Many years ago, when I was young and in my first practice, I had a patient who taught me a lot.
I keep saying that, but as I tell my residents: you can be a resident for the rest of your life, but you will never learn as much as you will during that first year or two in your practice.
That little storefront clinic in St. Henri was the crucible where I became a real doctor, where I made my first big mistakes, and where I made some of my most important “saves.”
Dex was one of my patients. I don’t remember how she came to my practice, but I cared for her for a long time. She was a very out and proud butch lesbian, not as common in those days. She favoured leather jackets with chains, death head jewellery and tattoos.
She also had very severe rheumatoid arthritis and many resultant deformities. Her rheumatologist, who had been following her faithfully since her adolescence, knew her well and was a wonderful and collaborative consultant.
One day she came in, chained her bicycle up outside, came back into my windowless office. “I’m worried Dr. Perle,” she said gravely. This was unlike her; she was usually a very tough and stoic customer. “What’s wrong?” I asked.
“At night, in my bed, I will start shaking uncontrollably, like I’m having a seizure.” I took more history and did a neuro exam, which was normal, but it did sound like she was having complex partial seizures. Considering everything, I decided to send her for a neurology consult. I don’t remember how she ended up going to a different hospital than the one where her rheumatologist practiced, but she did.
A week or two later, (yes things were like that back then) I got a consult letter from the neurologist. The contempt fairly oozed off the page! There was nothing neurological going on, the neurologist reported. The patient obviously had borderline personality disorder and was having factitious seizures. I should stop being so naïve and never let this patient darken the doors of their illustrious institution again.
I was suspicious and annoyed. I am not a psychiatrist, but I have often seen “borderline personality disorder” bandied about by some as a code for “I really disliked this patient.” Also, while I am not a psychiatrist, it was my understanding that people with factitious seizures did not usually have them when alone in their beds, but rather in the most public places, which increases their dramatic impact. I was worried that this could be a complication of her rheumatoid, although I did not know how. I called her rheumatologist, and he called me back in a few hours. “I’ll see her tomorrow,” he said.
The next evening at 6 p.m., he called me back to tell me that Dex was admitted to neurosurgery. “It was hard to see on the x-ray,” he said. “But I got an emergency CT scan, and she has a fracture of her atlas. Good catch, Perle. Her atlas was actually piercing into her brain when she moved into certain positions.”
The thought of this patient biking around town, with her head essentially held on by the strap muscles and force of habit made me nauseous. She underwent surgical stabilization of her C-Spine the next day and recovered well.
I never got in touch with the neurologist to tell him that his evaluation was not as accurate as it could have been. In retrospect I wish I had.
We all carry our prejudices with us wherever we go. We see our patients and make assumptions. Sometimes this is a good thing. Pattern recognition is a powerful tool in medicine. But sometimes our prejudices can lead to poor care, and even death.
The trick is to keep your mind open and listen to what the patient is telling you. It is always true, one way or the other.