Type-Casting

A few weeks ago our team, normally focusing in the emergency room on avoiding unnecessary hospital admission in over-70s, was asked to see a 45-year-old lady who had come to the ER for the second time in four days. The first time, she was sent home because she didn’t seem to have anything wrong. “I don’t feel right. I know something’s the matter but I can’t say what it is.” Physical exam, chest x-ray, laboratory workup: all negative. She was upset, crying, and complaining that nobody seemed to care.

This person looked to everyone like a classic attention-seeker. She was blind from oxygen poisoning as a baby, overweight, and had arthritis that made getting around difficult. She lived all alone in a small apartment. The doctor who saw her on that first visit felt sorry for her but knew that the ER was not going to solve her emotional and social problems.

Two days later she came back, this time she’d fallen and hit her elbow and knees on the concrete floor. X-rays were normal, she was offered pain medication, and told, again, Go home.  And be careful. But she wasn’t satisfied so she wouldn’t leave. By morning when we assessed her a social worker told us that as far as she could tell there was no social problem. The lady worked at a job, had enough money, didn’t drink or do drugs, had friends, and had been doing just fine in her apartment until about 5 days ago. I wondered if maybe her cat had died. We went to see her thinking we’d try to set up some counselling and connect her with a family physician. Anything to get her out of emerg.

It turned out she already had a family doctor, a young female. When I called her she told me it was important to make sure there was nothing seriously wrong with her patient. I mentally rolled my eyes because I didn’t think I needed schooling by some junior doctor, plus this patient had had not one but two capable medical physical examinations and relevant x-rays and tests in the space of three days. The previous night’s emergency specialist’s examination was legibly documented and completely normal. I had it fixed in my mind that we were dealing with a socially disabled chronic complainer and my job was clear: get her out of here. I asked the family doctor if there had been a referral to a psychiatrist or mental health team, but she couldn’t understand why we would be suggesting that. The lady was cheerful, bubbly, functioning just fine.

I was scratching my head walking away from the phone when our very astute physiotherapist asked if I would check this blind lady’s neurological exam. The physio had been trying to make sure the patient could walk safely before sending her home. He had me watch as she held her arms out straight, and the right arm drifted down to about 45°. We both knew this meant she had trouble locating her body in space, which gets really obvious when normal patients close their eyes, but of course this person couldn’t see her arms anyway.

I did two or three quick tests of function of the cerebellum, the part of the brain that looks after perception and adjustment of body position, and there was no question something was very wrong on one side.

Twenty minutes later we had our answer: a CT scan showed a medium-sized clot of blood in the cerebellum: a hemorrhagic stroke. Going back and asking her if she had any trouble grasping things she said yes, and it had been going on for exactly 5 days. Plans to send her home were cancelled and she was admitted and seen by a neurologist.

What happened here, and why is it worth posting so you can read about it? We in healthcare depend more than we sometimes know on educated instinct. It doesn’t take a doctor or nurse very many years to learn that most people represent a “type”: go-getter, cautious conservative, minimizer of symptoms, chronic complainer, bundle of nerves. The problem is that we default to these types in our mind, and it can be hard to avoid concluding that what we are seeing is just at-expectation for this type of person.

So a blind, fat, funny-looking middle-aged spinster lady crying and complaining with, apparently, nothing wrong except her sad chronic social troubles doesn’t get taken as seriously as a married, athletic, articulate male accountant of the same age with the same vague complaints. I thought I knew what was going on before I even saw her.

This isn’t sexism, either. The very smart young female ER specialist who saw this patient four days after her cerebellar bleed wrote on the chart “no lateralizing findings” (this means she says she did a neurological examination and found nothing). She must have decided to document the negative finding “for completeness”. There wouldn’t have been any doubt in her mind either what type of person she was dealing with.

What type are you? It may not be easy to see yourself as others see you but beware. Modern healthcare’s microscope is supposed to be gauging with precise objectivity what’s wrong with you and what you need, but your perfectly innocent personal characteristics might be messing with the focus.

About John Sloan

John Sloan is a senior academic physician in the Department of Family Practice at the University of British Columbia, and has spent most of his 30 years' practice caring for the frail elderly in Vancouver. He is the author of "A Bitter Pill: How the Medical System is Failing the Elderly", published in 2009 by Greystone Books. His innovative primary care practice for the frail elderly has been adopted by Vancouver Coastal Health and is expanding. Dr. Sloan lectures throughout North America on care of the elderly.
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