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.)