“The theatre, when all is said and done, is not life in miniature, but life enormously magnified, life hideously exaggerated.”
After knocking on the door and entering his room with my team accompanying me, I saw him sitting comfortably in bed over the sheets and covers flanked by his parents. His hospital gown was on, a rather obedient move for a 14-year-old adolescent. He was neither skinny nor fat– rather, he was in the midst of the mid-adolescent, unpleasantly swollen stage, when fat deposits in the breasts, hips and thighs making certain boys more gynoid in habitus. His face was triangular, boyish, with wisps of thin facial hair on his chin, upper lip, and sideburns that were still tentative, only vaguely implying a future need to shave. He had a basin in front of him on the retractable table above his bed and spat in there every minute or two.
“Chief complaint–inability to swallow/intractable vomiting” it said on the census sheet.
As I proceeded with my interview, his disinterested replies to my open, deliberately non-binary questions didn’t exceed one word grunts. Digging further for somatic clues as to what was bothering him was to no avail. Shifting focus to the psychosocial aspects of the history, he continued to nonchalantly and curtly answer all my questions in the negative– no to bullying, no to sex, drugs, alcohol, cigarettes, no to issues with sexual identity, no to any form of abuse, no to increased stress at home or at school.
His physical exam did not help either since it was completely normal. When I examined his abdomen, though, his eyes followed my hands carefully and he moaned ever so slightly, as if on cue.
I attempted to involve Mom and Dad in this crucial information gathering process, but due to their poor English it became immediately clear they were immigrants. They looked to their son for help describing what they thought he was experiencing. He refused to help his parents, and his disdain for their inability to communicate was obvious. I asked if they would like me to get the translator phone–dismissively they replied “We understand, we understand!” Despite my better judgement, I continued without the phone.
I noticed throughout this initial encounter the odd looks Mom and Dad had on their faces, looks that were disturbing in their affectation and the rapidity with which they changed. Depending on whom they addressed in the conversation, their visages switched between the Thalia/happy and Melpomene/sad masks of the theater, smiles of earnestness and obsequiousness when addressing me, and pouts of utter despair when addressing their son.
During the interview, when I mentioned the word “school”, his parents in unison looked at me with the happy theatre mask face and said “Good in school, good in school. ‘A’ student!”, to which my patient gazed at his parents with barely suppressed disgust. It wasn’t clear to me whether my patient thought his parents were feigning their linguistic shortcomings, whether he was bothered by the sycophancy his parents were displaying, or that he was just a regular, surly teen embarrassed by their parents no matter how they behaved. I felt sorry for Mom and Dad, but didn’t understand why their behavior was so melodramatic.
While I was reassured by the lack of any findings arguing anything life or limb threatening, I was quite disturbed by la belle indifference displayed by my patient. At this point certain tests were needed to definitively rule out any somatic illness, but I felt in my gut that this patient was suffering from a conversion disorder, the underlying psychopathology of which I had only scratched the surface. With this came some anticipatory tension on my part—a difficult conversation was in the offing.
After finishing the physical exam, the time came to communicate to the patient and parents my thoughts. My tension was peaking now. To allow me a moment to adjust and further formulate my rhetorical approach, I asked my team to offer their thoughts as to the patient’s diagnosis.
“Zollinger-Ellison Syndrome?” said one intern.
“Hiatal hernia?” said another.
“Mallory-Weiss tear?” chimed a medical student.
I solicited a few more possibilities from my team and pondered out loud their relative merits while adding psychogenic vomiting, cyclic vomiting, and some form of eating disorder as other remote possibilities. For teaching purposes I hid my baseline skepticism that this was an organic problem at all.
Then the senior resident asked me, “So what do you think?”
I answered, scanning the eyes of my team, then turning to the patient and his parents as I enunciated the words–“globus hystericus”.
The patient did not stop rolling the contents of his spittoon around as I communicated this diagnosis—his parents, on the other hand, listened intently to every syllable I uttered. I explained the reasoning as to why I thought what their son was experiencing was not due to anything physical, but simultaneously admitted I could not be sure without certain tests being done. Instantaneously after mentioning the word “test”, Mom’s eyes widened and her brows lifted—she hurriedly found her purse and produced a manila folder which she gave to me.
Inside the folder were the results of blood tests, imaging, and of an endoscopic examination, the bulk of which I was contemplating having done as part of the work up immediately following our conversation—every solitary result was normal. The doctor who previously saw my patient not two weeks before being admitted to the hospital had done everything needed to rule out any somatic problem. It was now my job to address the problem that did exist.
I explained to my patient and his parents that with this information in hand I was now quite certain that what he was experiencing was psychosomatic. I continued and related that I would not repeat any of the exams already done and that I expected him to eat and drink normally, in addition to tolerating his own saliva, all of which he had not done in the last two weeks. Lastly, I was going to bring in a psychiatrist to help expedite a transfer to an eating disorders unit.
Mom and Dad looked relieved—my patient stared at me unflinchingly and spat into his basin.
The next morning, Mom and Dad asked me if I could speak with a family member about their son’s case, and I agreed wholeheartedly. I was paged by a nurse a couple of hours later to speak with this family member who was demanding my immediate presence. I was nettled at being summoned in such a way, but complied. As I approached my patient’s room this time, I was assaulted by the smell of cigarette smoke, the intensity of which increased logarithmically with each step forward. Upon reaching the patient’s bedside, I introduced myself to the source of this smell, the great-aunt of the patient, while stifling a most intense gag reflex. She was in her mid-sixties, about 5-foot-six-inches tall, thin and wiry, with masculine clothing hanging loosely over bony protuberances, sporting a boyish haircut, and bellowing a fetid stench consisting of coffee, cigarettes, and halitosis that challenged my ability to remain conscious while in her presence. She shook my hand strongly with her large, bony hand, and proceeded to make it eminently clear that she ran the show in this family and that she was confused and unhappy with how things had proceeded until now. I spent the next twenty minutes recapitulating the case while navigating random jabs and editorial comments that obliquely pertained to my patient’s predicament. On a dime, her attitude changed to one of cheery thankfulness and proceeded to take on the role of facilitator and translator for my patient’s parents, for which they were appreciative. We all (re)agreed on the plan for a transfer to an eating disorders unit, and I explained that I would try to speed up the psychiatrist’s arrival to push this along.
At this point, I saw a pattern forming—the overdone, exaggerated, and rapidly changing behavior was a form of manipulation this family seemed to have developed to a fine art, and I was going to have to navigate this as best I could in order to optimally benefit my patient. I mentally prepared for anything.
The next day, late in the morning, the psychiatrist arrived, sauntering in with his $500 attaché case in tow. He was youngish, athletically built, impeccably dressed and coiffed, with one eye permanently inwardly deviated enough to be unnerving. As I explained the case to him, his responses were uniformly monotone, bereft of even a smile, despite my attempts to inject levity into the conversation. After I finished explaining the case and my need for his input, he agreed with the diagnosis without qualification and agreed to concur in writing to this effect.
I continued with my task list for the day and circled back to my patient’s chart in the late afternoon. The psychiatrist’s conclusions read: 1) Adjustment Disorder NOS, 2) Continue medical workup, 3) Reconsult as needed—in English, there is nothing wrong with this patient.
I called the psychiatrist up and made sure by my choice of words and tone of voice that I was in no mood for dilly dallying. He showed up several minutes later, and I sat him down.
“What part of our discussion earlier today was unclear?” I queried.
“I don’t understand your question,” he said.
“Were we not in agreement that the patient is suffering from globus hystericus, or at the very least, some form of psychogenic vomiting, eating disorder, or other somatoform disorder?”
“Do you agree with this diagnosis?”
“Do you agree with the need for a transfer to an eating disorders unit?”
“Then why didn’t you write this in your consult?”
“Oooohh…. well…. I didn’t want things to get complicated medicolegally in terms of the papers needed for the transfer, so I thought it would be better to keep things out of the psychiatric realm.” I bit my tongue and did not respond immediately to this gibberish—a few hours earlier we had just agreed that this case was most definitely within the psychiatric realm!
“Well, if you agree with me diagnostically, I will need you to say so on paper as well so we can move forward with this transfer. At this point this will be a voluntary admission, but I envision the possibility of this becoming an involuntary one. In that case, you and I must be on the same page as the two physicians recommending the transfer. Are you OK with this?”
“Great. Thank you.”
I never understood why the psychiatrist didn’t help move this case forward the first time he was consulted and I made sure before leaving for the day that he followed through—he did.
Once we got word that there was a bed available at the eating disorders unit, the next step was to get the parents to fill out the paperwork to effectuate the transfer. I gathered the parents and the great-aunt along with the psychiatrist, our head nurse, the intern and resident taking care of the patient, and we went to our conference room.
There I recapitulated the results of the medical work up and the evidence arguing for a psychiatric diagnosis being the explanation for my patient’s inability/unwillingness to swallow (he still refused to eat, drink, or swallow his own saliva, and had lost 6 pounds since admission to the hospital). Regardless of whether the precise diagnosis was globus hystericus, an eating disorder, or some form of somatoform disorder, I argued the utility of the transfer to the eating disorders unit. Mom asked about the nature of the treatment that their son would receive in this venue, which I addressed in detail, with the great-aunt translating everything (while I held my breath). The parents consented to the transfer and signed the papers. I let the social worker know the papers had been signed, and she informed me a little later that the transfer would happen the next day in the late morning.
Later that afternoon, I received a frantic phone call from my patient’s nurse—the family was refusing the transfer! When I arrived to the floor the great-aunt was accusing the psychiatrist and me of forcing the parents to sign the consent for transfer. Before I had arrived on the floor, she had bellowed to the nurses that she was going to sue us for keeping the patient in the hospital to run up his bill, given his good insurance status.
Back to the conference room we went, Mom and Dad, great-aunt, and me, with the consent forms that they had signed only a few hours ago. I started by saying that I was unclear as to why there was an issue with the consent, and followed by asking them if there was anything they wanted to ask or anything that I could clarify. The great-aunt grabbed the papers from the table, read them for fifteen seconds, scribbled a few indecipherable words on the forms, showed them to the parents who nodded, and all three signed the forms again. Satisfied, the great-aunt stood up and adjourned the meeting and walked out with the parents.
Thespianism, I now realized, ran deep in this family, and I was just privy to a grand performance. However, at this point, as long as the consents were valid, I would put up with any amount of grandstanding on the great-aunt’s part. It was academic to me who the family thought was running the show—I resented being manipulated, but I needed my patient to get the care he needed.
The next morning, the time arrived for the patient to be transferred. The EMS personnel rolled the gurney onto the floor, and as I accompanied them to my patient we kibitzed about the traffic. As we entered the patient’s room, his parents and great-aunt were there. The parents had their Melpomene/sad mask face on, the great-aunt, playing her part, was stoic and strong. The patient had an untouched breakfast tray on his table next to his spittoon, and was initially oblivious to what was transpiring in front of him.
Several seconds later, my patient’s brow furrowed—he made the connection between the just-arrived gurney and the techs unbuckling the belts in preparation to have him climb on. Immediately, without hesitation, he proceeded to eat his breakfast–eggs, toast, hash browns, sausage–quickly, washing it down with the orange juice and milk on the tray. No theatrics– no gagging, no vomiting, no spitting.
I looked over to the EMT’s and said, “We won’t be needing this transfer after all, but thank you for battling the traffic anyway.” I turned to Mom and Dad and said, “I will set up a follow-up with our psychiatrists on an outpatient basis for your son–you can go home now.”
About half-an-hour later I was sitting at the nursing station writing my notes for the day. I noticed out of the corner of my eye the patient, his parents, and his great-aunt walking together off the unit. The patient had his head down, refusing to make eye contact with anyone. His parents flanked him, their hands on his shoulders. With their Thalia/happy face on, they smiled at me. I smiled back politely. The great-aunt was behind them with a hand on each parent’s outer shoulder, looking down as she walked with them. I went back to my work and looked down. Once they passed the nursing station, I heard “Psssttt”. I looked up instinctually, and there was the great-aunt, head turned around, with a big nicotine-stained, partially toothless grin, winking at me and whispering “Thank you!”
I couldn’t help but think that those thanks were not for my services as a physician, but rather for my function as a supporting actor in the drama that was this family.
Richard Sidlow, MD, is a practicing pediatric hospitalist and seasoned medical volunteer whose essays have been previously published in Intima: The Journal of Medical Narrative, Blood and Thunder Journal, and Narrateur.