What was the first case that you had difficulty diagnosing?

One of my patients, Anna, had thoughts of killing her son. If these were “command hallucinations” where the child might truly be in danger, the course of treatment would be for her to be kept away from her son while she was experiencing the symptoms. If they were anxious or obsessive thoughts she would never act on, the course of treatment would be for her to spend more time with her son to be reassured that she would never carry out these actions.

That example underscored not only the difficulty in diagnosis, but also the extraordinary consequences of getting it right. Her case demonstrated that the two potential courses of action were polar opposites in terms of what would be therapeutic for her. Getting it wrong would have grave consequences.

Your patient, Lauren, made scores of trips to the hospital after swallowing knives, scissors, etc. And various people involved in her care became frustrated at the lack of a solution—some were cynical about the chances of her getting better. How can the hospital environment affect things?

We’re trained to begin to recognize when a patient’s discomfort begins to breed discomfort in the doctor or the other clinicians in charge of a patient’s care. Lauren is an example of someone whose life was really in chaos. She had deep feelings of abandonment and fell very far out of control. She tried to regain control through a maladaptive pattern of swallowing dangerous objects.

The typically orderly, calm hospital environment began to swirl into real chaos when she was admitted. Surgeons and medical doctors and psychiatrists, who were ordinarily very respectful and collegial to each other, began arguing with each other about who was responsible for her care. Nurses were agitated that she was admitted. Hospital administrators began to express frustration that they would have to do other paperwork. Suddenly this one patient’s internal chaos began to be visible in an external way, which was made manifest in the people who were caring for her. Because doctors are human, sometimes patients bring up in us feelings that are not entirely pleasant. We need to manage uncomfortable feelings that are brought up in the natural course of treating patients.

Is it difficult to make a diagnosis after a patient already has a reputation in the hospital?

It definitely is. Doctors are very busy and increasingly we have less and less time. Our patient loads have increased. So from an efficiency standpoint, we all take shortcuts in taking notes from the record and historical ways of characterizing patients. Most of us go into medicine with a sincere desire to help and cure people. When we meet patients that are difficult to help and potentially impossible to cure, it can bring up real feelings of inadequacy in the physician. We see this in psychiatry but also in the ways that our medical system resists sending patients into palliative care, often to the detriment of patients. There are patients who are terminally ill, whose illnesses are not responding to treatment, yet we send patients far too late to hospice and palliative care. I worry that it’s because of a doctor’s sense that he or she has failed if a patient cannot be cured. We need to make sure we don’t put our own fears in front of what’s best for the comfort of the patient.