The patient, a 29-year-old white female, has for several years received her medical care at a university residency practice. Her major medical problems include
· muscular dystrophy, progressive restrictive lung disease caused by severe disfiguring kyphoscoliosis, and chronic urinary tract infections secondary to multiple staghorn calculi colonized with Candida.
Reason for admission: She was admitted to the hospital because of increased urinary frequency, low grade temperature, and flank pain for two days, indicative of pyelonephritis.
Intern’s Perspective:
Ø Prior to interviewing the patient, the residents expressed concern that the patient tried to manipulate the medical staff, pitting her primary physicians against consultants.
Ø They noted her tendency to give conflicting information to various doctors and then blame treatment failures on them, commenting that the doctors “played games” with her.
Ø The residents thought she sabotaged their attempts to develop management plans for her medical care.
Interns interaction with the patient In order to gain a greater understanding of the patient’s illness experience, the residents asked her to discuss those physical problems she found most frustratingas well as the manner in which doctors “played games” with her.
Ø In the bedside interview, the patient noted that her main problem at the time was her lack of control over urination.
Ø Previously she had a schedule of regular urination at 9 a.m., noon, and at 3:00 p.m., each time with prearranged help from a paid assistant.
Ø At all other times, she avoided urinating even if she felt the need because of the difficulty and embarrassment involved in asking for help transferring from her wheelchair to a toilet.
Ø Three weeks prior to this admission she was seen in consultation by an infectious disease physician who suggested she stop her medication for the candidal nephrolithiasis.
Ø She reluctantly complied, worried that she would become incontinent off the medicine. Indeed, this proved true. She expressed her anger at this consultant.
Ø She was frustrated that her medical caretakers had not recognized the extent to which she had systematized her daily activities.
Ø In response to questions about game playing on the part of physicians, the patient cited how the urology consultants had started her on an experimental medicine in the past few months.
Ø She stated that no one ever informed her about possible reactions or interference with birth control pills she was taking.
Ø Subsequent to starting the medication, the regularity of her periods was upset.
Ø She expressed anger that the consultant physicians neglected her “identity as a woman.” She was also angered that her resident physician was frequently unaware of the changes in plans made by these consultants.
Points for Discussion
1. What are the themes emerging by talking to this patient?
2. By moving beyond talking about the patient as noncompliant and by appreciating the nature of her suffering, what could have the residents explored?
mindclinic 