Consult-Liaison Education Informal-curriculum Lessons Medicine Observations Policy

Red Herring: Epilogue.

I encourage you to read the entire Red Herring series before reading this post. Consider this your “spoiler alert”.

The patient really is fine.

She returned to the gastroenterology clinic several times for treatments to widen her esophagus. (It’s a neat procedure: The GI doctors insert a small balloon into the esophagus. They gently inflate the balloon to stretch the stricture a few millimeters. With repeated stretching, the esophagus will remain open.) The patient ate more. She stopped vomiting. Her weight increased.

For the sake of flow, I did not include two complications that occurred during the course of events:

Medication problems. Although I had written a letter to hospital staff that included the patient’s history and list of medications, the psychiatrists in the first hospital omitted one medication from the patient’s regimen. As a result, the patient developed distressing symptoms consistent with schizophrenia. (In some ways, this was a blessing, as this omission confirmed her diagnosis. As the patient had demonstrated minimal symptoms of schizophrenia as an outpatient, I would have been tempted to taper off medications… which could have resulted in an “unnecessary” hospitalization.) I suspect this error prolonged her hospitalization.

Transfers of care from outpatient to inpatient settings (and vice versa) are fraught with problems that often adversely affect the patient. People have proposed universal health records, care managers, and other devices to help minimize this potential for harm. For now, most of us continue to do the best we can with the current system.

Decisional capacity issues. After the patient was hospitalized the second time, the gastroenterologists had concerns about the patient’s ability to consent to the procedure to evaluate her esophagus. While she could communicate a choice, they had doubts that she could appreciate her condition and understand the risks and benefits of intervention. Her worker ended up going to the hospital to discuss the procedure together with the patient and physicians. We were fortunate that he was available to do this.

I wanted to share the tale of the Red Herring for three reasons:

All physicians are subject to bias. Patients can suffer as a result. Patients with psychiatric diagnoses sometimes do not receive appropriate medical attention simply because of diagnostic labels. This can occur even if patients are not demonstrating psychiatric symptoms at the time of the encounter. Physicians, including psychiatrists, may assume that these patients exaggerate or misreport medical symptoms. Alternatively, physicians may assume that medical symptoms are due solely to psychiatric conditions.

According to Wikipedia (not the best source of medical information, but anyway…), the prevalence of esophageal strictures is 7 to 23% in the US. The prevalence of schizophrenia is less than 1%. The prevalence of bulimia in the US is about 5%. Though esophageal strictures are more common than either psychiatric condition, we all somehow believed that the latter was the culprit in the case of the Red Herring.

We all often forget that people are not simply mind or body. People with psychiatric conditions still have physical bodies that can bleed, break, and hurt.

Physicians need time to provide good care. 15 minute appointments maximizes profits for organizations and physicians in private practice. 15 minute appointments often do not maximize benefit and value for patients. (To be fair, organizations and individuals need money to maintain clinics. If clinics go bankrupt, everyone loses.)

If I saw this patient for only 15 minutes, once a month, it would have taken me much longer to build a relationship with her. Without that relationship, I could not have directed her to go to the hospital. She would have (accurately) experienced that as coercion. Furthermore, my understanding of her symptoms and condition would have been limited.

If I only had 15 minutes a month with this patient, I would not have been able to advocate for her as I did. If we want our physicians to provide this level of care, we all must recognize that physicians need time to do so. (My patient was enrolled in a program for individuals with severe psychiatric conditions. My “caseload” of patients was purposely kept low; this allowed me to spend a flexible amount of time with people and to see them on a more frequent basis.)

Physicians must advocate for their patients. For those patients who are able to advocate for themselves, we must encourage them to do just that. Helping patients obtain the services they need to lead healthy, independent lives with limited contact with medical establishments should be one of our primary goals. This is particularly true in psychiatry: we should do what we can to get people out of the mental health system so they can get on with living their lives.

For those patients who cannot advocate for themselves, we must advocate for them. They otherwise will not receive the care and interventions they need to maximize the chances that they can lead healthy, independent lives. We have all read articles citing the enormous financial costs associated with undertreated or untreated medical problems. Furthermore, we will have failed our moral obligation to promote beneficience.

Thank you for reading the Red Herring. I appreciate your attention.

Consult-Liaison Education Lessons Medicine Observations

Red Herring (VIII).

The urge was to glance at the roster on the wall and go directly to the patient’s room.

Instead, I said to the clerk, “Hi. I’m one of The Patient’s outpatient doctors. May I trouble you to page her doctor so I can talk with him?”

Five minutes later, a man wearing a bow tie and a stethoscope around his neck walked onto the unit. He pitched himself forward when he walked; his shoulders were ahead of his hips, which were ahead of his knees.

“So you’re her psychiatrist, huh? She’s a nice woman.”

Yes, she is.

“GI scoped her this morning to open the stricture,” he said, waving his hand to direct me to follow him. “No complications. She should’ve gotten a breakfast tray by now. You see her yet?”

Before I could answer, he continued, “Interesting case. Not sure why she developed the stricture. You want copies of her notes? I’ll give you copies of her notes.”

My eyes skimmed the papers as he handed them to me. Though several pages mentioned a significant narrowing of her esophagus, none mentioned cancer.


After thanking him, I went to go see my patient.

“Hellooooooo!” she squealed, waving her twiggy arms at me. “So nice to see yooooou!”

“Hello,” I laughed, noticing the sign marked “NPO”[1. NPO stands for “nil per os”, which means “nothing by mouth”, which means that the patient should not eat or drink anything for a certain amount of time. The sign should have been taken down since her procedure was done.] above her bed. “Do you mind if I sit down so we can chat?”

“No, no, sit, sit!”

“What did they bring you for breakfast?”

She gingerly lifted the plastic cover off of the breakfast tray. Pointing at each item, she said, “Eggs… toast… cereal… milk… juice… fruit?”

“There’s tea, too.”

“I don’t like tea.”

I smiled.

“Please, start eating.”

She peeled the wrapping off of the plastic utensils, plucked out the spoon and fork, and set them on the table. Her thin fingers opened the small milk carton and the single-serving of cereal.

“What happened this morning?

After pouring the milk into the cereal, she dunked the spoon into the mixture and fed the flakes into her mouth. She chewed, then swallowed, with ease.

“They put something down my throat.”

With the fork she scooped a blob of cold scrambled egg into her mouth.

“Why did they do that?”

“To open it up so I can swallow.”

She bit into a slice of toast. It looked soggy.

“Did it hurt?”

She shook her head. “I’m fine.”

I smiled again.

She ate it all: The eggs, toast, cereal, milk, juice, and fruit in heavy syrup. The tea continued to give off steam in the corner of the tray.

“That was good,” she said.

We sat in silence for a while. She looked out the window. I looked at the thin muscles hanging off of her bones.

Abruptly turning to look at me, she said, “Thank you. You knew there was something wrong and you got me help. I was really sick. Thank you.”

My cheeks suddenly felt warm. A smile blossomed on my face. No longer able to hold her gaze, I looked away and said, “You’re welcome.”

Finis! Epilogue to follow. The story begins here.

Consult-Liaison Education Lessons Medicine Observations

Red Herring (VII).

It was raining. Cars were driving through the water collecting in the gutters. This made it difficult to hear her voice through the phone.

“I’m the consult-liaison psychiatrist seeing your patient,” she said. “Thank you for leaving a note for us about her.”

Huh. So she was admitted to a medical service. Good. Points to the primary medical team for getting the psychiatric consultant involved.

“How is she doing?”

“From a psychiatric standpoint, she’s fine…”


“… but, they scanned her chest and they found a mass. It doesn’t look good. They think it might be cancer.”

I stopped walking.

“What? Are you serious?”

“Yeah. They’re still doing the workup, but from what they saw on the scan, there’s a good chance that it’s cancer. They’ve told her and she’s okay so far. I’ll continue to see her. She’ll be in the hospital for a while.”

The cars continued to splash water onto the sidewalk. I closed my eyes.

“Thanks for letting me know.”

There’s an adage in medicine: The nicest people are the ones who get cancer.

God, how could you let a nice woman with a diagnosis of schizophrenia develop cancer? Have you no mercy?

Cancer? Could she really have cancer? Did I think it could be cancer? Of course I thought it could be cancer.

Did I?

Why didn’t the ED staff at the first hospital catch this? Could she have developed a mass in her chest in the span of three weeks? Maybe. Maybe it grew fast. But she had been vomiting for months….

Why didn’t I push the inpatient psychiatry staff ask for a medicine consult?

Because we all trusted the medical workup. There was no reason to doubt it.


But what if I had insisted on one? What if I had demanded it? She was losing weight and the inpatient psychiatrists couldn’t give me an explanation why. They thought her weight loss was due entirely to psychiatric reasons. Their strategy to help her gain weight—locking her out of a bathroom after meals!—wasn’t working. I knew this. They knew this.

I couldn’t stop them from discharging her from the hospital. What was I going to do? Block the exit and demand that she stay?

Maybe I trusted too much.

We all trusted. If they couldn’t find a medical cause, then the problem had to be psychiatric in nature.

How could we have completely forgotten that maybe they just couldn’t find the medical problem yet?

How could I have forgotten that?

The office staff were appalled.

“Should we tell the first hospital about this? They need to know. That could be a lawsuit right there.”

“But we’re not actually going to sue,” I said. “It doesn’t change anything for the patient. At least she’s getting treatment now.”

A few days later, the gastroenterologist called.

“Thank you for calling me. I understand that she has a mass? that she might have cancer?”

“We don’t know about the cancer part,” he said, “but there does seem to be a mass in her chest. We think the mass has been pushing on the esophagus, which caused the esophagus to get thick, like a callous. Then the diameter of his esophagus got smaller, so it became more difficult for her to swallow food. That probably explains her vomiting and weight loss.”


“Tomorrow morning, we’re going to drop a scope down her esophagus to look around. We’re planning on stretching the diameter of her esophagus a bit so she can eat.”

“I’ll come by tomorrow after the procedure. Thank you for letting me know.”

Nothing had changed. Everything had changed.

(Part seven of an ongoing series.)

Consult-Liaison Education Lessons Medicine Observations

Red Herring (VI).

She was still standing on the scale. 93 pounds. The rest of the team looked at her.

“What should we do?” someone asked.

We all looked at each other.

“Well,” I offered, “this isn’t an emergency—there’s nothing to do right now. She just left the hospital. They won’t take her back right now. Did That Hospital schedule any follow-up medical appointments for her?”

After flipping through the discharge papers, The Worker said, “Nope.”

Unable to restrain myself, I mumbled, “First they don’t call to discuss her care prior to discharging her, then they don’t schedule any follow-up.”

I probably shouldn’t have said that out loud.

Turning to the patient, I said, “I know you just left the hospital. But if your weight drops any more, we’re going to take you back. I’m still worried that there is something happening to your body that is making you lose weight. Does that make sense?”

“I don’t want to go back to that hospital,” she said as she stepped off the scale. “The food doesn’t taste good there.”

“Where would you rather go?”

“I can go to That Other Hospital.” She suddenly flashed a bright smile. “The food there is delicious!”

“Okay, we’ll keep that in mind. Hopefully, though, you won’t have to go back to any hospital at all.”

At our request, she came to the office every day. Two days later, the nurse asked the patient to step on the scale. The nurse then knocked on my door and said, “Come look at this.”

The three of us then peered at the numbers on the scale: 87 pounds.

Alarmed, I looked at the nurse. She nodded.

“I’m sorry,” I said to the patient, “but we need to get you back to a hospital.”

Unlike the last time, she did not protest. She only nodded.

“Which hospital do you want to go to?”

“The Other Hospital. The food tastes better there.”

The Worker joined the nurse, the patient, and me.

“She shouldn’t go back to The Hospital She Just Came From. They weren’t good to her there,” The Worker opined.

“Fair, but there are advantages to sending her back there. They already know her recent history, they are less likely to put her through repeat testing, they may take this problem more seriously—”

“Right, but they didn’t take good care of her.”

The patient looked at me with those eyes that looked too large and sunken for her head.

“Okay. Let’s try to get her to The Other Hospital. I can’t go with her—”

“We’ll call an ambulance this time. That way we’ll know that she’ll get to the emergency room.”

And so we went through the circus again. Poor woman: An ambulance was summoned, the medics helped her tuck her spindly limbs into the back of the car, and I again scribbled out a note with her treatment history. It now included a two-plus week hospital stay and subsequent weight loss. Just six months ago she weighed over 120 pounds! I finished the letter with a plea that she be admitted to the hospital.

The medic took the sheet of paper from my hands. We hoped for the best.

Thankfully, she was admitted to The Other Hospital.

Two days later, doctors started calling me.

(Part six of an ongoing series.)

Consult-Liaison Education Lessons Medicine Observations

Red Herring (V).

I called the emergency department that night. If she was released, I wanted to know. (Did she make it home safely?) If she was admitted, I wanted to know. (Did the staff know her past history? Experience had taught me not to rely on a paper trail alone, especially when the patient was travelling through multiple departments.)

Though nearly ten hours had passed, she was still in the emergency department.

“Were you the one who tied the note to her gown?”


The ED doctor on the other end of the line laughed. “We got that, thanks.”

He then told me about the evaluation—physical exam, labs, X-rays—and no significant medical problems were apparent.

“She’s going to be admitted to psych to rule out an eating disorder.”

Frowning, I sighed.

“Please give the admitting team my phone number,” I said. “I want to talk with them once she’s upstairs.”

Several days had passed. No one from the hospital had called me.

After leaving two messages with the attending psychiatrist, I finally got a phone call from the resident about a week later.

“How is my patient?”

“Your patient is fine… don’t worry….” She sounded bored.

“Did you receive my note with the past history?”

“Yeah… schizophrenia, eating disorder… we’ll take good care of her… she’s fine….”

“She hasn’t demonstrated symptoms of an eating disorder in almost two years. I’m worried about a medical etiology.”

“Uh huh, okay….”

“What is her weight now?”

“How much does she weigh? Um… I don’t know.” She suddenly sounded attentive.

“Can you find out right now, please?”

“Yeah, sure, sure… the nurses check it every day…”

“So what was it today?”

My patient wasn’t gaining weight. In fact, she had lost weight since her admission to the hospital.

“We’re locking her out of the bathroom for an hour after every meal so she can’t vomit. She seems to be doing well with that.”

Frowning, I sighed.

“But her weight is down?”

“Um… yeah.”

“Have you considered calling a medicine consult?”

“The patient was medically cleared in the emergency room. Anyway, we’ll probably discharge her soon and she can follow up with her primary care doctor.”

“Ideally, her discharge weight should be greater than her admission weight.” We both understood that my comment was a warning, rather than an opinion.

She quickly ended the conversation.

I visited her a few days later. She was more energetic, though still very thin. The hospital gown hung on her like a sheet on a clothesline.

“Hiya!” she greeted, her smile disproportionately large compared to the size of her face.

After exchanging pleasantries, we sat down on couch covered in dark blue vinyl.

“Have you been throwing up?”

“Yes. Sometimes.”

“You’ve been throwing up…?”


“They tell me that they keep you out of the bathroom after meals.”

“Uh huh.”

“When do you throw up?”

“At night.”

“Do you make yourself throw up?”


“Do you feel sick?”

“I’m fine.”

“Do you hurt anywhere?”

“I’m fine.”

I examined her face, halfway hoping that I could read her mind.

“Are they treating you okay?”

Yes, apparently they were, even though they really were locking her out of the bathroom for an hour after her meals. And, despite this, her weight was still dropping. My efforts to speak with the inpatient psychiatrists were unsuccessful.

I looked at her, unsure of what to say.

“Don’t worry,” she said. “I’m fine.”

Less than a week later, hospital staff called The Worker and told him that they were discharging the patient that morning.

“I wish they would give us more notice,” he grumbled.

He escorted the patient from the hospital directly to the office. We asked her to step on the scale. We all frowned as the digital numbers appeared.

“What? What?” the patient asked.

“93 pounds,” The Worker said. “You weighed 99 pounds when you went in.”

(Part five of an ongoing series.)