“Mrs. S died.” The junior resident’s voice quaked with fear over the telephone. It was 2 am in the middle of a cruel Minnesota winter night.
As the senior resident on a busy academic medical floor, I rushed to the hospital to review the patient’s chart. While I was driving, many questions came to mind. Of all our patients, Mrs. S had been the most stable. She was getting ready for discharge.
Mrs. S was a 56-year-old female in good health overall with a history of anxiety and depression. She presented with shortness of breath and chest pain and was admitted to our clinical floor for evaluation. Upon arrival, she appeared anxious, and her physical exam was unremarkable. Over the course of her stay, we ruled out cardiac ischemia. Though her chest CT showed two tiny pulmonary emboli, we felt it was very improbable that these were the source of her problems. Still, we started her on anticoagulation hoping the treatment would cause improvement. Her status, however, did not change. Convinced that anxiety and depression were the roots of her presentation, we included psychiatric follow-up in her discharge plan prepared the day prior to her death.
While reviewing her chart for the inevitable morbidity and mortality conference, I was struck by how frequently the term “anxious female” appeared. Had we forgotten that psychiatric signs and symptoms can deflect our attention from medical disorders? Had we forgotten that medical problems can masquerade as psychological conditions? In part, we had remembered these precepts. We had ruled out common medical causes of anxiety such as thyroid problems, asthma, and diabetes. But had we followed up on all leads? For example, right before her death, one physician had detected “muffled” heart sounds. A recent EKG had showed low voltage signals. In retrospect, I remembered that anxiety and depression are common in many medical conditions. Could the cause of those cardiac findings have been producing her psychiatric symptoms? Suddenly, I considered it possible, perhaps likely, that her seemingly psychiatric problem was in fact caused by a physical illness.
At the morbidity and mortality conference, we listened in shocked silence as the pathologist disclosed the verdict—cardiac tamponade in the setting of rheumatoid pericarditis. I realized that we could have saved our patient’s life had we not been blinded by stereotypes, prejudices, and misconceptions about mental illness. Depression and anxiety can simulate physical disease, but physical disease can cause anxiety and depression. Our patient had presented us with data, but our premature labeling of those data as exclusively psychiatric kept us in the dark. Clearly such labeling could be dangerous, even fatal.
As physicians, we should demonstrate compassion and caring for our patients, especially for the suffering, the weak, and the isolated. As medical educators, we should strive to become role models for our students while providing them with opportunities to gain early exposure to patients with both physical and mental conditions.
Regardless of whether we are residents or consultants and no matter what the crowd believes, whenever we work with a patient, we must frequently stop and take a fresh look. Regardless of how often patients have been seen or how many diagnoses they accumulate, they hope that one day a “good doctor” will unveil the mystery of their ailment. Our willingness to start afresh may help us discover the real person in front of us and give us the necessary powers to provide our patients with the treatment they expect and deserve.
Acknowledgments: The author wishes to thank Stephen Berman, MD, PhD, and Toni Gallo, MA, for their invaluable contributions in editing this essay.
Mariana B. Dangiolo, MD
M.B. Dangiolo is assistant professor of internal medicine and director of the geriatrics and palliative care curriculum, University of Central Florida College of Medicine, Orlando, Florida; e-mail: [email protected]