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 1

Sandy Brown's case is not atypical for a young adolescent with multiple somatic complaints. Dr. Liu became frustrated with his inability to make a diagnosis, reduce the symptom complex, and meet the stated needs of the mother. At this time, he should have taken a step back and reassessed the course of Sandy's medical history. If he had done this, he probably would have realized that he most likely was looking at the wrong patient.

One of the major diagnostic and management challenges of adolescent medicine is to distinguish relative organicity from psychogenicity. This mind-body connection exists with patients of all ages but is prominent during adolescence due to rapid physical and psychological changes and emerging issues surrounding emotional independence from parents. Adolescents often have somatic complaints such as headaches, fatigue, and abdominal pain. Although major organic disease certainly occurs, it is rarely associated with only single symptoms and lack progression of symptoms.

In this particular case, Dr. Liu should have become suspicious during the past year that Sandy had a psychogenic cause of her symptoms. There were several tip-offs to this: the vague and changing nature of the supposedly organic problems, the lack of progression of any obvious disease state and, importantly, Sandy's lack of concern. The mother, and Dr. Liu, wanted Sandy to have a disease that could be fixed.

As physicians rely on standard markers of pediatric development, so should they for adolescent development as well. These markers include progression of pubertal development, academic performance, friendship development, and family relationships. Dr. Liu could relatively easily obtain information that signaled problems with Sandy's physical and psychological development. For example, are her school grades dropping? Is she missing social functions due to the physical symptoms or to lack of energy? Is she arrested in the development of her secondary sexual characteristics? Is she losing weight? Are there increasing conflicts with her parents? School grades, like a reduction of platelets in early disease, are usually the first sign of either emotional or physical distress. One of the most important assessments that physicians can do is to compare a teen's last semester grade point average with what he or she is making now. Any two-letter grade drop in average should cause concern.

Another area that Dr. Liu failed to assess is the family context surrounding Sandy. Has the family relocated recently? Has there been a recent death in the family of a close relative? Has a parent lost his or her job? Are there marital problems? Do the parents or other siblings have health problems? Are there drinking problems? In this case, Dr. Liu should be highly suspicious that Sandy is the "identified patient" within a family that is in turmoil. Why is the mother so concerned? What "bad" disease does she worry that Sandy might have? Does Sandy represent a power struggle between parents within a deteriorating marriage? In addition to talking with Sandy alone, Dr. Liu should talk with the mother alone.

Lastly, Dr. Liu made one other major mistake—he failed over the past year to establish a trusting relationship with Sandy. Adolescents should be seen alone at each visit and parents should be counseled that what transpires during the exchange of information remains confidential, unless the patient is of danger to her/himself or to others. There is good evidence that adolescents are less likely to disclose sensitive information unless they are assured the confidentiality nature of the visit. In the present case, sensitive issues such as sexual abuse, domestic violence, and marital discord need to be assessed. Disclosure of this information is enhanced if Sandy knows that Dr. Liu is her's, and not her mother's doctor, if she is approached in an authoritative rather than authoritarian manner, and if she trusts that what she shares with Dr. Liu will remain confidential.

In summary, over the past year, Dr. Liu has permitted Sandy's mother to control the diagnostic and management strategies employed. He failed to recognize that although adolescents often have somatic complaints, they are not fond of taking time away from school or social groups to have a medical visit. Something else is going on that Dr. Liu needs to evaluate. It is not surprising that he felt frustrated upon seeing Sandy's name on the patient chart outside of his examining room. This emotion should alert him to the fact that he has yet to establish the underlying cause of the numerous visits and changing symptom complex.