Seeing the patient, not just a problem
It was early on a Monday morning, and I had been drawn to this particular patient room on the 10th floor. It had belonged to Mrs. Whittier, whom I had examined three days ago, on Friday.
The sun, just up over the mountains to the east, brightened the drab yellow-green walls of the room. I pushed the heavy door closed, and the room became quiet except for a muffled, far-away siren and the occasional voice that drifted in from the corridor. I detected the faint smell of disinfectant; they had cleaned the room and remade the bed for the next patient.
The only window that opened was the short one with hinges across the bottom. It opened inward by pulling on the latch, like a mailbox. I gave it a pull, letting in traffic noise for a moment, then closed it.
It would have been difficult for Mrs. Whittier (name changed) to step up onto the radiator and squeeze through that window. But the night nurses hadn’t noticed when, in the early hours of Saturday morning, she climbed onto the thin ledge and jumped to her death. I stood by the window straining to look down. The mental image sent a shiver across my back.
My senior resident had broken the news of the tragedy as soon as I came in that morning. This wasn’t the psych ward. This was dermatology. Dermatology patients don’t commit suicide. Had there been any clues? Had we directed our attention to her skin disease -- she had been admitted for psoriasis -- while overlooking a profoundly depressed, suicidal woman?
Admittedly, the diagnosis was a severe form of psoriasis, the pustular type, the Von Zumbusch type that covers the entire body, and she had struggled with it for years. Her disease was so severe that when she came in for an appointment with her dermatologist, he decided to put her in the hospital. Again. There had been many prior hospitalizations. Maybe Mrs. Whittier had had enough of the repeated admissions with less-than-satisfactory results. More likely, we missed something much larger. Regardless, we, medicine, the profession of medicine, had failed her.
I was a fourth-year medical student at the time, and one thing I did learn: All illness is about the whole patient. A bone breaks, the person suffers. One medical problem triggers a cascade of issues, both physical and emotional.
The sad truth is, the whole patient often gets left behind.
The complexities that lead to suicide are issues I am not qualified to discuss in detail. However, I have known patients or colleagues who committed suicide in the absence of obvious depression or mental illness. Two, including Mrs. Whittier, were utterly shocking. Others apparently were bold decisions in the face of untreatable disease. But, as extreme as suicide may be, I still can’t help thinking that we in medicine can do more to prevent such outcomes.
I know from experience that specialists sometimes consider complaints outside of their specialty as out of bounds, to be deflected. However, our primary job as physicians is to help patients. Addressing a patient’s general well-being might rarely uncover a serious problem; more often than not it merely builds goodwill and trust. To not ask, however, is to potentially miss detecting a patient in trouble.
Nearly every day, through exploration of the status of the whole patient, I try to show my residents that we are doctors first, specialists second.
James Channing Shaw is a dermatologist at the University of Toronto.