AMA Journal of Ethics^®

Case

Dr. Liu is not surprised to see Sandy Brown's name on the patient chart outside the examining room as he approaches. He hasn't seen Sandy in nearly a month. That's a record, or close to it. Sandy, now 12 years old, has visited Dr. Liu's office frequently over the past year and half. On most occasions, Sandy's mother, Martha, has a pretty good idea of what's wrong with Sandy and what Dr. Liu should do to "fix it." She calls whenever Sandy complains of not feeling well. In the past year, Sandy's symptoms have ranged from earache, cough, and flu-like aches and pains to headaches that Martha has diagnosed as "sinus" headaches. She tells Dr. Liu what antibiotics and other prescriptions Sandy should have. When she isn't sure exactly what Sandy is suffering from, Martha is terribly fearful that there is something seriously wrong with her daughter and tells Dr. Liu what tests he should run to find the problem.

Not long ago, Martha brought Sandy in saying that she had trouble breathing and had had coughing attacks every once in a while over a period of two weeks. She also mentioned that Sandy made "wheezing" noises when she tried to breathe during these coughing attacks. She told Dr. Liu that she thought Sandy might have asthma like her brother, Jack, who is 16 years old. Sandy's symptoms are very similar to Jack's. Martha asked Dr. Liu to prescribe Advair^®. Jack was taking Advair^® and it seemed to be working well for him, so she thought it would work just as well for Sandy. In fact, Martha said, she had seen it advertised frequently on television. It seemed to be a miracle drug for lots of people who had asthma. Dr. Liu examined Sandy and concluded that she had a mild upper respiratory viral infection. He prescribed rest and plenty of fluids and Tylenol if she should run fever. To be on the cautious side, Dr. Liu scheduled pulmonary function tests with bronchial provocation to assess for possible reversible airway obstruction. The results were negative.

The last time they were in, close to a month ago, Sandy (as reported by her mother) was complaining about having frequent stomach pains. "She rattles on about how her stomach hurts. Before it was once or twice a week, now it's very frequent…about 3-4 times a week. It must be something serious. Sandy's not a complainer, and Pepto-Bismol sure isn't working. Doctor, don't you think you should do an upper GI series to figure out what's wrong with her stomach," Martha pleaded. This time, Dr. Liu wanted to examine Sandy alone. He asked Martha to step outside into the waiting room. Martha initially objected, but Dr. Liu simply stressed that he needed to see Sandy by herself; it was an appropriate standard of care for a child her age. Martha eventually heeded.

When he examined Sandy, asking her where it hurt, how it hurt, how long it hurt, and so on, she didn't seem overly concerned about her symptoms. She responded to his questions, simply stating that her pain moved "all around her stomach." She couldn't really describe what type of pain she was having, just that it lasted a few seconds. The pain was not associated with food or activity. Sandy had no history of upper GI symptoms such as nausea or vomiting or lower GI symptoms such as diarrhea. The physical exam was essentially unremarkable, and Dr. Liu told Martha that if Sandy's pain persisted or got more severe, she should return to see him.

Dr. Liu believes that Sandy is a rather healthy and active child, though her mother believes the opposite. She often tells him, "I love my daughter with all my heart, Dr. Liu. A mother knows when there's something wrong with her daughter. I know there's something wrong with Sandy. You must help us." No matter what he does to reassure both Martha and Sandy (though Sandy doesn't seem to need the reassurance), they appear with more symptoms. He wonders what symptoms Sandy will have and what more Martha will demand of him. Most of all, he wonders how he will manage to restrain from shouting out that Sandy's most serious problem is her mother.

Commentary 2

It seems that Dr. Liu thinks that Martha is the problem and not her daughter, Sandy. However, Martha is requesting help for her daughter and not for herself. The challenge for the physician is how best to help Martha without condemning her and thus rejecting her.

I believe that Martha's fears and concerns are genuine but that the object of her concerns is misplaced. Accepting the legitimacy of her fears and concerns is an essential step for the physician to obtain Martha's trust and confidence. With this in mind, Dr. Liu should talk with Martha alone and find out more about what she, Martha, thinks about Sandy and what is going on in her (Sandy's) life. How is Sandy doing at school? What kinds of social activities is she engaged in? Has she started to menstruate? What does Martha expect of Sandy? What does she most fear might happen to her daughter? The answers to these and related questions might help shift Martha's preoccupation with Sandy's body to the larger picture of her overall growth and development and where she (Martha) fits into that picture.

Martha certainly needs help but shouting at her that she is the problem will help neither her nor her daughter. When you are feeling morally judgmental or beginning to feel angry towards a patient or family member, it's a good time to step back a bit and review your assessment. On reflection, there may be another approach that makes more sense to you and is more helpful to your patient. Consultation with a trusted colleague is often most helpful in such cases.