18 September 2014

Doubt, but verify

(My entry to an essay contest.)

I struggled with knowing when I should believe my patients on the locked psychiatric ward. Some of my patients were reliably forthcoming and honest. Other patients’ stories were clearly unrealistic (one told me that he was being chased by black, chainsaw-wielding government robots that travel through walls). And others made prosaic claims (such as their name and age) that sounded credible, but proved untrue. After being misled several times by my patients, my attending physician advised me to become more of a skeptic. I began taking what my psychiatric patients said not just with a grain of salt, but with a heaping helping.

One day, I met a new patient, Jensen, who had been committed to the psychiatric ward that morning. He was a lanky, disheveled-looking methamphetamine addict who subsisted on begging and theft. He lived in a distant town. Fresh out of prison, he had decided to come to our hospital because he had recently contemplated suicide. A staff member who interviewed Jensen on intake suspected that he was malingering in an attempt to score a warm bed and a square meal.

When I interviewed Jensen, I asked why he had contemplated suicide. He replied that he had become depressed ever since his daughter had been raped and murdered by his best friend. I assumed a look of sympathetic concern and expressed my condolences. My empathy was forced, though. I doubted Jensen’s story. And I especially did not want to be fooled by yet another patient.

Over the course of the interview, I delicately obtained more details about the supposed crime: where it had occurred, who had been arrested, where the case had gone to trial. Afterwards, I hopped onto a computer and queried an internet database of news articles. Several articles came up that confirmed Jensen’s grisly story. I felt horrified 
and sickened. I also wondered whether anyone could experience what Jensen had gone through without being plunged into despair.

Discovering the veracity of Jensen’s story forced me treat his pain as real, and to engage with it. When I met with Jensen that afternoon, I felt more sympathy towards him. I told him that my heart went out to him for what he had suffered. Despite our different backgrounds, I felt as though I was beginning to understand him. We seemed to connect particuarly well.

The tragedy that had befallen Jensen gnawed at me that day. It marred my sleep that night. As I mulled over his story, Jensen struck me as someone who had endured a near-mythical degree of torment. Jensen’s life story seemed to be an allegory, one that embodied society’s ills and condemned the cruelty of man.

When I visited Jensen the next morning, he begged me to be released from the hospital. He told me that a friend had offered to drive him home, but only if he were discharged that morning. At rounds, my team decided that Jensen no longer appeared to pose an acute threat to himself. We acceded to his request and discharged him.

I was able to provide Jensen with more humanistic care because I verified his story online. Was looking online the right thing to do here? I am not completely sure, but I think it was. 
When I am curious about how a former patient is doing, or when I want to better understand a patient’s story, I sometimes feel tempted to search online. I nearly always resist the urge, though. “Googling” a current patient is an act fraught with ethical and practical concerns. Some information found online is inaccurate or misleading, and it could inappropriately bias a clinician. Some patients may feel it is improper for their doctors to be searching for them online.

I also worry about the potential to violate patient privacy. Companies routinely store and analyze data that include the search phrases a user types in and the exact location of their computer. If a clinician seated at a hospital computer performed a series of searches on a patient, private companies (and our government) could probably piece together confidential medical information such as where that patient received their medical care and what diagnoses they carried. (I tried to protect Jensen’s privacy by using vague search terms that could not be tracked back to him.)

In the acute psychiatric setting especially, though, online searches could have tremendous utility as a fact-finding tool. Already, psychiatrists routinely solicit “collateral information,” which might include hospital records, police reports, and conversations with family members. The collateral information can reveal whether a patient’s statements comport with reality, clarifying between diagnoses such as psychosis, antisocial personality, and malingering. Another benefit of an online search is that it can vindicate a patient such as Jensen who makes genuine statements that are not believed.

On the whole, I am leery of clinicians’ “Googling” their patients. But I think there are infrequent circumstances in which searching online is warranted, my encounter with Jensen among them. I am grateful for how confirming Jensen’s story helped me connect with him more deeply, and helped me lend a sympathetic ear.

Shortly after Jensen was discharged, I hopped into my car to run an errand. Pulling up to a red light near the hospital, I recognized the panhandler standing in the center median. It was Jensen. He saw me, and smiled and waved. I rolled down my window. I explained that I could not give him money, but told him where he might be able to get a free bus pass home. He thanked me. I wished him the best.

Jensen was standing in the median because he had invented the story about his friend with a car who would pick him up. He had correctly predicted that the ruse would speed up his discharge. And so, despite my efforts, yet another patient ended up fooling me. The difference was that now, I did not mind.

The light turned green. I drove off, never to see Jensen again.