recall when one of my fellow interns asked to finish her DEM shift twenty minutes early so that she could go to the doctor. Her supervising senior registrar refused her request and told her, “Routine appointments need to be made outside shift hours.  If you are sick enough to be off work, you should be here as a patient.”  My friend explained that this was neither routine, nor a life-threatening emergency, but that she thought she had a urinary tract infection.  She was instructed to cancel her appointment, dipstick her own urine, take some antibiotics out of the DEM supply cupboard and get back to work.  “You’re a doctor now; get your priorities right and start acting like one” was the parting message.

Through my medico-legal and medical educator work, I’ve had the opportunity to talk to several groups of junior doctors about self-care issues and the reasons for imposing boundaries on whom they treat, hopefully encouraging to them to establish good habits while they are young and impressionable.  I try to practise what I preach: I see my doctor semi-regularly and have a I’d-like-to-help-you-but-I’m-not-in-a-position-to-do-so mantra down pat.  I’ve used this speech many times to my advantage, such as when I’ve been asked to look at great-aunt Betty’s ulcerated toe at the family Christmas get-together, and to write a medical certificate and antibiotic script for a whingey boyfriend with a man-cold.

The message is usually understood but the reasons behind it aren’t always so.  My niece once announced knowledgably, “Doctors don’t treat family because it’s too hard to make them pay the proper fee.”  This young lady wants to be a doctor when she grows up, but must have different reasons than I did at her age. She doesn’t even like jelly beans! 

Adapted from an article first published in MIPS Review Autumn Edition, 2012 

Published on Meducation.net  December 2013 “Physician don’t heal thyself“,