JoEllen Patterson PhD, Family Therapist
University of San Diego
Several years ago, I was working with an elderly cancer
patient and her husband. They had been
referred to me by a wonderful physician in my collaborative care setting. The
wife had received grueling chemotherapy and radiation. Her prognosis was bleak.
I knew the physician
to be conscientious, kind, and exceptionally thorough. The physician eventually told the couple that
there were no further treatments available to treat the patient’s cancer. The couple was furious at the doctor "for
giving up” and spent their next therapy session criticizing the physician’s
heartless care. They hoped that I "would be more caring than the physician.” I
was unsure how to respond. Eventually, they
implied that "we” had failed them. They
did not schedule another session with me.
I wrote a brief note in the chart but failed to discuss the
session with the physician. I also realized later that I had not known how to
respond quickly to being triangulated into the conflict between the physician
and the couple. The physician eventually
learned that the couple sought alternative treatments in Mexico, and the women
died a painful death in a Tijuana clinic.
When I eventually told the physician about the session, he said he had
no idea that they were so angry with him.
Why hadn’t I told him?
I thought about this case for a long time and what I might
have done differently. Here are some of
- I wish I had viewed the doctor-couple
relationship as my patient, at least briefly.
I would have encouraged the couple to talk to the physician about their
feelings of abandonment instead of simply ruminating about his "indifference”.
I could have even offered to facilitate the discussion.
- I was sometimes too concerned about interrupting
the overwhelmed physicians to talk about an individual patient. So, I would write a note in the chart instead
of taking their time. In some cases, I
should have "interrupted” the busy physician to talk about a specific patient
situation. This was one of those times.
- I wish I had found more ways to gradually give
the couple "hope” even when the clinic could not offer them a cure. I think I was too focused on the medical
prognosis to move the conversation to an emotional/spiritual prognosis.
David Clarke MD, Gastroenterologist
Oregon Health and Science University
I met Catherine thirty years ago during my Gastroenterology Fellowship
at Harbor/UCLA. We spent only an hour together, but the encounter completely
changed my career. In her mid-thirties
she developed severe constipation, largely unchanged even with simultaneous
administration of four different laxatives at double the usual doses. Diagnostic evaluation over two years by her
family doctor and two universities was unrevealing.
When I asked if she had been under a lot of stress recently, as other
doctors had asked her, Catherine shrugged and replied, "Just the stress from
My next question was: "Were you under any stress earlier?” I was
wondering if she had experienced a specific stress when her illness began two
years before. She interpreted the question to mean the more remote past.
"Yes,” she replied calmly and
with little hesitation. "My father molested me.”
This was the first time anyone had made this revelation to me and I had
no idea how to respond. Without any childhood stress of my own to recall, or
any medical training about how to relate this information to her illness, I was
at a loss for words.
She went on to say her earliest memory of her father molesting her was
at age four. The molestation continued regularly for the next eight years. When
she began menstruating, he stopped. There were no other incidents of abuse or
personal trauma in her life.
I was aware of a psychiatrist on our faculty, Harriet Kaplan, MD, who
was also an internist with expertise in mind-body medicine and requested a
consultation. Four months later, I ran
into Dr. Kaplan in an elevator and asked how Catherine was doing. "Well, I
haven’t seen her in over a month, Dave,” she replied. "Her bowels are working
just fine now.” She had even stopped taking the medicines I had recommended.
I was shocked at the concept of
alleviating a serious physical condition solely by a few months of counseling.
Over the next few years, I learned everything I could from Dr. Kaplan and
during 25 years of practice treated over 7000 such patients myself.
Dr. Clarke invites you to find out more about psychophysiologic disorders and an upcoming conference at www.ppdassociation.org and www.stressillness.com.