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April 6, 2021

The Day I Missed a Patient’s Suicidal Message.

Author’s Note: This is a story about how I became averse to social media. Or at least it was my first battle scar from tangling with the virtual world. Names, key details, and concrete personal identifiers have been changed to protect everyone involved in this story except me, the author. Additionally, some of this relies on my memory, which has faded with time. So, take all of it with a grain of salt. 

~

Often I will see patients because their spouse, mother, father, daughter, son, or some other significant recommends that they end up in my office. We sit together and do the awkward introduction that usually starts with:

“My wife said I should see you,” “My mom thought you could help me,” or, “My children want me to be here.”

This is not unusual in a smaller community, where the grocery store is a social outing, the degree of relative separation between blood relations is about three people, and pretty much everyone knows variations of everyone else’s business, like it or not, including mine.

This encounter started pretty much the same. The patient’s stepfather had met me through work, and he determined that I would be a good fit for his stepdaughter.

The stepdaughter had been through quite a few doctors by then, had had a number of surgeries, procedures, and medications to seemingly treat her “condition” which was something close to a chronic disease of some fashion or another. It had yet to be identified but was a conglomeration of abdominal pain, anemia (low blood), fatigue, and intermittent weight loss.

By the time I saw her, she had had an abdominal organ removed, another couple of surgeries, and even a quasi-permanent feeding tube placed to supplement her nutrition. She was younger, so I was intrigued by the thought of diagnosing something that might help her find treatment, understand her illness, and maybe even have a better life. Thus far no number of surgeries, procedures, tests, or exams had procured a diagnosis.

I was still young and idealistic then.

Figuring out a diagnosis is part and parcel of the heart of a good internist’s purpose. One principle I like to employ is called Occam’s razor. Basically, in the thirteenth century, an English Franciscan friar named William of Ockham formulated his philosophy that a simple explanation is usually the correct explanation. Medical doctors exploited the friar’s problem-solving hypotheses and still use them in diagnosing today.

In other words, when something seems as though it is a particular diagnosis, it usually is. Often in medical school students are told that when hearing hoofbeats, think of horses, not zebras, and make the obvious diagnosis.

This case, however, was anything but simple.

My initial encounter with my new patient, Rebecca, as I will call her here, was nothing short of a small family gathering. Although an adult, she came sandwiched between two parents, one of whom was in the medical field.

I was struck by their choice of seating, right beside one another, three people on two bariatric seats. No one even tried to sit in the provider’s seat, as is often the custom when several people try to squeeze into a small exam room for an appointment.

Rebecca, who was in her thirties, was the only one who provided a response to my questioning, which made things a little easier, but I remember feeling perplexed after the 30 minute visit. The parents seemed weary and offered little, the exam verified the surgeries and the tube, the labs were generally normal enough, and I still could not find a linking diagnosis to explain her problems.

I did what we all do when we do our job completely. I reviewed her chart and asked for old records.

Mesmerized, I learned that the pathology report for her abdominal surgery interestingly did not show any frank disease, thus seemingly a normal organ was removed.

I learned that the feeding tube was more of a judgment call, and I saw mention of an eating disorder in the remote past, which piqued my curiosity about her weight loss.

Just about every symptom eventually led to some procedure or surgery, and still no linking diagnosis.

No Occam’s razor.

I turned this around in my mind. I really wasn’t sure what had transpired with this case. Did medicine fail the patient (i.e. did we do too much?), or did the patient, in lieu of her likely somatic complaints, fool medicine? And what to do here? She was once again seeking help for abdominal pain, wanting answers.

First, I reviewed the case with one of my colleagues, a bright young woman who had recently joined our group. She was baffled, too, and the diagnosis of Munchausen was mentioned in passing.

Next, I called the patient and asked if we could talk more about my findings.

We met and talked, and I wasn’t sure how well it went. I explained the pathology report, the normal labs, the continued procedures. I talked about somatic symptoms—overly extreme physical symptoms, often without an obvious cause, causing emotional distress.

I wondered aloud if this had led to procedures that might have been avoided if we had the vantage point of a Monday morning quarterback, in hindsight knowing that the procedures had not helped.

Rebecca listened and then asked if I believed her when she told me that she had symptoms, or if I thought it was in her head.

I answered that it could likely be a very delicate combination of both, and certainly I was not trying to dismiss her symptoms. I just wondered if there was a way we could avoid doing such radical procedures in the future unless we absolutely had to. When she left I was certain she would never see me again.

However, a month later Rebecca ended up in the hospital for an accidental ingestion, and she asked for me to care for her. I became convinced the ingestion wasn’t exactly accidental.  The encounter was awkward, but we were able to remedy the illness, and she was able to return home. I was again left wondering about the case.

As is the case of Father Time and Mother Nature, life went on, and work distracted me a bit, and Rebecca stayed away from my office and the hospital.

Then one day an email arrived, notifying me that Rebecca had sent me a message through Facebook.

This was an odd message since I didn’t think we were friends on Facebook, although I really didn’t pay very much attention to that account. I was busy with my family, so whatever it was would have to wait.

As a Gen Xer, Facebook really wasn’t my favorite way to connect with my friends, family, or long-lost acquaintances. We didn’t grow up with this. Many of us had reluctantly but gradually acclimated to the daily interruption this offered until it was a daily, hourly habit some couldn’t live without.

I personally couldn’t keep up with all of the posts, pictures, and information, and I had a relatively large problem brewing within my own family needing my attention. Facebook seemed to add just one more thing on my already filled plate.

Further, with an election on the horizon, the platform had gotten political. I already had enough stress at home and I didn’t need more in my virtual world. I found myself becoming irritated with Facebook.

Adding to the complexity was that patients now had yet one more way to communicate with me outside of the normal channels. Yuck. I put the email out of my mind.

The next day I got up and went to work as per my normal routine. I always started with hospital rounds, and I entered through the back door. My colleague who had been on call for the previous night (the same colleague I had consulted initially about Rebecca) met me by the door. She didn’t even bother to greet me.

Distressed, she said, “Rebecca tried to kill herself last night. I’m so sorry.  The case is really messy Krisa, and she is in surgery right now. You are going to want to look it over, though, because in the ER she claimed that she contacted you and told you she intended to kill herself and that you negligently never called her back. But I can’t find a record of that anywhere.”

As with any traumatic news, my mind took a little bit to catch up. I looked at my partner, standing troubled in front of me, pacing a bit in her green scrubs and white coat.

“Shoot,” I said, buying time while I put the pieces together.

“She sent me something yesterday through Facebook,” I told my colleague.

“But I didn’t open it because I wasn’t working.  I had no idea…”

My voice trailed off. “It was on Facebook,” I emphasized but it felt hollow on my tongue, like a feeble excuse. Underneath it all, I felt sick and ashamed that I didn’t look at the message.

Never would I assume such a dire message would come to me through Facebook. While not an appropriate patient communication channel, I still couldn’t help from feeling awful about what had transpired.

I worked that day, and later I visited Rebecca, who was resting on a ventilator in the ICU. She was lucky. She had a skilled surgeon who had pieced her bowel back together. She would survive this attempt. Her family was holding vigil, and once again they sat closely together, broken, weeping, and desperate to have better news about their daughter.

I gave my condolences but I did not mention the Facebook message which had been documented in her chart, incorrectly implying she had gone through normal channels to report her suicidal ideation.

The record stated that she had, indeed, contacted me, told me she was suicidal, and I had not answered her. Nowhere did the medical record mention that her communication had been through social media, and I doubt anyone taking the history had thought to ask.

That night I removed myself from Facebook completely. I closed my account.

I really had no regrets about it. In addition to the unlimited accessibility for patients, I saw political tension escalating, with too much access to everyone’s opinions. It wasn’t worth the stress.

I admit that I had even engaged a bit with a family member who I loved about politics, and I wasn’t too excited to be doing that. I knew I wouldn’t miss Facebook that much, and I knew the less accessible I would be to patients, and the less I knew about my family and friends’ different opinions, the better my life might be.

As I hit the delete button to my account, I thought a bit about Facebook and accessibility. Maybe accessibility was exactly the problem we, as people, have with social media.

Too much accessibility, access, interaction.

Maybe our thoughts were meant to be kept private, in our own brains, and not put out there in the world for everyone to see.

Maybe we would have less conflict and more respect and love for one another if we didn’t air out every thought, experience, and opinion we have.

Maybe we would be able to talk to real people when we are suicidal, instead of thinking an amorphous message would help us when we need it.

Maybe we are meant to actually speak with one another, to hear each other’s voices, see each other’s faces, and interact in real-time rather than virtual time.

Maybe, just maybe, we are meant to be actual people, not just virtual people, who don’t have unlimited access to one another through computers, phones, and tablets.

Since Rebecca’s suicide attempt I have tried to re-engage with social media on different platforms, on rare occasions. I always enjoy seeing pictures of people’s children, wishing people a happy birthday, seeing their successes, among other things.

Sadly, I then tend to have a little PTSD and I recall Rebecca, and when my account grows to bigger than my comfort zone, I panic and delete it, afraid that something like Rebecca’s story could happen to me again. Fully aware that there are privacy controls, I still am afraid of being too accessible, and I suspect that feeling will never, ever go away.

Seriously, though, never will Facebook.

~

 

 

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