As recompense for the daily slog that is residency, Signout is going away for a much-needed week or so at the beach. She promises that when she returns in mid-October, she will be tanned, rested, and ready to resume taking everybody's shit. Meanwhile, please enjoy some of her greatest hits [in her own mind].
Since it's October, and therefore time to start preparing in earnest for Christmas, today's selection is presented as a seasonal offering. If you are a wacky gentile and it happens to whip you up into a holiday frenzy, Signout cannot be held responsible for your resultant purchases.
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For several weeks in December, I worked with an adolescent medicine doctor who was like magic. Watching him massage our spectacularly manipulative patients into compliance was like watching someone fit a greased elephant into a cigar box. His motto was, as he told me repeatedly, "Every behavior that persists is being rewarded on some level."
We had a patient for a time, an 11-year old girl I'll call Precious. Precious had previously been diagnosed with lupus, a chronic and very real illness, but had been admitted this time for abdominal pain. Shortly after her admission (and her extensive workup), it became clear that her acute symptoms were what we politely call "inorganic"--meaning, they originated in her mind and not in a localized disease process.
Precious had been hospitalized many times before. She knew what worried doctors, and early on, she made damn sure we worried about her, often through disingenuous means along the lines of faking abnormal vital signs and abnormal urine output. Dr. Magic ignored these bids for attention and instead began to educate Precious about coping with her functional abdominal pain. At this point, she began refusing to eat, drink, or even sit up, saying these things caused her too much pain.
She was good. Even Dr. Magic felt challenged.
"She really, really wants to be in the hospital," her nurse said. Dr. Magic agreed. He thought that, while some of her pain might be real (as in a somatization disorder), some of it might also be made up (as in the very different factitious disorder)--and all of it originated in her head. There was a clear reward for acting sick: Christmastime in a children's hospital means loads of activities, attention, and toys. She'd only get these things if she remained admitted as an inpatient, and she'd remain admitted if she remained sick.
You don't have to be pubertal to understand the logic, and yet I still had no idea how to get her to act as well as she was.
What we needed to do, Dr. Magic said, was to realign the axis of behavior and reward around something we could actually give or take away. We then needed to use that thing to stop rewarding her bad behavior--acting sick--and start rewarding good behavior--coping with her pain, whether real or not.
From the day of her admission, Precious' room had been filled with the artwork she loved to create, along with piles of distractions provided by her doting family and by the hospital, itself. Now, Dr. Magic took me into her room, where we took down the drawings and hauled out sacks of games and toys. He explained to Precious how things would work: she could eat and walk and, little by little, earn her stuff back. Or she could lie in bed and be hungry and bored.
In other words, Christmastime in the hospital wouldn't be fun unless she demonstrated coping skills. And the second she demonstrated coping skills, she'd go home. It was an ingenious trap.
She knew it, too. I was on call that night, and late into the evening, I could hear her sitting in her bed and screaming in frustration. Dr. Magic popped in after an evening meeting. "This is a good sign," he said, then disappeared in a puff of smoke.
The next morning, I woke her while listening to her chest. "How are you feeling?" I asked. "It hurts to swallow," she said, "but it's something I think I can cope with. Can I go home?"
Yes, she could.
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And what if you were wrong? What are the consequences for that child?
None of the evidence you have presented even comes close to being a reliable proof of diagnosis, and the validity of the so called treatment. It is all layer upon layer of arbitrary, subjective definition based, circular attribution and inference, based on weak non-findings (ie absence of evidence). It tells us far more about your underlying prejudices than anything the child is suffering from.
The fact that the child might have, in some sense, submitted to your diagnosis and 'treatment', means nothing more than she was placed in a nasty double-bind (your "ingenious trap"), and had no choice but to put on an act of compliance and 'recovery'. It does not mean that your approach was legitimate or that it worked. (Unless by 'worked' you mean getting her to shut up and stop reminding you of your unethical incompetence.) As far as I can see, all you have done is humiliate, degrade, and further traumatise that kid. You most certainly did not solve her problems, whatever they might be.
Somatisation and fictitious disorders are essentially untestable diagnoses, virtually impossible to prove, and very difficult to directly disprove (falsisfy). Once a diagnosis is made, whether right or wrong, it usually sticks and seriously prejudices all future interactions between that patient and the medical system. Useless nonsense. An excuse for medicos to cover up the fact that they don't have a proper explanation, and don't want to admit it.
The sorts of arguments you used are the same kind that were historically used to dismiss and denigrate patients with Parkinson's, multiple sclerosis, hypothyroidism, etc., and most recently, gastric ulcers, and we all know how that one turned out, don't we? Your approach is just another form of the old hysterical conversion, personality disorder, and lack of moral fibre crap. Medicine has a long and disgraceful history of this sort of rubbish. Whenever it gets caught out on one disorder, it just moves on to the next unexplained disorder, with no apologies or sense of remorse.
Every behavior that persists is being rewarded on some level.
Dr Magic
Oh really? Classic psycho-drivel ideology, that can be spun to 'interpret' any situation in favour of the diagnostician/therapist's position, no matter how ridiculous. A fine example of the vacuity of "motto" driven medicine.
I think your and Dr Magic's behaviour was the real psycho-pathology here, and a pretty disgraceful one at that. It certainly was not compassionate, constructive, science-based medicine. Moralising, politically convenient, socially sanctioned bullying is a more apt description.
The pseudonyms you gave the child ('Precious'), and your wonder-hero mentor ('Dr Magic'), reveals much about your real underlying attitude.
You talk about behaviour that persists in patients. Might want to take a close look at your own behaviour, and that of the medical profession in persisting with this unethical illogic, and consider the real possibility that the patient's behaviour persists because you (and medical science) have so far failed to find the ongoing, underlying organic disorder. As previously noted, there is considerable precedent in medical history for this happening, and we are not so clever and knowledgeable (and ethical) that it could not happen again, and again, and again...
Did you follow up on long-term this patient, and confirm, with hard independent objective measures, that she has actually 'recovered'? That she has resumed a normal level of participation in education, social, and (if old enough) employment activity? Or have you just washed your hands of her? Does Dr Magic conduct rigourous, long-term, independently verified follow-ups on these patients after being subject to his 'treatment' regime? My bet is neither he nor you do.
And if she has not 'recovered', are you going to indulge in yet more disingenuous, responsibility avoiding, circular reasoning and blame her for that?
If, at some future point, after you have finished patting yourself on the back and congratulating yourself on how clever and insightful and tough you are, it turns out the kid actually has a serious organic problem, are you going to go back and apologise to her and her family for inflicting this sneering, incompetent humiliation on them? If my experience with other doctors and researchers is anything to go by, chances are overwhelming that it will never happen. No, your thoughts will almost certainly turn to how you can avoid malpractice suits, protect your reputation, and keep your job.
[Signout] promises that when she returns in mid-October, she will be tanned, rested, and ready to resume taking everybody's shit.
While vulnerable, innocent young patients continue having no choice about taking your shit full on. Narcissistic, self-important, arrogance.
Hope you had a nice holiday. I wonder if your erstwhile young patient did? And if she didn't would that be her fault as well?
I have no doubt that you think I have been rough and unfair on you, but I would respond that it was justified and that you got off lightly under the circumstances, and that the patient in your story was treated far worse. If I had my way people like you and your super-guru Dr Magic would be very publicly exposed and permanently struck off the register, and I know for a fact that am very far from alone in that view within medical science.
(And by the way, I do know the peer-reviewed database in this area of medicine very well, and it is sloppy, superficial stuff, dressed up in pseudo-scientific, pseudo-compassionate rhetoric.)
So Obdulantist, what conversion order were you diagnosed with that you're blaming on an undiagnosable "organic cause" after what was probably a ridiculously expensive negative work-up that makes you so bitter against medicine?
Wow, did commenter #1 and I even read the same post? Or re-read it in my case? I remember reading this post in the archives when I first found Signout's blog a while back. Since I read all of her posts - and I do mean all of them, love those archives! - I had a pretty good feel for the kind of 1st year resident she was. Yep, the kind I would want to take care of my kids. There is a difference between heartless cruelty (neither she nor Dr. Magic were being so) and management of manipulative patients (yep, this is what they were doing), and Signout gets that. I've observed my five-year-old niece behave in a similar fashion to the patient described . . . I think the docs here made a good catch.
As for the vacation to recharge, regroup, relax, what have you - an excellent idea for all people in stress-ridden professions. I am looking forward to my next one myself, so happy travels to ya' Signout. Cheers, ctenotrish.
Oh, Obdulantist. You so crazy.
Are you the old N=1? If not, I'll give you her phone number, and you can form a support group.
Yes, the repetitious negative accusations made by Obdulanist have a similar "aroma" to N=1's comments.
An experienced Dr. can often "magically" see through manipulative behaviour, with the end result of actually helping the patient recover faster, better, while channeling their energy in a more positive and constructive direction.
I think people differ greatly on this issue. For example, if it were completely unidentifiable as my own, I would have no problem with a picture of my naked ass being posted on the Internet. Others would be absolutely horrified by the prospect.
Signout reader named Benjamin Langer, who himself has a very nice critical piece on intelligent design in the current edition of SCQ.