The young woman with a wart on her nose
BMJ 1999; 319 doi: https://doi.org/10.1136/bmj.319.7221.1349 (Published 20 November 1999) Cite this as: BMJ 1999;319:1349All rapid responses
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It appears to me that we as physicians
need to develop the ability to read expressions,
gestures, and postures ('body language'), in order
to be able to more accurately perceive what
the individual (patient) would like to tell us
but very often cannot. Most problems are not of
an intellectual nature, and most suffering
involves brain areas we choose to call 'primitive'
; it is not easy for people to put such suffering
into words, much less those we are trained to use
and hear during a standard (one may say Oslerian)
medical history and review of systems.
A criticism (what might be termed "damning
with faint praise") often heard by physicians
who do succeed to any degree in perceiving
patients' concerns before they voice them, or in
"filling in the blanks", i.e. understanding what
else they have on their mind but cannot say, is
"You're the first one that's listened to me!".
Surely we can augment the admirable data-
base of science and technique we each must absorb
with more robust communication tools: organs not
only of expression but of perception. We owe a
debt of gratitude to the physician who cared
enough to share the story of the depressed young
lady whose cry for help was inaudible; we need
to do better, and we can--if it becomes a
priority, and if the humanists can retake
medicine from the lawyers and bureaucrats.
Competing interests: No competing interests
Dear Sir
I'm an Italian Gp and you can be sure that every practitioner has to face similar medical and human situation many times during the whole professional career.
So, what to do? There's only one satisfying answer: to follow his own science and conscientiousnes, both at the best.
Unfortunately skill is not all that you need, the most of times is only a matter of fortune.
Regards
Dr. Giampiero Di Maio
Bologna, Italy
e-mail bemarit@libero.it
Competing interests: No competing interests
Donald W MacCorquodale's "A memorable patient: The young
woman with a wart on her nose" is an important piece - even
if it is only a "Filler." I believe this woman had facial
dysmorphic syndrome, a delusional state, that has a
well-recognized risk for suicide. These patients almost
never agree to see psychiatrists because they are
delusional. Cotterill described similar patients under the
title of "Dermatologic Non-Disease" a number of years ago.
The syndrome has also been called "Dysmorphophobia."
These syndromes are fascinating, and perhaps not all that
rare. I have seen a number of similar patients, and find
that they often respond to a sympathetic ear. A more common
delusion - but a related one - is parasitophobia. This is
not a phobia - but a false fixed belief. These patients
also only rarely accept a psychiatric referral.
Thank you for publishing this.
Competing interests: No competing interests
Recognizing distress signals
Editor - Donald MacCorquodale's young woman with a wart on her nose
(BMJ, 20 November, Vol 319 p 1340) was trying to transmit a distress
signal on an unusual wavelength. Whenever I hear of a suicide, especially
a totally
unexpected one, I wonder whether one of us in our profession failed to
receive, or recognize, such a distress signal.
The one I have had on my
conscience for 45 years was a young man, a relatively new immigrant to
Australia from Central Europe. I had taken out his acutely inflamed
appendix a few months before and got to know him a little during his
convalescence, so my failure to recognize his problem was all the more
inexcusable. He wanted to see me on a day when I was frantically busy,
everything seemed to be happening at once, two women in labour, an
accident at a nearby factory with several men needing stitches, and a
waiting-room
full of patients. His complaint was that he couldn't get a date with a
girl he was attracted to, thought he must smell bad. I saw him in the
hall, not my ofice, and was very brusque, told him not to bother me with
such a trivial problem when he could see how busy I was. He turned and
walked quietly away. Next morning I was called by the police, wanting to
know what he had seen me about. He had a receipt from our receptionist for
an office visit on the previous afternoon and that night he had put the
barrel of a
rifle in his mouth and pulled the trigger. I knew instantly what a
terrible wrong I had done him, but no amount of lamentation could restore
him to life.
I hope I never again failed to recognize distress signals transmitted on
unusual wavelengths. In my teaching of medical students I have often told
this story of his needlessly wasted life, each time seeing his face in my
mind's eye as I tell it, hoping, not to atone for my missed diagnosis, but
that others may learn from my terrible mistake.
John Last MD
Emeritus professor of epidemiology
University of Ottawa,
451 Smyth Road,
Ottawa, ON K1H 8M5, CANADA
Competing interests: No competing interests