Do we share with our patients?

Dr. Thomas Harbristle was the doctor who scared me most during my training. He was a general surgeon, just over five feet tall, and his manner was curt.“That’s my name at the head of your bed.” He would announce loudly to introduce himself to a newly admitted preoperative patient. They would nod silently, and tend to remain quiet as he finished his brief discussion of their future surgery with his usual brusque “Any questions?” I don’t remember that anyone ever dared to ask any.Looking back now, I see the reasons behind my trepidation lay more with me than him, though his bedside manner certainly contributed to my fears. This was my third year of medical school, and it was already obvious I was heading for psychiatry rather than surgery, partly because of my embarrassingly poor manual dexterity and visuo-spatial skills. To cap it all, Dr. Harbristle had once caught me gazing out of the window when I should have been listening to his explanation of abdominal examination. He hadn’t said anything, but he didn’t need to. His scowl was enough to make me worry about whether I would get the necessary passing grade.Usually, I was part of a gaggle of five students working together with him on the wards and in the operating room, so I could hide in the crowd. But in the outpatient clinic, he would only take one of us at a time, which is why I was sitting there in the background when he met Mr. Gentleman.“Dr. Sutherland, can I tell you something?”“Of course, you can Sally,” I replied, noticing how hesitant she seemed. “Anything you like.”Sally was a first-year student who I was meeting to discuss careers with. I am the most visible psychiatrist to new students in our medical school, and so I have lots of these meetings. Sally wanted a career in mental health, and we chatted for a while about the various pros and cons of the job. “It’s kind of personal.” She said, with a lowered gaze.“That’s OK.” I said, wondering what was coming next. “I promise to keep it confidential.”“Well, I suffer from an anxiety disorder myself.” She said, followed by a quick glance to check my reaction.“I’m sorry to hear that, but it’s quite common.”“I know it’s a really common illness, but is it OK to become a psychiatrist like that.”“It’s not unusual for people to choose psychiatry for a career if they have had some mental health problems themselves, Sally. We probably attract a slightly higher proportion of students like that.”“And it’s OK?”“That depends. It’s a bit of a double-edged sword. If you have your anxiety under control then it might actually make you a better psychiatrist, because you will have a much deeper insight into how the patient feels. But if your anxiety is still impairing your function, then of course that’s not so good.”At this she started to look hopeful again. “It’s definitely under control. But supposing it comes back again?”“Then it’s like any other recurrent illness. If a doctor becomes too unwell to work effectively, they take some time off until they’re recovered again. Anxiety would be no different than any other disease.”Mr. Gentleman looked even more nervous than I did in Dr Harbristle’s outpatient clinic, but he had a good reason for that. He'd just been diagnosed with colon cancer, and was hearing from my boss that he'd need a hemicolectomy. Having half your colon removed would worry anyone, but it was the resulting colostomy that seemed to be troubling him most. “I can’t do that,” he stammered, after he heard the description of a stoma.“Oh, people get used to it,” said Dr. Harbristle, sounding a little milder than usual.“We have a colostomy nurse working with us, and she can help explain the details and teach you how to look after it.”“Isn’t there any other way?”“Not to start with at least. We need to give the lower bowel a rest while it heals.”“But that’s terrible,” said Mr. Gentleman. He had the consent form in front of him, but now he pushed it away. “I don’t know if I can live like that.”I felt the tension in the room rise, and I was beginning to feel his agitation. Given Dr. Harbristle’s reputation as a no-nonsense practical man I wasn’t sure what would happen next, and I had to make an effort to not let myself shift uncomfortably in my seat as I sympathized with our patient.Students like Sally often head off to do their residencies in other places after graduating from medical school, but our postgraduate program had a good reputation, and so a fair number stay to complete their undergraduate medical degree and specialty training in the same city.Five years after our career planning session, Sally came to work with me in one of her final training positions before she'd be able to work independently as a new psychiatric colleague. The intervening years had matured her, and now I saw a quietly competent young woman, who fitted easily into our multidisciplinary team, and whose patient care quickly showed me that she was ready for her final graduation.On Friday afternoons, I set aside an hour to talk with my resident. Sometimes we thought more deeply about an unlucky patient’s seemingly intractable problems, sometimes we talked over exam preparation since Sally’s big final assessments were looming, and sometimes we came full circle and talked again about career planning in such a varied and extraordinary medical specialty.“Where are we headed today?” I asked, setting down the coffees I'd brought.“I need to ask something,” she replied, looking uncharacteristically diffident.“Whatever you like, this is your time.”“Catherine J is a lady I’m seeing as an outpatient—52-years-old, married homemaker, with an anxiety disorder.”“I think I remember the referral. How’s she doing?”“We’re a bit stuck. A high-dose SSRI and some CBT have lessened her symptoms a little, but now she’s developing agoraphobic avoidance of going out.”“What kind of places?”“Shopping malls, her daughter’s school, even going to friends' houses.”“And your treatment?”“I’ve explained all the details of a behavioural approach, constructing a hierarchy of easier places to go first, and I’ve maximized the medication, but she simply won’t take the first step. She doesn’t see how the systematic desensitization could possibly work.” I nodded approval of her plan to gradually expose Catherine to more locations while schooling her in the anxiety management techniques she'd need to make the process bearable, but if Catherine wouldn’t engage with the process then this, like any psychotherapy, wouldn’t work. “That’s too bad,” I said, starting to think.“But I have an idea; I just didn’t know how much I’m allowed to do it.”“Oh?”She paused, timid again, in a way that I hadn’t seen since that long-ago meeting with her when she was a medical student.“You know I have an anxiety disorder.”“Yes, but you haven’t mentioned it for so long. Are you OK?”“Yes, I’m fine. But when it hits me, I get agoraphobic just like Catherine. I was wondering if I could tell her about me, and whether that might persuade her to give the treatment a try.”“Hmm. That’s a good question.”“Can we ever tell patients about ourselves? I haven’t come across any rules about this.”“In general, the answer is ‘no’. We want to focus on the patient’s issues, and not our own. There’s a risk to saying ‘I know just how you feel,’ because their response might be, ‘Oh no you don’t.'”“I get that. And I can see how it would make it harder to keep your professional distance.”“Particularly if your patient has some dependent personality traits. I have a couple of people who are always asking me personal details, and it makes me even more determined not to share anything.”“But can’t it help sometimes? I was hoping that if Catherine heard how I had needed to use the same behavioural techniques that I’m advising her to do, then she might decide to engage with the process. She really needs this to work.”“It might be worth a try. Let’s just check a few things first. Do you think she might become highly dependent on you?”“I haven’t picked up any hint of that. Her life before she became ill was pretty independent.”“And how would you feel about a patient knowing your history. Would you be OK with that?”“I’ve thought about it, and I certainly wouldn’t want to be telling everyone. But I think I’d be all right with it in this case.”“Then feel free to go ahead. And I hope it works out well. Keep me posted.”“I will. Have you ever seen it work?”“Once you graduate and start to work on your own, then you no longer get to see the details of how others practice, so I haven’t come across many instances of this. And I don’t have any diagnoses to reveal myself. But yes, I can think of one or two examples where it made a difference.”The consent form for surgery still lay on the desk at a long distance from Mr. Gentleman. Dr. Harbristle had been sitting silently for a while, looking into space, while his patient anxiously watched his face for any sign of what would happen next. I was no less concerned either, because I had seen the pathology report and knew that without surgery the cancer would inevitably kill him within a year or two. Whereas the prognosis for his stage of illness would normally be a greater than 50% chance of cure. Just so long as he had the operation and could be persuaded to accept a colostomy.Finally, Dr. Harbristle’s attention returned to the room, and he made the gesture that he must have been contemplating, and which would turn out to secure Mr. Gentleman’s future.“You know,” he said, opening his white coat to reveal the shirt and trousers below. “It really isn’t as bad as it sounds.”Then he tapped the bulge that lay at his waist, and we all heard the slosh of the liquid within.Dr JP Sutherland is the pseudonym for a practicing psychiatrist. The Medical Post has independently verified his identity, and he writes here anonymously to provide an added layer of privacy for his patients. His case reports are non-fiction, but the names and other identifying details have been changed. Read more of his work here.

Do we share with our patients?

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