To be effective as GPs, we must remain vigilant and not expose ourselves to unnecessary risks
GPs care for patients with a range of maladies. We do not pick and choose.
Comprehensive care is embodied in the definition of our discipline, and while some of us have special interests, the expectation is that we will care for an unselected population of patients not defined by gender, organ system or disease. Included in that population are patients with chronic mental illnesses, such as schizophrenia, bipolar disorder or borderline personality disorder.
Our practice ran a weekend roster where one in five weekends someone worked all day Saturday and Sunday. This was before the advent of the so-called “24 hour clinics”, including those occasional ones adorned with grand pianos.
It was during one of these weekends that I first met Jenny. She was an attractive, well-groomed, expensively dressed woman in her mid-40s, which was 10 years older than me at that time. She was divorced and lived with her elderly father. Her two adult children lived independently. Her address indicated her abode was in the expensive end of town.
The consultation seemed very straightforward. It was the “flu season” and she had a full house of flu-like symptoms and signs. I offered a diagnosis and, for better or worse, prescribed some antibiotics. She wanted to know if I was new to the clinic and whether or not I intended to stay. Jenny then ended with a remark that I thought strange at the time, but only understood the significance of later when I had time to read through her file. She said: “I hope you don’t go the same way as Dr Bill.”
I set her file aside and during the lunch break began to delve into it. Boldly inscribed on the front of the file was a message: “Never to see Dr Bill”. Bill was my senior colleague. He seemed honest, knowledgeable, dedicated and caring. In short, he seemed a patient’s ideal GP.
Why would someone be deprived of his services? All was revealed as I read through the notes. Jenny had a long history of schizophrenia. A particular feature of her illness was an encapsulated delusion that Bill had raped her and that he was trying to do this again and again by gaining entry into her well-protected mansion. I could hardly wait until Monday to discuss this case with Bill.
What followed was a sad and disturbing tale. Some 10 years earlier Bill had done a Pap smear on Jenny, fortunately in the presence of the clinic nurse, given the nature of Jenny’s mental-health problems. She subsequently reported him to the Medical Board for raping her. Bill had to defend himself before the board. Never an enjoyable experience.
Naturally, the case was summarily dismissed. But Bill felt traumatised and scarred. And Jenny’s delusions continued. She had never accepted the diagnosis of schizophrenia, had refused treatment and was not going to be influenced by any decisions of a Medical Board to change.
About 12 months later I was asked to do a home visit at Jenny’s place. I was relieved to hear that the patient was Bruce, her 85-year-old father, who had been treated for chronic heart failure. Having worked my way through the security system at the front gate while Jenny restrained a barking, salivating German shepherd dog, I was ushered past the front door and upstairs to Bruce’s bedroom.
I left Jenny’s home deeply worried and concerned. She was clearly mentally unwell and needed help.
As I reached the top of the stairs I noticed a strategically placed shotgun. Shooting foxes and rabbits seemed an unlikely past time in this heavily populated suburb. I flippantly asked Jenny if she was expecting any intruders. She responded, “Only Dr Bill”. This sent a shiver down my spine and sparked my irritable bowel into action.
Bruce’s bedroom seemed very stuffy. I noticed the air vents in the walls had been covered over with newspaper. Bruce whispered to me: “It’s to keep Dr Bill out. She really needs help, you know.”
Bruce was unwell. He was short of breath and clinical signs were compatible with exacerbation of heart failure. He needed hospital admission. I explained this to him and to Jenny who was waiting downstairs. I arranged this at the local private hospital, called an ambulance and suggested to Jenny that she might remove the shotgun when the ambulance was in attendance.
I left Jenny’s home deeply worried and concerned. She was clearly mentally unwell and needed help. Efforts to convince her of this in the past had failed.
I was just as concerned for the wellbeing of my colleague Dr Bill. There is a history of paranoid patients shooting or stabbing their doctors with some well-publicised cases. Schizophrenia also carries a high risk of suicide, and although Jenny did not appear depressed, voices might have instructed her that she should take her own life.
I discussed my dilemmas with colleagues at the clinic and with Dr Bill, and felt that I needed to report this to the police in the hope that the police surgeon might become involved and Jenny would be compelled to be admitted to the local psychiatric facility.
The police acted quickly, removing the shotgun, which was unlicensed. The police surgeon in attendance arranged for admission for psychiatric assessment. Jenny then spent the next four weeks in hospital and was discharged on antipsychotic medication. The report I received indicated that although she was much calmer, her belief in Dr Bill’s nefarious activities had not changed. Encapsulated delusions are hard to shift.
It is important to remember that most schizophrenic patients are not violent and do not pose a risk to doctors or other health professionals.
We are, however, experiencing record numbers of assaults directed at health professionals, particularly in emergency departments and towards paramedics on the road.
As I write this piece, a surgeon in Melbourne is in a coma, having been assaulted outside the emergency department at Box Hill hospital in Melbourne.
Many of these attacks are fuelled by drugs. In particular, methamphetamine. To be effective, we must remain vigilant and not expose ourselves to unnecessary risk.
Dr Leon Piterman is Professor of General Practice at Monash University and has been in clinical practice for almost 40 years
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