CASE REPORT
Square Pegs For Round Holes
Dona Denton M.D.
University of Rochester

     This is a true med/psych case that illustrates the allure of its complexity and the frustration of its politics.

     MRL is a 47-year-old woman who lives with schizoaffective disorder and OCD. She has high levels of anxiety at baseline and has suffered through severe bouts of depression. Her father, a physician, and mother are both dead. She was a dancer in her youth and an accomplished pianist and singer. She is an avid reader.

     I had been her primary care doctor for a year in the medical clinic on-site at Strong Ties, the community outreach mental health clinic for the chronically mentally ill. She was healthy except for obesity, which had been a burden all her adult life. Her health care maintenance was completed finally with her first pelvic exam in four years and the assistance of some Ativan and her case manager. The results were unremarkable.

     She presented to the office one day complaining of irregular bleeding. Suspecting she may be unknowingly over representing the frequency and volume of bleeding, I asked her to keep a log of her bleeding and return in one month. Using her well-established OCD traits to her advantage, she did as I asked in detail. She returned and had in fact had more than half of the month with bleeding. Based on her age I suspected she was perimenopausal and asked about her mothers menopause history. Her mother had died rather suddenly with a "female cancer" ,she thought uterine, thankfully not known to be inheritable. I conservatively requested FSH and LH to document perimenopause. Her hormone levels came back clearly and convincingly postmenopause. After much discussion, she agreed to a pelvic ultrasound. The ultrasound showed a highly thickened endometrium, raising suspicion for an endometrial cancer. At this point, it was necessary to refer her outside our clinic to the University OB/GYN clinic. Referrals with this population are not without risk. MRL had the unfortunate experience of overhearing a clinic staff person ask her GYN, "haven't you had enough of that crazy schizophrenic?"

     With some reassurance from the GYN and myself she was able to return there for an endometrial biopsy that showed endometrial carcinoma. After clarifying the treatment alternatives and recommendation with the OB/GYN, it was agreed that I would give her the news with the support of her case manager present. Her psychiatrist, therapist, and CDT team were aware of the results and prepared to provide extra support as needed. A total abdominal hysterectomy was planned. The surgery was successful and initially looked curative on gross examination. Two weeks after her surgery, as I was beginning to think this acute period was at its end, I received a panic call from my patient saying she wanted to kill herself and felt betrayed that I had not told her the bad news. She had had her two week post surgical follow up appointment with a different OB/GYN (her GYN had gone out on maternity leave) and had been told that there was a need for five weeks radiation therapy because of cells found in the uterine neck that were cancerous. The data supporting this aggressive treatment were subsequently forwarded to me. The data lacked any consideration of treatment side effects both acute and chronic. It lacked evidence to support radiation treatment for patients with the minimal involvement that was seen in my patient. MRL did give informed consent with an understanding of the potential side effects and benefits of the treatment.

     She completed five weeks of radiation with acute bone marrow suppression and now has ongoing radiation cystitis and proctitis that we are managing. I am grateful for our frank discussions about possible outcomes. Her priority was to minimize any risk for recurrence, knowing that she would likely have ongoing side effects and what the treatment of those side effects entailed.

     If the standard med/psych complexities were not enough, there was another ongoing saga in the psychosociopolitical arena. Since MRL lived alone, in a third floor apartment, it was predictable that she would need more conducive, supportive situation than the typical three day admission with discharge to home. She has a history of psychotic decompensations at times of stress, the most recent around a planned musical performance that she was unable to complete requiring hospitalization six months prior. In spite of various attempts to arrange aftercare in advance, she was denied consideration at any institution based on their need for a PRI which must be completed at the time of consideration and is based on the persons present medical, psychiatric, and social needs. Predictions are not allowed. Subsequently, she had her surgery without medical complications, but was increasingly anxious and ruminative about the uncertainty of her pathologic findings and discharge plans. She began to pick at her wound and pace, talking incessantly about multiple fears and a preoccupation with dying. Socioeconomic pressures mounted as it was decided she was too well for any acute bed and too sick for any non-skilled facility. Now in the realm of special cases, an administrative physician representing the insurance company agreed to a discharge to a crisis facility for six days of stabilization. At this point, my patient had occupied an acute bed for-four extra days and was discharged on the weekend to a facility that had to obtain extra weekend staff to accommodate her discharge. She was able to go home in six days with visiting medical and psychiatric nursing services and the support of her intensive case manager.

     The barriers to providing smooth, cost effective management of patients with complicated, but predictable situations are the same ones that the institutions and management organizations intended to manage costs face. This case illustrates the unnecessary costs both financial and emotional to the institutions and patients when cases with special needs are ignored. All too often psychiatric patients with medical problems are caught in these management gap areas, and we along with them. It will be a challenge as a med/psych provider to help the institutions and management organizations realize that cost effectiveness may not be found with these patients when the standard care model is applied. One still cannot fit a square peg into a round hole, unless of course you don't mind buying a table saw to make the adjustments.

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