Things Are Seldom What They Seem

July 22, 2019

Doing a review of systems wasn’t “rocket science,” as they say-but it was a classic example of medical science and of why psychiatrists are physicians first.

WHY PSYCHIATRISTS ARE PHYSICIANS FIRST

As Gilbert and Sullivan wrote, “Things are seldom what they seem, skim milk masquerades as cream.” Medical disorders may also masquerade, not as cream but as psychiatric disorders, as occurred in Maureen’s case.

Maureen had every reason to be depressed. Her live-in boyfriend left after 5 fitful years. Since then, her energy waned. She rarely slept through the night and couldn’t make it to morning team meetings.

Not surprisingly, her job was in jeopardy. Worse yet, her company was also in jeopardy, for the fashion industry had been floundering ever since “fast fashion” priced out their designer dresses. Her once-prestigious brand would be “cutting the fat” to stay afloat. They hinted at lay-offs to come.

Even when she was in time for the morning meetings, Maureen couldn’t concentrate. She made careless and costly errors. She received a formal warning from her boss, who said that her “presenteeism” was worse than her absenteeism. He referred her to HR, expecting them to do the dirty work of dismissing her.

Maureen left a voice message for me, saying that she had explained her situation to Eileen, the head of HR, who suggested a medical leave of absence, rather than the immediate termination recommended by her supervisor. She received my name from the company’s Employee Assistance Program (EAP). To me, this sounded like a generous offer, especially since it came with short-term disability benefits; however, there was one caveat. Maureen needed to seek psychiatric treatment while on leave. Maureen was told in no uncertain terms that she needed a psychiatrist to “sign off” on the disability and to prescribe medications as needed. HR would not accept a note from the texting therapist whom Maureen had found through a subway ad.

I knew from the get-go that there would be plenty of papers to sign, and annoying insurance forms to complete, along with regular clinical care, should I schedule her appointment. The EAP staff knew that I would not endorse questionable disability papers, and I made sure that Maureen knew that I could promise her an evaluation but could not promise anything more before completing that evaluation.

Maureen arrived at her appointment, looking pale and haggard for someone so young. She had neglected her grooming, which didn’t go unnoticed in the fashion industry. Her nails were chipped. Three inches of dark roots told me that her self-care had lapsed 6 months earlier, since hair grows half an inch a month.

Her speech was slow and monotone. Luckily, she was not and never had been suicidal. I could count on the EAP to catch those serious symptoms before referring patients to an office setting.

Maureen’s psychiatric history was straightforward. She had one previous depressive episode in college, also after a break-up. Symptoms were milder and remitted with therapy that she received from student health services. Her family history included uncles with alcohol use disorders and early deaths from cirrhosis but no other serious psychiatric disease. Maureen had the good sense to avoid alcohol because of this family history.

It would have been easy enough to diagnose MDD, recurrent, fill out her forms, start an SSRI, set up follow-up appointments, touch bases with her therapist, and leave it at that. But there was no way that she would leave my office without reviewing her medical history as much as her psychiatric and social history. A “review of systems” is a standard part of any initial evaluation. Obliging psychiatrists to apply the same “E & M” (“evaluation and management”) codes used by all other physicians (rather than unique behavioral health codes of the past) drives that point home even more.

On her intake forms, Maureen noted that she had anemia back in college-which remitted 5 years ago. In the section about exercise she wrote that she had stopped exercising when she felt too weak to walk to the gym. As always, intake questions included LMP (last menstrual period), since it is imperative to avoid certain medications in potentially pregnant patients. She scribbled a series of question marks after that question. I asked her to elaborate.

Upon questioning, Maureen mentioned that her periods often lasted so long that she wasn’t sure when they began or ended. She recalled that her college gynecologist attributed her anemia to heavy periods but did not recommend treatment or further work-up. Maureen added that her previously mild menstrual pain had become major pain. When asked about her last primary care or gynecology visit or recent laboratory tests, she looked up sheepishly and said that she hadn’t seen a doctor for 2 or 3 years.

I needed more data about Maureen’s medical status, since any number of medical conditions can affect mood and cognition, even when someone has obvious social stressors that can precipitate depressive symptoms. So, I bargained with Maureen and told her that I would sign her disability papers a week at a time, with the proviso that she consult a primary care physician and a gynecologist in the interim. Again, the ever-efficient EAP head had those doctors on direct-dial. To expedite matters, I handed Maureen a lab slip, knowing that basic lab results would return electronically the following day, but thyroid functions would follow in a few days. Those tests would be ready by the time she scheduled her PCP appointment.

Maureen was started on sertraline, but I emphasized that her unexplained medical problems could also cause lassitude. Her gynecology appointment was arranged quickly, and the gynecologist took the time to call and say that she felt large masses during the office examination. She suspected fibroids but needed imaging studies and a biopsy to support her suspicions and to rule out something more serious. In the meantime, Maureen’s lab tests returned with strikingly low hemoglobin levels. The repeat lab test ordered by the gynecologist later that week showed even lower levels. The gynecologist recommended iron supplements in the interim and explained the treatment options to Maureen.

The biopsy report came in. Luckily, there were no cancerous cells. Unwilling to wait for a response to medical treatment when her hemoglobin was dropping, the gynecologist scheduled a myomectomy. By then, Maureen’s stomach pain had increased and interfered with traveling to our appointments. We decided to make do with telepsychiatry appointments until she recovered from surgery.

It was late in the day when Maureen telephoned me to say that her surgery took far longer than expected. The gynecologist called in a GI surgeon to assist with dissection of a bowel loop wrapped around the 5-pound fibroid. Maureen wasn’t sure of the specifics. What was certain is that Maureen’s worsening stomach pains were something other than the vague aches and pains of depression. The gynecologist warned her that she could have developed gangrene that required a bowel resection, or might even have died from sepsis, had the mucosal membrane ruptured, and had they not acted so quickly.

While she recovered, Maureen’s surgeon assumed responsibility for documenting her disability and our telepsychiatry appointments revolved around titrating her dose of antidepressants. I half-expected her to transfer all treatment to her PCP, but a few months later, Maureen scheduled an office appointment.

She bounced into the room, looking like a different person. Her cheeks were rosy; she had “pep in her step” or so she said. There were no signs or symptoms of depression. She said that this near brush with death made her appreciate life. I asked about the insurance paperwork, since insurance paperwork prompted her first appointment with me. Maureen said it was moot: her company collapsed since she left on leave, and her disability benefits disappeared. Yet she seemed happy. She received a severance package and paid COBRA benefits and now had renewed energy and enthusiasm to seek new work.

I, too, had renewed enthusiasm about the importance of medical training to the practice of psychiatry. I confess that I cringe when I hear people say that “psychiatrists prescribe medications” without considering the need for a differential diagnosis and the significance of the “big picture.” Maureen’s life was at stake; this was more than a matter of mood. Doing a review of systems was a rather simple matter and putting those pieces together could be done by any doctor. It wasn’t “rocket science,” as they say-but it was a classic example of medical science and of why psychiatrists are physicians first.

That’s all well and good-but what happens when psychiatric physicians are not available? The supply is dwindling. There are some innovative solutions on the table, including “integrated care.” But that approach presupposes that patients already have PCPs in place-and many younger people consult urgent care for minor problems without forging relationships with PCPs. Curiously, as per Peggy Drexler’s Wall Street Journal article on March 1, 2019,1 millennials are more comfortable with therapy, even texting therapy, and may bypass psychiatric assessment as well, as happened with Maureen.

Currently, pediatricians can fast-track into child psychiatry fellowships, but I don’t know of plans to fast-track PCPs into general psychiatry training. Perhaps that’s something to consider, especially for PCPs who miss the doctor-patient relationships that get lost in an increasingly impersonal and corporatized health care delivery system. Perhaps there is a solution in sight-but dismissing the value of medical training in providing psychiatric treatment is not the solution.

References:

1. Drexler P. Millennials are the therapy generation. Wall Street Journal. March 1, 2019. https://www.wsj.com/articles/millennials-are-the-therapy-generation-11551452286. Accessed June 20, 2019.

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