Virginia Woolf published these words in 1925, 55 years before the diagnosis of posttraumatic stress disorder (PTSD) was formally defined in the 1980 Diagnostic and Statistical Manual of Mental Disorders (DSM) III, nearly 80 years before the Iraq War, and more years than that before President Obama would meet with the American Medical Association to discuss the future direction of U.S. health care.
Woolf, who was sexually abused as a child, likely suffered from symptoms consistent with bipolar disorder, and ultimately committed suicide at the onset of World War II, describes Septimus Smith, a “shell-shocked” World War I veteran with the signs and symptoms that would meet the current diagnostic criteria for the diagnosis of PTSD. Woolf was ahead of her time in accurately describing this phenomenon and exploring the interactions of the PTSD sufferer with the workings of the medical system of the time. A closer look is revealing, even today. Septimus Smith and his wife, Rezia Smith, seek a medical opinion from the physician Sir William Bradshaw. At first glance, Bradshaw is “not merely of lightning skill, and almost infallible accuracy in diagnosis but of sympathy; tact; understanding of the human soul.” Bradshaw makes a quick and accurate diagnosis of Septimus' condition, which he “ascertained in two or three minutes,” and recommends that standard treatment of the time—Septimus is to be sent away to a home in the country where he “should drink milk in bed.”1(p284)
But more subtly, parenthetically even, Bradshaw is struggling: “The stream of patients being so incessant, the responsibilities and privileges of his profession so onerous . . . weary[ing]” (emphasis added). And though he “never hurries his patients,” he draws his diagnostic conclusions in two or three minutes. When Septimus stammers once, Bradshaw notes that “it was growing late.” When Septimus stammers again, Bradshaw tells him to “try to think as little about yourself as possible” before dismissing the Smiths. How often have we gone through our day finding the work flow of patient care “incessant and onerous”—only to finish the day “wearied”?
And what is the result of this interaction between Septimus Smith and his astute and accurate diagnostician? Septimus and his wife feel that “they had been deserted.” Septimus had displayed the psychological symptoms of PTSD—he couldn't concentrate, couldn't remember his trauma, attempted to “confess” that he had “committed a crime.” Bradshaw does not have the time for it. And finally, when the doctor is called to his patient's home, it is too late. Septimus commits suicide: “He did not want to die. Life was good. The sun hot. Only human beings—what did THEY want? . . . ‘I’ll give it you!' he cried, and flung himself vigorously, violently down on to Mrs. Filmer's area railings.”1(p329) Septimus wants to tell another person what he did during his traumatic wartime experience. He wants another human being to help him make some sense of it. He tries to tell his physician. But his astute and accurate physician provides a diagnosis and a recommendation for treatment only.
I've found that I can often make accurate diagnoses in “two or three minutes”; however, patients need more than those two or three minutes to accept, understand, and be educated about that diagnosis and how they can participate in their treatment. And how long does it take to feel cared for? Unfortunately, I'm only paid to make the diagnosis and institute treatment, and my imposed schedule of 20-minute back-to-back appointments reflects this for my panel of patients. I've “dismissed” patients with a correct diagnosis and the appropriate treatment, despite sensing that the patient was still in need of explanation and empathy as I left the room to get to my next appointment. Within the current health care system, I have become a Dr. Bradshaw—astute, accurate, and dismissive.
One might think that today's medical treatment would avoid the problems and outcomes that Woolf documents. But my experience and today's headlines suggest we are not doing much better. A recent article, “Senate committee holds hearing on suicide rate in the military,” relates the account of a 33-year-old former soldier “undergoing mental health care . . . [who] had just seen his primary care provider and psychiatrist over the last few days prior to committing suicide.”2 The legacy of Septimus Smith continues.
What does this mean for primary care? We learn from a related article that “the Army is working on increased training for primary care providers in mental health.”3 Yet in the wake of this effort, primary care physicians will be harder to come by: “By 2020 or 2025, the deficit could be as great as 200,000 physicians—20% of the needed workforce.”4
With primary care physicians becoming scarce and requiring additional training to handle our modern-day Septimus Smiths, we may again create “accurate and astute physicians having to render their diagnoses in two or three minutes”—leaving our Septimus Smiths and their spouses to feel “dismissed.” Virginia Woolf knew this in 1925.
We are now primed for health care reform. Can we do better this time?
Richard Mansfield, MD, MS
Dr. Mansfield is staff physician, Department of Primary Care, Veterans Affairs, White River Junction, Vermont, and assistant professor, Dartmouth Medical School, Hanover, New Hampshire.