Chapter 2.2: no patients, no problem?

The wordplay continues.

Of the many ways COVID-19 has affected medicine, the impact on medical education is one I hope has no lasting effects. It seems selfish to say, but the pandemic has made it really hard to see patients and get direct clinical experience on placement.

Poor me, complaining about not having to go to hospital. Quick, bring me a 50-200nm sized violin.

Still, I’ve managed to see a few patients and one of them gave me a rare “House MD” moment. If you haven’t watched House, I’d suggest it- but please note it’s really not what happens in medicine. Our doctors are more like Hugh Laurie in Blackadder. I’m more of a Baldrick.

No problem?

I was asked to see this patient, who we’ll call “Cuddy” to continue the theme that about 2% of you reading will get.

Cuddy was due to go home the next day and I was told to get a neuropsychiatric history and examination for my own learning. Clue 1.

As I approached the side-room, I noticed the door was already open. A sign on the front asked to leave it open due to claustrophobia. Clue 2.

As I entered the doorway to gown and glove, I started to hear cries of pain and breathlessness. It was from Cuddy. There weren’t any sounds walking up to the room, only when I got into view outside.

Hence the House moment, which wasn’t really that difficult, but as a medical student you take what you can get. Being asked to do a psychiatric (mental state) examination + phobia + exaggeration of symptoms in front of (who she thought was) her care-giver made me think Cuddy had one of the interesting Psychiatric disorders such as somatic symptom disorder, factitious disorder (“Munchausen’s”), hypochondriasis or malingering.

These disorders are difficult to pick apart and we have to be very careful not to belittle or disregard a patient’s symptoms, especially complex things like pain. It’s important to be thorough in the history, examination and investigations.

After speaking to Cuddy and examining, plus some sleuthing on the previous investigation results, it became apparent that there was no evidence of anything medically wrong. Cuddy was clearly a very anxious person, with significant psychiatric history, but no clinical signs or investigations to suggest an underlying cause.

Cuddy had hypochondriasis– a disorder in which patients will fake and/or exaggerate symptoms because they truly believe they are ill, but there is nothing medically wrong with them. This was confirmed when talking to the junior doctor who sent me (he never gives me easy ones).

I got to thinking about the complex issues with this patient. In Cuddy’s mind, the pain and discomfort were real and she really has something wrong with her lungs. It must be so frustrating to be told “there is nothing we can find medically wrong with you”. She admitted this sounded exactly like “it’s all in your head”. It’s probably what they were thinking, too.

I think on reflection I did my best to empathise, not shut down Cuddy’s feelings (despite being biased going into the room) and maintain an open mind. However, I had the luxury of time and a safety net of being able to “check the right answer”. If Cuddy were my patient, would I have gone about it the same way?

These complex patients are the ones that we seem to learn the least about, but in reality can present the most challenges. I think going forward I’ll try to notice how these complex cases are handled and whether the patient’s needs were met. In general, the NHS does an amazing job of this.

In other news, I got my first COVID-19 vaccine, got confirmation of my second publication and have started to progress with my Instagram page (Myth_Microscope, thank you for asking).

Let’s keep trundling on.

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