Protecting the patient from medical care

Be careful the diagnosis you make,

Could it be that the patient’s a fake?

If they take too much caring,

And just leave you swearing

That this one sure takes the cake. 

Synopsis:  I’m a family practitioner from Sioux City, Iowa.  In May 2010, I left my position of 23 years, and honoring my non-compete clause, traveled for a year doing locum tenens work.  In June of 2011 I joined up with the Community Health Center, which provides care for the underserved.  I’m now working part-time, which, for a doctor, means 54 hours a week.

In another century, in another state, I cared for a patient who feigned seizures.  She knew enough neurology to easily fool me and almost enough to fool a very good neurologist.  Before HIPAA, fax machines and the Internet, we did the best we could for the young woman coming in off the highway in the middle of the night, not realizing that her “epileptic” activity came under her complete conscious control.

On her third hospital day, we started getting information in from hospitals and clinics in other states.  I spoke with her parents but she had burnt bridges years before; they stated without rancor that they wanted nothing to do with her. 

The patient was the first I would care for with Munchhausen’s syndrome, a disease where the patient makes the doctors believe illness exists when it doesn’t.

I cared for such a patient today; because of confidentiality I will reveal no details.

Munchhausen patients constitute a no-win situation for the doctor.  If not confronted, they continue the drama, and the illness never resolves.   If confronted, they deny, dissemble, and project, and move on to another facility.

Some but not most work.  Most but not all lead geographically unstable lives.  Occasionally parents use their children to create medical chaos, giving rise to the syndrome of Munchhausen by Proxy.

Some patients have physiologic abnormalities, such as a blood test or an electrocardiogram that never normalizes.  Some have horrendous scars.  A subset of patients uses words and physical findings to obtain narcotics either for their own use or for resale.

They play a dangerous game; I have seen limbs amputated and surgeries performed.  Mostly Munchhausen patients die from medical misadventure.

Once the patient has the diagnosis established, there exists no effective treatment.  At best, a doc hopes to not personally making the patient worse.

Sometimes, the patient seeks nothing other than attention, and I have set up thrice weekly appointments for months to try to protect them from medical care.  But others thrive on manipulating the medical establishment, and find no satisfaction outside of misdirected heroics or anger.

Still, they are human beings, and I wish I had a good treatment for the person I saw I today.


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