They may make our hearts sink, but treating somatising patients can be uplifting if we learn to look within ourselves
They may make our hearts sink, but treating somatising patients can be uplifting if we learn to look within ourselves
Edith was in her late 60s when I first met her. My senior partner in the practice was contemplating retirement and saw it as his moral duty to hand over all of his “troublesome patients” to me, the new boy on the block.
Edith was single and had never married. She lived about eight kilometers from the clinic, which meant a train journey to attend her regular visits.
It was only years later that I discovered that the ulterior motive for her visits to our patch was that her friend Mildred lived around the corner from the clinic. Mildred was also one of my patients. Edith and Mildred had been lovers for many years. It was unfashionable, uncomfortable, and perhaps unnecessary, for them to come out. Importantly, they cared for each other, and that is all that mattered.
I always felt that Edith had modelled her demeanor on that of Barry Humphries’ comic creation Dame Edna Everidge. In fact, based on rough calendar calculations, the converse may have been closer to the truth. Dame Edna may well have plagiarised Edith’s manner and haute couture.
She was tall and lean. Always wore a purple or turquoise hat or beret, matching gloves, eagle-like glasses, a matching handbag, high heels, and occasionally a fur. I felt she was dressed for a night at the theatre rather than a Friday afternoon outing to a suburban general practice. Her nose was always heavily powdered and her cheeks drowned in rouge. She spoke with a high-pitched, piercing voice. If she’d had elocution lessons then she must have missed the lower-register classes.
Edith had a long history of bowel problems. Numerous tests and specialist visits had failed to reach a classic text-book diagnosis. Irritable bowel was the label attached to her malady, and as is often the case, multiple interventions failed to alleviate her suffering.
Edith always scheduled her appointments for 4.30 on a Friday afternoon, thwarting any of my attempts for an early exit. As a young doctor relatively inexperienced in patient-centred care, I would listen to Edith describe, in almost poetic terms, the passage of food from her oral cavity to the anus. Each turn and twist of the gut provided its unique challenges. I tried to explain her symptoms in physiological and psychological terms only to be met with a further battery of ailments that defied any known syndrome.
At the end of these 30-minute consultations, I was usually presented with a paper bag of her freshly prepared pumpkin scones. Having spent a consultation travelling through the interstices of Edith’s bowels, the pumpkin scones were hardly an enticing delicacy.
Friday afternoons were filled with trepidation. Was Edith on my appointment list? Patients such as her were frequent attenders so the likelihood was always high that she would fill my 4.30 time slot, en route to Mildred.
I needed an escape strategy. Something that would enable me to terminate the consultation after 15 minutes, diminish the tension in my gut if not in hers and save my heart from sinking. I thought of a solution. I instructed my reception staff to call me after 15 minutes to attend an emergency in the treatment room. This seemed to work, however,
after four or five such carefully planned emergencies, Edith politely asked: “Doctor, why is it that you always have an emergency at 4.45 on a Friday?”
I was lost and defeated. Therapeutically destitute, I was now trapped and emotionally bereft.
I discovered then and there that I was the problem. I needed to understand myself and my reaction to Edith at a deeper level. The discovery of Balint’s work, learning about the nature of somatisation and somatoform disorders, later helped me to manage Edith and many others like her. It is a pity I was not exposed to this literature as a junior doctor and to the role of reattribution in helping patients understand the disorder and in
helping me cope with patients such as Edith.
Post script
The term “heart-sink” patient was coined by the late Dr Michael Balint, a psychiatrist who worked with GPs in
the 1950s to explore the emotional dimensions of consultations and the feelings of GPs when confronted with difficult patients.
He subsequently wrote the seminal text, The Doctor, the Patient and his Illness, and was the founding father of Balint groups now scattered all over the globe which meet regularly to explore the problems facing clinicians.
Every GP has a number of heart-sink patients. They are ubiquitous. Their symptoms are difficult to diagnose and even more difficult to treat. We use the terms somatisation and somatoform disorder to attach a label to these patients. The label itself does not make it easier to connect with them nor help them understand that there may be a psychological basis to their suffering.
These patients do not go away. After repeated multitudes of negative tests and specialist referrals they are still convinced that something has been missed. There is absence of agreement between physician and patient.
Each time I and other GPs see these patients on an appointment list we are thrown into a state of despair and frustration. The butterflies rise in the stomach. The heart sinks.
Leon Piterman is Professor of General Practice at Monash University and has been in clinical practice for almost 40 years
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