Imperfections

Every organization has its flaws. They are inevitable, and over the last week I have come to realize one here. I encountered it in a particular patient and then began to notice it everywhere. It is a problem that I, a student of psychology, see far more often than most, but whatever bias I may have it is real, and it costs the patients, this hospital and this country far more that any of us realize.

Last week I took a detailed history of a patient in our general ward. He was experiencing difficulty breathing on even the slightest exertion; and an X-ray showed a partially collapsed lung and several other abnormalities. I understood by talking to him that he had been to several doctors before without much success and had finally come to Hedgewar hospital because of its good reputation. It was suspected that he had a tuberculosis infection, but the existence of other possible illnesses was still in doubt and we needed a CT scan to understand them better.

As soon as the idea was proposed to him he became noticeably frightened. I talked to him briefly later and overheard some of his conversations with others. He had a bad experience some time ago where the electricity had gone out in the middle of the CT scan and he became trapped inside the machine in a pitch dark room. He was worried that something similar was going to happen again and was so scared that he even said ‘let me die, but I’m not going into that machine’ (obviously translated from Marathi). Without the scan we could not just blindly give him treatment so we discharged him.

He was not referred to another doctor and was not given any treatment. Nothing was done to understand the nature of his fear or to try and overcome it. If he dies, he will not die because of his tuberculosis, he will die because of an irrational fear. I do not blame the doctors involved but rather the culture; when I questioned his treatment the response was simple, ‘who has time to treat a psycho (yes, this description was used several times) when there are plenty of other patients waiting?’. This question, though callous may seem rational, but only to someone who is thinking only of the now. The patient has remained ill. He will likely see several other doctors for treatment. He will not get better, he will be readmitted to hospital, his family members will have to take care of him, they will take time off work, and their lives will be greatly impacted. He will cost the hospital, the health system, his family, the economy and the country more now, than if his psychological issues were addressed properly.

Yesterday a man came into the outpatient department with diffuse body pain, trouble sleeping and trouble digesting food. Many tests and investigations had been undertaken over two years and they had all come back normal. My preceptor astutely observed that there was probably a psychosomatic component to his illness so I asked whether I could explore the issue. I sat with the patient and his wife in another room. We started talking about his complaints and then his family, his work and his children. He told me that he had five children and his eldest daughter was married two years ago. Eventually, after a little prodding he told me that his daughter’s husband was severely beating her and that a year ago she ran away from him and returned to live at home.

Although the patient and his wife were absolutely practical about the issue and were in fact encouraging their daughter to run away they admitted that there was definitely a social stigma, and they were feeling the brunt of it. It appears that the wife is thought to bear a greater proportion of the responsibility if a marriage does not work. Furthermore, after she returned home, the husband would call every now and then and threaten her and the family. So as a solution they disconnected their phone.

As treatment my preceptor prescribed some anxiolytics, mostly to help with sleep. But there was really not that much more he could do. He didn’t have the time or the resources to counsel them, and the nature of their problems was only revealed because I had the time to sit with them for 20 minutes. Again, this is in no way my preceptors fault, but it is the fault of a culture that systematically and pathologically pretends that psychological issues do not exist and in my opinion is unknowingly suffering the consequences. If our patient’s somatic symptoms were indeed a manifestation of his anxiety, he will surely be back. If his anxiety is not treated his symptoms will get worse. He may be hospitalized; his family which depends on his income and support will suffer. His kids’ education and future healthcare will be impacted.

Given that the doctors here do indeed care for the community they serve; and given that they approach the clinical and social aspects of medicine with an impressive degree of competence, the psychological aspect of illness needs to improve to the same standard. I’m sure as they come to realize the burden it causes, its importance and emphasis will increase in their practice.