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Psychotherapy Casebook

The Problem of the Doctor as Patient

The Problem of the Doctor as Patient

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EDITOR’ S NOTE

Through this column, we hope that practitioners in general medical settings will gain a more complete knowledge of the many patients who are likely to benefit from brief psychotherapeutic interventions. A close working relationship between primary care and psychiatry can serve to enhance patient outcome.

Dr Schuyler is a psychiatrist and a member of the palliative care team at the Ralph H. Johnson Veterans Administration Medical Center, Charleston, South Carolina.

Prim Care Companion CNS Disord 2015;17(6):doi:10.4088/PCC.15f01911

Published online: December 31, 2015.

Corresponding author: Dean Schuyler, MD, Geriatrics/Extended Care, Ralph H. Johnson Veterans Administration Medical Center, Charleston, SC 29401 (deans915@comcast.net).

Funding/support: None reported.

Potential conflicts of interest: None reported.

I love my job. I was hired 6 years ago to join a palliative care team at the Charleston Veterans Affairs Hospital in Charleston, South Carolina. I have worked with many patients as they prepare for the "end of life." I focus on their thinking. I apply the cognitive therapy model taught to me at the University of Pennsylvania many years ago by Aaron Beck, MD. Most of the veterans on this 20-bed nursing home unit have loads of free time. Many are unable to ambulate, so they do not leave their rooms. For many of my patients, this lack of mobility provides time alone with their thoughts.

My job combines one part cognitive therapy and one part relationship. I am really very good at it. Most of the patients have a major medical illness. We talk about the strategy of constantly reminding oneself of one’s disease, which appears to be unhelpful and only to produce anxiety. Many patients have been able to sustain a focus for their thoughts. Once they have been on the unit for a while, their nutrition improves. Smoking cigarettes is deliberately made difficult. Some patients, unexpectedly, have actually become candidates for discharge from this end-of-life unit. The roles of health care provider and patient have always seemed clearly delineated. That is, until I met Mr A.

CASE PRESENTATION

Mr A is a 72-year-old white male psychiatrist who has never been hospitalized and never had surgery. So, he has never been confined to bed for a significant period of time. In June 2015, he had a prostate biopsy that revealed adenocarcinoma. He had what I will call a "stage 1" decision to make: What would he do? He explored the options and decided on surgery at the local medical center. Mr A’s surgery, a radical prostatectomy, was scheduled for August 2015. He and his wife had planned a 2-week vacation beginning at September’s end. He thought that this would leave enough time for him to recover and then for them to go on their trip. But things do not always work as planned.

Complications in recovery led to a Foley catheter being placed, removed 8 days later, and then put back 3 days after it was removed. He has made progress, but this recovery stage has dragged on for a month so far. Mr A spoke extensively to his surgeon and spent a significant amount of time reaching the decision with regard to scheduling the surgery, but no one has spoken to him about recovery. He requested more sick leave time from his job. He has called his outpatients and scheduled their appointments for later in the month. He has been presented with an inordinate amount of time to fill on his own. In addition, there is little that he has found that he can do for himself, so he is dependent on his wife, who has been his caretaker. Although Mr A is used to being active and providing for himself, he has found his usual lifestyle difficult to follow. It is not a good idea to think about the problem and its treatment—he would never suggest that to his patients. And, yet, that is where he finds himself at this point.

PSYCHOTHERAPY

Therapists are cautioned not to treat members of their families. Children of therapists have been noted to be neglected or given inadequate care. I am reminded of the cobbler’s son with a hole in his shoe. How could his father let that happen?

So, I know what Mr A needs to do, but he is finding it quite difficult to adopt the role of patient when he is used to the role of "doctor." He often has thoughts about his condition and sometimes calls his surgeon for his perspective. He has had a hard time creating an alternate focus to direct his thoughts. To him, this recovery stage has seemed interminable, and he had no preparation for it.

I have asked multiple health care personnel about this problem regarding how to spend large periods of unstructured time. Each of them has shaken his or her head and acknowledged that they too have questions, but no answers. I have not received useful advice, merely "time may take care of it." Some have said that it will shrink down to a brief period of time once it is over. Interestingly, this has not helped Mr A. I have been told that "He will be more sensitive to his patients once this is over." This has not helped much either. Some people who work in health care who underwent surgical procedures have noted that it "took a year before they recovered."

Mr A and his wife cancelled their vacation plans. He could not sit for a lengthy airplane ride and could not deal with a vacation filled with movement and sightseeing. He remains committed to his model of therapy to help others deal with their situations. He remains much better at focusing on a patient and a problem, but no better at helping himself.

Any suggestions?

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