Case Study - A patient with Mental Health Problems
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Case Study - A patient with Mental Health Problems
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I have put this case on D2D because it caused a good deal of interest and discussion amongst medics and legal advisors when it came to light. It has not (to my knowledge) been published before.
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Case Study - A patient with Mental Health Problems
posted at 10/12/2012 8:00 PM GMT
on bmj.com
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Posts: 959
First: 15/7/2011 Last: 21/5/2013 |
I have put this case on D2D because it caused a good deal of interest and discussion amongst medics and legal advisors when it came to light. It has not (to my knowledge) been published before. I am very interested to hear members opinions and particularly Adrian if you have a moment: Mr B was a 29-year-old man with depression. He saw his GP, Dr H, regularly and was prescribed antidepressant medication, which was helping. His consultations would often be long, as he discussed his feelings at length. Over the next few weeks Mr B was bothered by unilateral earache and mentioned this to Dr H, who examined his ear. Dr H said it looked healthy and gave reassuring advice. However, rather than improving, Mr B’s earache seemed to be getting worse and was waking him at night. He explained this to Dr H on a subsequent visit. Dr H put his sleep disturbance down to low mood and again reassured him about his earache. The GP thought this was a reflection of his depression and discussed increasing his antidepressant medication. Mr B saw several different GPs about his earache over the next few weeks – it had become a constant, nagging pain. Minimal examination notes suggested otitis externa, for which he was given a steroid spray, and otitis media, for which he received three different types of antibiotic. Mr B was rather distressed about his earache and felt tired. The GPs thought this was a reflection of his depression and discussed increasing his antidepressant medication. Shortly after, Mr B developed left-sided nasal congestion and an aching sensation in his neck on the same side. He was seen by Dr H again, who thought he was run-down and that focusing on his health in a negative way could be part of his depression. The most frightening thing for Mr B was that he became aware of swallowing difficulties. He had had one choking episode so had changed his diet to eat softer foods. He noticed that he was losing weight and feeling tired all the time. He made another appointment with Dr H to discuss this. Dr H made a record that no abnormalities had been found on examination, but this did not include any record of a cranial nerve examination. Dr H attributed his symptoms of tiredness, generalised weakness and weight loss to his low mood. After eight months of GP appointments, Mr B attended his local emergency department because he was feeling so unwell. He had a CT followed by an MRI scan and was quickly diagnosed with a large destructive mass centred on the left naso-pharynx and skull base, eroding bone and spreading into the anterior pituitary fossa. The tumour was found to be a low-grade adenocarcinoma. Mr B was given palliative radiotherapy, which relieved some of the pain for a time, but the prognosis was terminal. Mr B was very upset and angry and made a claim against his GPs. |
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Re: Case Study - A patient with Mental Health Problems
posted at 10/12/2012 10:57 PM GMT
on bmj.com
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Posts: 154
First: 19/1/2012 Last: 18/5/2013 |
Gosh, sorry to hear about this, it's an awful thing to happen and there is not much else to say than that. I work in liaison psychiatry and we see people everyday with medically unexplained physical symptoms of all sorts. It is by nature a diganosis of exclusion and everyone's deepest worry is always missing something physical - both the medics who refer to us and us psychiatrists. The majority of the time the error seems to go the other way - we over-investigate, doing unnecessary and sometimes intrusive investigations, which don't show any physical cause and only serve to make everyone (rather ironically) more anxious (whilst the underlying psychological cause isn't being addressed).
It's always easy to see things with the benefit of a 'retrospectoscope' and we are human as doctors, things do go wrong and people do make mistakes. I think it's how you reflect on them that can make a future difference as sadly nothing changes awful things about the past (and I guess sometimes we all learn from other people's mistakes too). I think the main learning point from this for me would be to remember to discuss complex cases with colleagues - to get a fresh pair of eyes/ears on something is usually helpful - and to always keep re-assessing symptoms, and then re-thinking diagnoses. I'm quite lucky - I work in a big hospital team so all cases get discussed regularly and lots of different people from across different professions would see one patient. I also have lots of time to spend with patients and to reflect on what might be going on - I'm aware GP's don't always have these luxuries in these pushed times... |
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Re: Case Study - A patient with Mental Health Problems
posted at 11/12/2012 9:13 AM GMT
on bmj.com
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Posts: 959
First: 15/7/2011 Last: 21/5/2013 |
Thanks for your comments Alice. Do you think that when Doctors move into Psychiatry and are doing the exams (seeking promotion) etc etc that as they become SpR's and Consultants that their knowledge and skills in the 'physical' or general side of medicine decline?. I am not suggesting for a minute that one would expect a Psychiatry Consultant to diagnose complex medical problems that a Consultant Physician would be able to do - or am I being unfair to Psychiatrists who are actually very aware of physical health problems patients could have?. I have deliberately not stated the conclusion of the case but what do you think might have happend legally speaking?. I must emphasise that the Psychiatric and GP notes were very poor (as sadly is often the case). Furthermore, the patient did actually have many appointments with several different GPs. Do you think the GPs were lulled into assuming that the symptoms and demeanour/attitude of the patient made it more likely they would be inclined to assume mental health issues were the principle problem?. Many thanks for contributing, it is very helpful to me because I also learn a lot from reading and considering people interpretations. |
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Re: Case Study - A patient with Mental Health Problems
posted at 11/12/2012 3:24 PM GMT
on bmj.com
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Posts: 6
First: 21/7/2012 Last: 11/12/2012 |
There but for the grace of...... However, perhaps an important message to come out of this is the fact that psychosomatic disorders should only be diagnosed when a general medical cause for the symptoms, or the severity of the symptoms, really has been given serious consideration. It seems that in this case the GP was too ready to atribute physical symptoms to the mood disorder.. a cautionary reminder for all of us. Meanwhile, we do see casualties of the overemphasis on physical presentations of depresion in campaigns aimed at improved recognition and diagnosis and even choice of medication. Even without the retroscope the time-frame in this case does indicate poor management. Psychiatrists obviously cannot maintain clinical skills and awareness of advances in other disciplines as the years go by after specialisation. Unfortunately some are very stubborn about accepting this. Others aren't and perhaps, if this treatment-resistant, atypical mood disorder had been referred to a psychiatrist, she would have asked for another opinion on the unexplained symptoms. |
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Re: Case Study - A patient with Mental Health Problems
posted at 11/12/2012 3:50 PM GMT
on bmj.com
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Posts: 6
First: 15/11/2012 Last: 5/4/2013 |
Unfortunately it is quite common for 'heart sink patients' to develop recurrent new symptoms after a previous complaint has been satisfactorily treated. I remember an elderly lady who kept coming back with complaints all along the GI tract, alternating between dry/sore mouth, dry & tickly throat, dysphagia/dyspepsia, abdominal pain, dysuria and constipation, she was seen by the ENT team, gastro-enterologist, urologist and pain team, who all gave her treatment to improve their specific symptoms, but which triggered other symptoms, nothing serious was found on comprehensive investigations (scopies and scans), but in the end she died with an acute strangulated hernia, which had only caused her to be sick for two days, which she attributed to her neighbour's soup. However, the patient who was seen by several GPs and presented with crescendo complaints should have been taken seriously before! The own GP can have a blind spot for his heart sinks, but if they go for a second opinion the colleagues should approach the patient with an open mind, and two failed antibiotics should make a doctor think twice before prescribing a third. A sore throat leading to dysphagia and weight loss should at least trigger an FBC, if not more comprehensive tests.
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Re: Case Study - A patient with Mental Health Problems
posted at 11/12/2012 4:52 PM GMT
on bmj.com
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Posts: 135
First: 25/5/2011 Last: 23/5/2013 |
There are a number of systemic issues in this case that it might be worth commenting on. Firstly, I notice that it was recorded that the consultations were long. GP appointments are not usually intended to be long and, within the time constraints of a busy practice, may well have given rise to a conflict over this issue and the patient then being viewed as a "heart-sink" patient to some extent. Perhaps discussing feelings at length is better described as "ventilation" of feelings and frankly does not really help the GP to assess the clinical situation and make decisions on the important questions of the level of risk, whether treatment is required and where the patient can be most safely managed. Then, if they are to remain at home, to consider whether community services are required in addition to medication. Unfortunately under the current system once these decisions have been made, the patient has the opportunity to make endless repeat appointments to attempt to ventilate further with different doctors and for no real benefit to the management of their case. Their need for somebody to talk to in a therapeutic manner is not easily catered for in general practice, and the situation of a GP sitting helplessly watching the clock move relentlessly on while knowing that the ventilation will achieve very little of use, can inspire unpleasant feelings of helplessness which might make the patient's company unattractive. Real psychotherapy is a far more structured business than bursting in on your therapist unannounced while they're trying to do a busy morning surgery. That said, and even assuming that some degree of intolerance was starting, once it was mentioned to Dr H, Mr B's ear was examined and found to be healthy. Dr H had clearly then not written Mr B off as a neurotic. As far the tumour is concerned, I would suspect that this is a "once in a professional lifetime" diagnosis for most GPs to see something like this. The incidence of nasopharyngeal cancer in men in 2007 was 0.5 per 100, 000. Assuming a GP saw 10,000 different patients in a working lifetime, then this is 0.05 patients that they are likely to see with this condition. The unspoken concern I suppose is that Mr B's complaints were later seen as being neurotic and so ignored from a physical health management point of view. I personally doubt this was the case, since a number of other GPs then later reviewed him, examined and treated him, for the common ailments that most GPs will see all their life. Equally the increase in anti-depressant treatment was perfectly reasonable from the description. I'm assuming that it was the left ear that Mr B complained about, and if so, then the blocked nostril and aching neck are not impossible to relate to a simple ear problem. One solitary episode of choking would not usually trigger a referral for an ENT opinion and I am quite sure that having a quick look down the pharynx would have been normal. I assume that the lack of cranial nerve examination comment refers to a testing of the gag reflex - a very unpleasant experience for some patients and not necessary for treating common causes of ear pain. It is not common practice to perform a full cranial nerve examination when seeing a patient for earache in general practice. I also imagine that most neurologists do not attempt to see a new patient in ten minutes including a full cranial nerve examination. The most common symptoms of nasopharangeal tumour are lymphadenopathy and paralysis of the soft palate. Hand on heart, I have never recorded a soft palate examination in my life for earache and I doubt that any GPs routinely do. To summarise the position at this point, we now have a fleetingly rare tumour presenting in an uncommon manner. In retrospect it is easy to become worried that eight months have now passed. The loosing weight and feeling tired could easily have been as a result of his mood disorder. The next systemic error is within the NHS and that is that referrals for vague uncertainties are not routinely welcomed. Most ENT departments are too overwhelmed to start ringing the local GPs and asking if there was anybody that they could examine in order to keep themselves from getting bored. I suspect that it was not felt that there were enough purely ENT signs and symptoms to go on to justify the use of a precious new patient appointment except the length of time - eight months of ear pain in a man being treated for depression. The problem is that in GP land, all sorts of unexplained weird and wonderful presentations come in and clinical uncertainty has to be tolerated. The NHS is designed to only offer a basic safe service, not a 100% hit rate. Clinical judgement is difficult to rationally describe and is best gained by experience alone.. For the mathematicians however, I refer to the incidence figures and would say that mathematically, Dr H was never meant to see one of these. One might ask why the GP did not just order a CT scan and MRI scan like the later clever doctors at the hospital. I am quite sure that most GPs have no access to the big toys at the hospital and unless a single organ doctor can persuade the radiologist that it needs doing, nobody gets irradiated. Also I wonder, if the clinical signs had been that obvious, why did the team not perform a MRI scan initially? I would suggest that this supports my view that this was a difficult diagnosis to make. Sadly, the prognosis for these tumours does not appear to be very hopeful in general and I get the impression that curative surgery does not exist given the tumour's location. I for one am happy to say that I don't think that I would have diagnosed this either. Too rare, atypical presentation and with the distraction of a mood disorder. I don't think that any of the GPs who saw him can be criticised either. It is simply unrealistic to expect a 100% success rate within the current arrangements. I notice that you mention psychiatric notes in your second post, but no mention of seeing a psychiatrist in the history. Even if seen, under the current arrangements a psychiatrist would usually ask the GP's opinion on physical matters and suggest that they refer to ENT due to the funding arrangements. The single organ of the psychiatrist is the brain and any other physical skills that remain are now usually those learned as a house officer. We do however regularly discuss the complications of our drugs and so I think most other doctors would be surprised at our interest in diabetes, lipids, ECGs and the QT interval, epilepsy, smoking and weight monitoring. For some explanation of the difficulties faced I would refer you back to my post on the questions of whether psychiatrists neglect patients' physical health problems. http://doc2doc.bmj.com/forums/bmj_bmj_psychiatrists-neglect-patients-physical-health-problems?plckFindPostKey=Cat:BMJForum:BMJDiscussion:6d6e1701-72df-414d-ae9a-66293c784838Post:2920a414-36a7-4259-be77-bb1f9aaadeea My final conclusion is to find no evidence of negligence by Dr H. I can understand why this would cause discussions and disagreements, but under the NHS arrangements, not what may be available for the President of the USA 24 hours a day, in my opinion Dr H performed as expected by a group of his peers and no worse than I would have done. Dr H was also no doubt devastated, as clearly was the patient by what was discovered. My heart-felt sympathies to Mr B and his family should they ever read this. |
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Re: Case Study - A patient with Mental Health Problems
posted at 12/12/2012 6:26 AM GMT
on bmj.com
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Posts: 959
First: 15/7/2011 Last: 21/5/2013 |
Many thanks for your comments and contributions - particularly Adrians which reflects very similarly to the opinions I received from expert General Practice assessors. I want to remind everyone that my opinion as a lawyer is largely irrelevant, the view whether negligence or other want of practice comes from Doctor peer review - my job is to take all the information and assess whether a case can be defended. This case was tragic. The GPs and myself felt very saddened by the awful terminal illness this poor gentleman was facing - but emotion must not affect my judgement. Having looked at the totality of the evidence gleaned from the patient, all the Doctors involved and expert assessors I took the view that (despite poor GP documentation) each GP had on each occasion given the patient reasonable care (the law does not require care to be exceptional or superb) and that the case should be defended., Which it was and the patient ultimately withdrew his claim. I had a meeting with the patients lawyers who could not understand how a patient with deoression who had multiple visits to Doctors over several months could have ended up with terminal cancer. Having been fully briefed by expert assessors (in the same vain as Adrians assessment)I explained clearly why we would defend the case and that in a court room I felt confident that each Doctor could clearly explain and justify his actions on each visit. It was not reasonable for a General Practitioner - given the circumstances of this case - to have leapt to the judgement that the patient had an invasive cranial carcinoma. We would vigorously defend the case and had extremely eminent expert witnesses to give evidence in support of the GPs actions. Sadly such meetings are very acrimonious and mercenary. People often say it is better not to let your opponent know all your cardss. I disagree - in such cases one must lay out piece by piece everything you intend to bring to the courtroom and pull no punches. If the opponent is simply seeking money he will slink away. If he feels genuinely aggrieved then such a meeting will result in his lawyers advising him to withdraw the claim. I inadvertently quoted 'Psychiatric notes' in my second post, it should have referred only to GP notes - Psychiatrists were never named as co-defendants. I know I sound like a broken record but I just cannot emphasise enough that cases that are easily defendable frequently cannot be defended because notes are so poor. I know GPs are very busy and the same applies to hospital Doctors but concise entries that are legible, accurate and state clearly the issues at hand are imperative - recording negative findings can be even more important. I must sound patronising to experienced Doctors but please ensure your notes reflect the professionalism of your practice. I recommend reading Adrians observations and comments above - they reflect closely some of the information given to me, his assessment is sound, In cases such as these the expert assessors invariably come up with suggestions for how such problems might be managed in an effort to avoid a repeat or to improve practice. Some are just plain obvious, others are to improve practice. This is one comment: Symptoms should only be put down to anxiety or depression after organic causes have been excluded. Taking a good history and performing a thorough examination is essential. attendees sometimes need special consideration to make sure nothing has been missed. This could involve taking some time to read through the whole story of consultations, particularly if the patient has seen several different GPs, and gathering together exactly what examinations and tests have been done to ensure things have not been missed. |
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Re: Case Study - A patient with Mental Health Problems
posted at 14/12/2012 11:01 AM GMT
on bmj.com
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Posts: 339
First: 17/12/2011 Last: 15/5/2013 |
A very sad case. I am aware that I am a 'high referrer', but I have a sort of rule that if a patient is unwell and has been seen more than three times by a GP, without a definite diagnosis, then I would tend to ask for Consultant advice unless there was a good reason for not referring. I think that as GPs , we have to listen and then listen again to our patients. Persisting unilateral otalgia with out any routine signs is unusual in General Practice. Medicine can be a bit like gardening, when you have experience you can recognised the abnormal [the weeds] earlier. One sometimes needs to think laterally and think , what if the diagnosis is wrong, what else could cause the symptoms and signs. But pride comes before a fall and as Ewart Smith says , there but for the grace of .... |
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Re: Case Study - A patient with Mental Health Problems
posted at 14/12/2012 1:11 PM GMT
on bmj.com
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Posts: 1786
First: 7/3/2009 Last: 22/5/2013 |
These are my concerns: too many times we get "locked in" on a diagnosis, especially if the patient has a previous psychiatric history. Second, GP is not a universal ultra specialist in all cases. Such reccurrent complaints should've brought the doctor to refer to a specialist much earlier. Too many times examinations are partly done. You have and earache? Lets examine the ear.True, but then what about the fact that there are other structures around? The skull, the neck, lymphatics, oropharynx, nasopharynx, lymhatic drainge, muscles, parotid gland etc etc etc. There are things you can examine and when there is something suspicious a referral to specialist and imaging is a must. And the fear to refer "because it is unnecessary and I will be laughed at by consultant, ot I will be told that I spend money on unnecessary diagnostic procedures etc. etc" is an enemy for all of us.First clinical judgement, then money issues. And yes, by all means, when there are physical complaints, first rule out organic disease, only then consider mental problem as reason for the complaint, and even then keep a watchful eye if symptoms do not disappear. How long should and ear ache till one decides on a consultation? And who says that depressed patients can't develop serious ilnesses together with the depression? By the way, serious symptoms affect depression to the worse. Keep a very detailed record of the patients visits. Perhaps you are "locked" on something, but your colleague can see things differently.Consult with your colleagues about cases that are not getting better. |
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Re: Case Study - A patient with Mental Health Problems
posted at 17/12/2012 7:01 AM GMT
on bmj.com
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Posts: 959
First: 15/7/2011 Last: 21/5/2013 |
In Response to Re: Case Study - A patient with Mental Health Problems: These are my concerns: too many times we get "locked in" on a diagnosis, especially if the patient has a previous psychiatric history. Second, GP is not a universal ultra specialist in all cases. Such reccurrent complaints should've brought the doctor to refer to a specialist much earlier. Too many times examinations are partly done. You have and earache? Lets examine the ear.True, but then what about the fact that there are other structures around? The skull, the neck, lymphatics, oropharynx, nasopharynx, lymhatic drainge, muscles, parotid gland etc etc etc. There are things you can examine and when there is something suspicious a referral to specialist and imaging is a must. And the fear to refer "because it is unnecessary and I will be laughed at by consultant, ot I will be told that I spend money on unnecessary diagnostic procedures etc. etc" is an enemy for all of us.First clinical judgement, then money issues. And yes, by all means, when there are physical complaints, first rule out organic disease, only then consider mental problem as reason for the complaint, and even then keep a watchful eye if symptoms do not disappear. How long should and ear ache till one decides on a consultation? And who says that depressed patients can't develop serious ilnesses together with the depression? By the way, serious symptoms affect depression to the worse. Keep a very detailed record of the patients visits. Perhaps you are "locked" on something, but your colleague can see things differently.Consult with your colleagues about cases that are not getting better. Posted by yoram chaiter Yoram, I fully endorse your comments. Such an appropriate response you outline must surely help to prevent errors being made. |
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