Balint

International Balint Award 2006

Copyright Adrian Lală. Not to be copied, modified or redistributed without prior consent of author and citation.

 

Being a first year medical student doesn’t give you a large opportunity to interact with patients. Having that in mind and trying to find a way to correct it I’ve enrolled in the Emergency and Resuscitation Medical Ambulance system as a volunteer in hope that this will help me make a good idea of what medical practice is all about and also to help me create a vision of what my future patients could be going through before arriving at the hospital.
After receiving the Basic Life Support diploma I had the chance to work with some very good doctors and take part in the solving of medical cases of all sort, many of them being experiences from which I’ve learned things that will probably guide me through my future career in taking of people’s physical and psychical health.

During a night route, at 1:20 AM we received the chart of a 17 year old boy suspected of a drug overdose. I’ve been to overdose cases before but the doctor I was working with that night went over the things we should be doing upon arrival at the patient’s house. The age of the patient and the fact that his father was the one who called the ambulance was at first thought of as a strange thing, most of our overdose patient being over 20 and in a distinctly bad social situation.

Arriving at the house – a 2 room flat at the 2nd floor of a fairly good neighborhood we were greeted by the patient’s extremely frightened mother that quickly guided us to one of the rooms where the 17 year old was sitting on a chair facing the wall in front of him, glaring at it with an absent, almost ghostly look. I have to say that I was more impressed by this child’s look than I was of patients in much more horrible situations, thinking about it later I arrived at the conclusion that it was because of his age and the fact that, as I was to find out, he was very scared and without hope. It was my first-encounter with a seemingly conscious patient that was not responding to any questions or other means of interaction.

In the same room were the patient’s father – age 52, his mother – age 46 and for a short while his 19 year old sister. The doctor told me to give the patient a regular checkup, consisting of blood pressure, blood sugar level and body exam for needle marks, bruises, eye responses, etc. During this time she was talking to the father. All the exams came out very good, a sign that the boy was in good physical health, we even encouraged the family that he had a good muscle tone and he is a very healthy child from this point of view. What seemed strange at that moment was the father’s reaction which became very anxious and starting arguing with the doctor telling her that he knows better because he is a police officer and had a very good experience with drug consumers and addicts. When asked what gave him the suspicion that his son was one of these people he told us of a strange paint-thinner smell that he felt in the last 3 months, at this moment was the child’s first response, looking up to his father in a very hate-filled way. It was becoming more and more obvious to the doctor and I that we weren’t dealing with the usual medical case of drug abuse but with a complicated family situation that was hardly in our grasp.

A very strange but revealing moment was the next one when I asked the mother to give me her son’s identity card so I could fill in some information on the chart; she asked the son where he kept it but got no answer in return so she went in his room to look for it. After about 30 seconds the father reached for the phone and called the police precinct he was working at. The mother came in with the card and asked him what he was doing and he answered aggressively “I was calling the police station to see why he’s identity card id missing, in what kind of trouble he is in.” It was then known to us that the family was in a crisis and was searching for help in every corner they could find, either by calling the ambulance at 2AM for a fake reason and by calling the police for no reason at all. It was a very confusing moment because I didn’t know where my attention should be projected, on the father or on the son, because both attitudes seemed abnormal to me. I even thought that we should abandon the case because of the horrible chart mismatch, I felt an urgent need to get out of that atmosphere, I was a little bit frightened by the situation but on the other hand I thought I was very lucky to have an experienced doctor beside me.

After that the father went on to tell us stories about his youth and how he would obey his parents and not cause them any trouble, how he became a police officer just like his father and made him proud and how even now, at that age he had a better relationship with his father then he has with his son. The problem started to seam to me like any other generation conflict between father and son, only I had never seen one that has degenerated so bad that the son would be in the state that we found him in. We asked him if he ever tried to communicate with his son and ask him about his problems in order to understand his points of view but, again, we were struck by refusal and even ignorance on his behalf.

Using the excuse that we had to start writing a chart the doctor, which happened to also be a licensed psychologist, pulled me away and told me that we were probably dealing with an induced schizophrenia of the child and that she also spotted some problems on the father’s side. When I asked her if it was of our duty to help these people she told me something which I hope to never forget: “medicine is never a matter of duty, but of competence and good will”, furthermore she told me that there was something “very strange about the boy” and that I should go with him alone in the other room and try to find out what the actual problems are, if I could, she suspected that because of my close age he would open up to me. During this time the patient’s mother was growing more and more anxious and was looking at the father and asking him whether their boy was ok, whether he was going to be fine, and if it was an overdose or not. Hearing this, the doctor reassured them that it wasn’t even the case of an overdose, but this statement didn’t really seem to help them much since the father had already confirmed her fears before we could say anything about it.

Finding myself alone with the patient in the other room I noticed that he finally started to have some normal behavior such as looking around, blinking, he even looked straight at me. Meeting his sight I took the chance to connect with him and asked him questions that looked more like questions a friend would ask, rather than a doctor. I asked him why he thought his parents suspected him of drug consumption and I was very surprised by the fact that the young man that 5 minutes earlier was just sitting in a chair looking point-blank at the wall in front of him, not even blinking was talking to me as any normal person would. He told me that “this” was going on for over 6 months, that his father was constantly “harassing” him and that he just wouldn’t accept any arguments that he brought in his defense, therefore he had chosen to completely ignore him and everybody else in his family. I asked him about his relationship with his sister and he told me that because of the fact that his father was forcing her to spy on him he had to “give her up to”, adding that she has “her own problems to take care of” since she was in her graduate year and had to prepare for her exams. He also told me that the only person that he is sorry for is his mother but that he couldn’t get close to her either because she was under the father’s strict authority. It was very hard for me to ask him whether he was actually taking drugs or not, but when I did I got an answer which I probably should have expected: receiving my question with a smile he told me that “it would have probably been better” if he did, but he doesn’t. I asked him what did he mean by that and he told me that he could never take drugs, especially paint thinner – what he was accused of, because he knows “what those things can do to you”, and that in a burst of laughter he said that even if he wanted to he didn’t have the money to do it anyway. I then asked him if he had any explanation for the smell that seamed to be the root of all these problems and he told me that he had started smoking almost a year before and had arguments about that, afterwards his father had started accusing him of more serious things that he “honestly did not do”. He even started to confess that he ran away from home for 2 days a couple of months before because of the strict severity that he “was forced to endure” there. When I asked him about his school results he looked satisfied and said that was not one of his problems, that he is trying to keep up under the circumstances and that he can’t wait to finish high school and gain his independence. Realizing that I had made some progress in communicating with him I tried to be sensitive to all his needs in order to maintain his morale, but it was hard for me at this point to help suggest any decision or strong advice because the situation was very delicate and complicated. It seemed rather weird to me that he would open up so quickly and sincerely, I had no explanation for that but I was glad it was happening because comparing his situation when we entered the house with the one he was experiencing then there was an obvious evolution for the better.

At that point I was very confused; I couldn’t understand how a person could go so quickly from a state in which we suspected him of schizophrenia to one that was fairly normal for a child of his age. I asked him if he ever tried to cooperate with his father in finding a solution to their arguments but he replied that it doesn’t matter, that he plans to leave this home for good the moment he turns 18; also after telling me this he smiled and said that he couldn’t wait for that moment to come. My confusion got even more intense when I realized that I was about to fall into the trap of considering that there was nothing wrong with the person in front of me, and that I was beginning to forget my role there

During the conversation I often thought that I was very lucky not to have the problems I was being told, which made me even more reluctant to try to give him any advice because I was considering myself not to be the right person to do so. Although being consumed by them, it wasn’t very hard to hide those feelings from the patient.

Returning to the first room to talk to the doctor I found that she was expecting me and looked like she had something important to say to me. She told me that she had talked to the father and that the biggest problem was there, not with the son, responded by telling her what I had found out in the other room. It seams that the father and son hadn’t spoken a word to one another in 6 months and that the situation was critical. The doctor explained to the father that there was no problem with his son, that she was almost sure that he didn’t even consume drugs, let alone be addicted or suffer an overdose, at which point the father hit the ground with his foot saying “no, I know better, he is an addict and I want you to help me put him into a rehabilitation center”. Knowing that I had an experience with patients that had undergone drug rehab and hoping that there was a small chance that the father would respond to that, the doctor asked me to explain to him what treatment in that sort of place implies, as she went to give the child a final exam.

I began by assuring the father that I had a good experience in working with addicts and rehab centers because I was part of an association that activated in the field of post-addiction maintenance of ex drug consumers but I didn’t want to confront him directly with my conclusion that his son was not one of those cases, and so I started to tell him stories that I thought will get his attention and maybe change his perception. I could not get a single doubt into him that he was wrong, after about 30 minutes of explaining what rehabilitation is all about, all I got from him in response was a “well, that was a nice story, kid, but you don’t know anything about my problems, that one (referring to his son) needs help and I’m going to make sure he gets it”. Hearing this I was disappointed and I’m ashamed to say that for a moment I felt like I wanted him to feel for himself what his son was going through. It was the first moment that night that I was scared, I don’t know if it was because I didn’t know what to do anymore or because I was imagining what the 17 year old in the other room was about to undergo after we were to leave their house.

It was exactly that fear that made me think even harder about the possibilities I could find to help this man, with which there was clearly something wrong, to make him understand the fact that he was mistaking to have such radical attitudes towards his son. I then did something that goes beyond the competences and the attributes of an emergency service volunteer – I asked the father to come with me in one of those rehab centers he was talking about and see what kind of patients he could find there. At first he was reluctant to do so, but I strongly suggested that from my objective point of view he was doing nothing right in his attempt to help his son. At that point he seemed to have the first doubt that he could be wrong in addressing the problems and I was very happy to find out that he had accepted my invitation. When the doctor came out of the child’s room he looked at me and confirmed my feelings that our patient was actually healthy in every way, that the only thing wrong with him is a slight bad attitude and nothing more. She pulled me away for a couple of seconds and said to me “he is as normal as a child can be when the father is not in the room”. I told the doctor about my intent to take the parents to see a rehab center and she looked angry at me and told me that I wasn’t allowed to do so, but then she gave it another thought and said “but then again it might help them realize some things”.

The doctor then said out loud that he has proposed to their son to see a psychologist but he refused by telling her that there was nothing wrong with him and that he didn’t need to talk to one. The parents looked surprised to one another, probably disturbed by the fact that their son was speaking about his problems with a stranger and refused to talk to them at all. The doctor then continued to address the father saying that she hopes he learned something from what I’ve told him and that she thinks the visit that was going to happen the next day will help him understand both his son’s problem – that of having a father that is wrongfully accusing you of taking drugs, but also the fact that he should think twice before making some decisions. The doctor made it indirectly clear that she thought that the primary guilt for the situation is the father’s. After that talk I was told that the patient requested me to talk to him again and I went back to his room while the doctor had a conversation with the both parents together. Later I found out that in that conversation the parents refused the doctor’s suggestion to undergo some family therapy with a professional doctor by the excuse that they feel this sort of thing are better of being sorted out in the family.

As I entered he said “hello” and apologized for the problems he had caused me and the doctor, he made it specifically clear that he is not apologizing for the ones he is causing his parents. I told him it was ok and a talk concerning seeing a psychologist started. He told me that he didn’t want to see one because he didn’t think he had any problems, an even if he did he couldn’t trust a psychologist to give him advice or answers concerning them. I explained that he didn’t even need to have “problems” to see such a person, and that it will do him good to talk about what he was experiencing even if he didn’t consider those things to be his problem. I suggested the school psychologist if they had one and also wrote him the name and telephone number of one that I knew had experience with this sort of cases. After that I went on to open a short discussion about colleges thinking that it might do him well to have some plans for the future to look forward to, he seemed disappointed about that perspective but then again he said he has enough time to think things through. I told him I would be more than happy to help him understand that his decisions needed to be thought out very deep before having been made, but that it was best that he sorted these things out with a specialized person. He then told me that he was glad it was me and that doctor that came and not someone else. I explained that it was impossible for him to receive all the help he needed during our visit, and emphasized the fact that the best thing he could do is take the advice I had just given him. After our conversation I could sense that he just might take into consideration seeing that therapist and I felt proud that I may have convinced him to do so when the doctor said she couldn’t.

After completing our chart for the young patient, a chart that said “no diagnose could be set”. We left the house. Both me and the doctor looked at one-another and though how good it was to be away from the tension that surrounded us in that house. She said that I handled myself good and that if I analyzed the situation a bit I had many things to learn from it, I’m glad to say that she was right.

The 2nd day I went on to meet the parents at a local hospital but only the father showed up for the meeting, I asked him how did things go after we left and was glad to hear an answer starting with “my son said”. He said his son told him that he is not taking any drugs and that he is inclined to believe him, but that he wants to go ahead with visiting the ward as promised. As we entered I explained that there was no reason for him not to believe or trust in whatever advice I or the doctor had given him and that that kind of situation can’t be completely solved by the ambulance or the police, for that matter. The nigh before I was given some very good pointers of what I should be discussing with him during our visit. I was careful in showing him some very shocking patients and he was noticeably impressed by the suffering he was seeing. His most powerful reaction was upon the sight of a 16 year old patient while having a crisis. After the visit I had the first normal conversation with him, one in which I really felt like he was listening to my arguments. It made me feel really good that he was actually opening up to the possibility that he was the one making a mistake and not his son, and for the first time I felt there was some hope of a healthy ending to this case. The problem with working on an ambulance is that you never know the actual ending of a certain situation, especially one of this sort, but this aspect strangely inspires me to always give my best since it might be the only chance that I could have to help people that desperately need to be helped.

__________________________________________________________________________

Being intrigued by this situation and driven by deep thoughts and strong emotion derived from that case I went on to study things that would help me better understand what it was all about and how could I have given them more efficient advice or assistance. The next day all I could think about were possible scenarios of what happened before and after our visit at the patient’s house, I thought long and hard about the attitudes of every member of that family and I tried to create an empathy maze to help me systemize the information I had to work with. It was very strange to me to realize that out of 6 cases I had to work on that night, 2 of them being a matter of life and death, my mind was only on this one – a case that was more psychological then medical. Reflecting on the facts I came to the conclusion that I had to carefully take into consideration every piece of information I could remember.

I took this case into a Balint group at the University and after going through it many perspectives opened up and I had a larger picture of the circumstances concerning it. Being asked questions about the case made me look more closely at some of the details I had missed during the experience; also I found out that the situation would had been empathically overwhelming to most of the participants at the group. That made me get passed my fears of not doing so well so I could reflect on things from a calm and objective point of view.

The first thing that I came to realize was that everyone in that family had a certain problem. The father was confronting the idea that his authority was undermined and that his view of himself as a young child was not at all what he was dealing with in his son. After thinking it through I came to the conclusion that the discomfort I felt when talking to him was a matter of my condition of a student. Since before I had witnessed his refusal to listen to even the doctor’s advice I was very discouraged in trying to explain him my view of the situation, especially when this wasn’t the case of a medical act but a pure nonmedical advice. I had to get passed my feelings and take care of the problem in the most objective way possible; if that man was to take any facts into consideration they would have to be seen and acknowledged by himself and not supplied by someone else. Having that in mind I went on and gave him the opportunity to do so but by that I actually went over the line of medical and even psychological assistance. It was very clear to me that since I and the doctor had so little time to deal with these people and given the fact that they strongly refused any help from a specialized person all the advice and support we would give them had to be serious and we needed to make sure that it would be taken into account after we left.

The 2nd day, I think, was very important on many aspects. Firstly the father had no confidence in either myself or the doctor I was assisting so taking the time to meet him and explain our point of view came as a proof of our good intentions which in the end he appreciated. Creating a good relationship with him was crucial if he was to take any of the advice we had given him, since there would be no other chance to support that advice with the perception that it came form competent and good willing people. Furthermore I was determined to make him realize how wrong he was in accusing his son without proof, I can’t say if the feeling I experienced was the need for a success or the fear of failure but it determined me to express myself strongly concerning this aspect and I think that even this determination of mine had an important part to play in the father’s final reaction. During the visit I insisted on explaining to him every part of treating a drug addict, with all the painful details and the psychical implication in the process, and I was always putting his son in the role of the patient. I could see for sure that it had a strong effect on him and was glad that I could finally get that. Walking out of the ward with him I explained that the doctor that had been at their house the night before was both a very good physician and a psychologist. He was actually glad to hear this and said to me that he thought that situation could have been the only possible one which implied him or his son actually seeing a psychologist.

In my dealing with the young patient I was fortunate to find one that could open up and share his problems with me, although confused at first by his contradictory attitude towards me in comparison with his family I tried to always remember that I am there to take care of his medical problems and not anything else. At first that was very confusing since I could find nothing wrong with him, he seemed like any ordinary boy. Even now I can’t explain why I couldn’t objectively take into consideration the fact that he was playing a double role that was hardly the case of someone who didn’t need help. Regarding whether I was the right person to offer him the help he needed the problem still stands, but considering the fact that I was the only one that seemed to communicate with him I could say that I did my part well. In our conversations I felt very sorry for him and even sorrier for the fact that I couldn’t really do something to help him on the spot. When dealing with other types of patients there are usually step-by-step rules you must follow in a crisis situation or at least one ordinary thing you can do to reassure him, but in such a case I found myself disoriented and confused in an empathic dead end situation. My first instinct was to encourage him to have an opened relationship with his sister but that failed since after telling me his situation I could understand the fact that there was an obvious hostility between them, one that was maintained and supported by the family scenario. When he told me about his concern for his sister’s exams I realized that in fact I wasn’t dealing with a person totally indifferent to the needs of the people that surrounded him as I thought so and tried to act accordingly. I was thinking that any advice I gave him at that time should be a lasting one since it had to help him get over a phase that was not going to end shortly. The emotional build-up I was experiencing was getting overwhelming and it was getting harder and harder to be objective due to the complicated situation and my lack of experience in psychology. The worst thing I had to confront was considering the person in front of me a friend in need of help instead of a patient; that made me overlook some of the basic principles that I had learned and followed at every case I had assisted except for this one. Being sorry for a patient, as I realized, in most cases does nothing but to distance you from the objective point of view and puts you in a situation where you’re likely not to make the best decision you could make.

In the 45 minutes, as I approximated to be the total time I had spent with the boy, I came to find out many aspects of his life and often I confessed that I wouldn’t had known what to do in his place. The feeling of uselessness I had was very disturbing but it kept me thinking about that should be done. It wasn’t the first time I had felt this but it was strange because all the other times were in the cases of patients that had a life threatening emergency that had gone bad, which was hardly the situation here. The fact that upon leaving the room he told me that he was glad I and the doctor had come made me feel a lot better. I was glad that because of my position as a medical student and my age that was close to the patient’s, I actually played an important part in helping him realize that he could find support if he looked for it.

This episode was educative on how there could be situations when a certain patient may need assistance not from a doctor but from someone that seems to have an objective point of view, a person to whom the patient can react to and share his problems with. On this account it should be taken into consideration the involvement of medical students in cases regarding young patients that will not respond well to their doctor. I’ve learned that a patient’s compliance to a medic’s advice or treatment is directly influenced by his personal opinion of the person that is offering it and even more intensely by the way it is offered. When the father was advised to see a family therapist he immediately refused and accused me of trying to pass the responsibility, but when I offered to personally help him understand my point by sacrificing my own time he was bound to believe that I am really trying to help him and that I have no hidden reason for doing so.

Furthermore, the noticeably good doctor-student relationship at the case location was very well appreciated as the father confided the 2nd day when he said that he wished he could collaborate with his son as well as he saw us collaborate that night. I was swift to tell him that it required efforts on both parts and he seemed to draw a useful conclusion from that.

 

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I was and am still amazed by the complexity of the term “medical help” since, as I found out, you can never draw a line between the physical and the psychical care you have to assure a patient. In order to have a good doctor-patient or student-patient relationship one must firstly take care of the patient’s emotional needs or at least try to assure him that they are taken into consideration, otherwise he could be struck by unwanted reactions on the patient’s behalf, as I was by the father’s indifference to my attempts of broadening his views. The dual aspect of the physician is beginning to be more and more a need than a choice. My student-patient relationship that night was deeply influenced by the excellent communication between me and the doctor. It was very important for me to know that there was an experienced person there that could help me in the difficulties I had in approaching the patients, and I have to say that without the doctor’s valuable input I don’t think we could have made any progress in dealing with that family’s problems. What I have come to conclude from this aspect will be of great importance in my future making of decisions concerning the way I communicate with patients.

Firstly, the case I have presented is not a common one and unlikely to come about in the practice of the majority of medical students but I have to emphasize the fact that because of its strong empathical requests it is a marker for the importance of the doctor/student’s desire and capability to acknowledge and understand every aspect of his patient’s sufferings, either pathological or not, before proceeding to offer the actual medical care.

Also, it should be taken into account that some situations that on first view seem not to have anything in common with the usual medical act should be approached with great care because, untreated, they may derive into even more complicated ones, this widens the area of the level of competence any doctor or student that is working under the pressure of the emergency medical act should have.

In addition, the involvement of medical students in the earlier mentioned cases should be closely observed by a competent doctor and should invariably be doubled by a close doctor-student collaboration which comes not only in the student’s aid but also in the patient’s. This is especially true for situations like the one I presented when the time of interaction with the patient is short. Showing a good relationship and collaboration between parts should be considered of vital importance by any medical team in the act of treating a patient.

In closing, must mention the importance in the fact that any medical student or doctor is aware of the possible conditions that have driven a person to show up as a patient and how those conditions are acting as factors of influence in the patient’s receptiveness to advise, treatment compliance and feed-back. The therapist must be aware of every aspect of a patient’s emotional state; this, in some cases, implies the co-working of a part that has the best chance of receiving the necessary information and a part that is specialized in treating the illness or preventing it. The refusal to work in these conditions due to possessiveness over an area of expertise or lack of confidence between parts should be avoided by consideration of the patient’s wellbeing.

My condition of a first year medical student may have been a decisive factor in some of the conclusions I could draw from the encounter I presented in this essay, but I have the faith that if faulty, these conclusions will be further corrected during future practice. In my presentation I tried to lay out the facts as correctly and completely as I remembered them; my personal opinions and subjective entries were marked as being so, with the hope of succeeding to expose these aspects as well as they could be exposed.

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