I have known for several months that things were coming to an end between Helen and myself, and that I would probably have to be the one to actually end our relationship.
Helen’s medical condition is quite ordinary, but her reaction to it is unusual. She is convinced that she has some dreadful, yet undiagnosed disease. Years before she even became my patient she had been thoroughly evaluated and all the tests had been normal. A few more confirmatory tests reassured me, but not Helen.
She spiraled into a deeper state of panic about her symptoms and she started to call Autumn several times every week with new concerns, demanding that we drop everything and reevaluate her. She has refused to go to the emergency room when her symptoms have sounded dramatic on the phone, and she has refused to see my colleagues at the clinic when I have been too booked up to see her right away.
I tried to apply my usual strategy for working with anxious, doubtful patients. I gave her weekly double-length appointments in order to show her I was taking her seriously and wanted to address all her concerns. By seeing her often I hoped to decrease her panic between visits, but this made no difference. She has also resisted the notion that her symptoms may be worse when she feels anxious about them. She vehemently refuses to see our behavioral health specialist.
Our last several visits have followed the same pattern: I would ask about her symptoms, which always remain the same, then I would ask about her medication, which she never takes as prescribed. She would then tell me she has spoken with an acquaintance – a nurse, pharmacist or fellow sufferer of a similar condition. Inevitably, this other person has nothing good to say about my diagnosis or proposed treatment strategy.
Every time Helen has brought up the concerns raised by her friends, I have responded by reviewing how I arrived at her diagnosis, what the literature recommends for treatment, how the medications are dosed and how one monitors the condition and the treatment. Every time I have done this, Helen seems okay with my treatment plan, but by the next time I see her, the process starts all over again.
During last month’s visit, I put her chart aside and said to her:
“You really don’t seem comfortable with how I am handling your medical care.”
“Well, it’s just that – I mean, how do we know we’re on the right track?”
I remembered Rhonda Weston, who for almost a year kept saying she wasn’t feeling right. Her physical exam and all her medical tests were normal, until suddenly she developed the slightest lymph node swelling, which turned out to be non-Hodgkin’s lymphoma. Within two years she was dead, despite the best of treatment by Boston and local oncology specialists.
I went over Helen’s symptoms, the testing we had done, the diagnosis and differential diagnosis and my treatment recommendation, based on the literature I had reviewed and shared with Helen. I explained to her that after going over her history and evaluating every symptom she has told me about, there was no sign at this time of anything more dangerous going on. I reminded her that I always wanted to know if any of her symptoms changed, so I could evaluate them in the context of what we already knew.
“No test is perfect, Helen, and that’s why I’m always checking in with you to make sure there aren’t new symptoms or new findings that we need to consider. I am doing my very best to keep an eye on your condition.”
“I do trust that you’re doing your best, it’s just that I’m scared.”
“You’re scared that there’s something I’m missing?”
“What’s your biggest fear, your deepest fear?”
“I don’t know; just that I have something bad.”
I told her I understood, but that it wasn’t in her best interest to stay under my care when she had so many doubts. I suggested she look for another doctor, who might make her more comfortable than I could.
“No, I want to stay with you”, was her answer.
A few weeks ago Helen told me about a fourth cousin in Philadelphia, with the same symptoms, who suddenly ended up in a coma and on life support at a university hospital.
I knew I wasn’t going to break through her fear. I gave Helen the names of three or four doctors within easy driving distance who are accepting new patients. I told her I was sorry I hadn’t been able to help her more and that we really couldn’t go on like this. I gave her formal notice to find another doctor within 60 days.
I didn’t expect to feel relieved after doing this, but I had not anticipated how sad I would feel.