I walked into the patient’s room and saw my sister. At least, Mary* could have been my sister for her age and complexion seemed to match. As I opened my mouth to speak, her shaking hands, thick palpable nervousness, and a downwards stare portrayed an individual uncomfortable and unaccustomed to a physician’s office. I greeted her with a smile, stating my name, position, and purpose. Just as I had with the patients before her, my first question was to ask why she had come in. The words—“I’ve been feeling depressed”—were quickly and quietly spoken.
I witnessed Mary’s familiar face lower to the floor as her quiet, delicate nature came to light. I felt a reverence for her feelings of grief, a scene that might quickly be compromised due to my inexperience. It took a few moments, but she gradually warmed up to our discussion as I centered the interview around her journey to the office. We talked about her mother’s supportive and guiding influence which had led her to request the visit. We discussed the coping mechanisms she was trying, including an increased reliance on marijuana, which had proven unsuccessful in warding off feelings of self-doubt. I reassured her that the attending physician would provide excellent care, good enough that I would recommend him to my own sister. A vivid image of my sister passed through my mind. I could see her, or them. My conversation with Mary felt familiar.
Despite that I had never worked with a patient challenged by mental health concerns, my confidence in understanding Mary climbed as I completed her interview. Perhaps due to her semblance to my sister, I left the room with what I felt to be a complete picture of her condition. As I began my oral presentation to my preceptor, I boldly told him of her one-year history of feeling depressed. I described in detail her symptoms, including nausea and vomiting, which I proudly deduced had stemmed from her use of marijuana.
The seasoned physician listened patiently and then paused for a moment. “Did you ask Mary if she’s ever considered killing herself?” he asked. I stared back at him. I was tempted to try and rationalize why I had not, especially with all of the other important history items that I had obtained. “No,” I frankly replied back, somewhat embarrassed by overlooking what he knew was a key part of her history. Like an expanded balloon experiencing an air leak, I felt the common deflation of an overly confident medical student. I discreetly tried to cloak the puncture.
Why hadn’t I asked? Without meaning to, I thought about how my sister would never do something to hurt herself. Even with family, suicidal ideation can be a sensitive subject to address. I didn’t want to intensify my discussion with Mary, especially since she had already extended herself in discussing her drug use. Mary was vulnerable in coming alone to a new provider visit. I would need appropriate justification to ask a question like that. If she did struggle with suicidal thoughts, what would I have to do with that knowledge?
As I contemplated these questions, the attending told me about selective serotonin reuptake inhibitors, or SSRIs. They are one of the most commonly prescribed antidepressants. Citalopram, or Celexa, works very well to treat patients who are experiencing depression. However, there is an FDA black box warning prominently displayed on the side of the medication. This warns of the possible increase in suicidal thoughts or actions in some young adults at the initiation of treatment. For these patients, prior suicidal ideation is further investigated with extreme precaution prior to prescribing the medication. If these thoughts are already present, alternatives are further considered. Completely unaware, I had left Mary’s room without a vitally important aspect of her history. Although the medication could improve how she was feeling, giving Mary this antidepressant could contribute to a negative and permanent change to her life.
We returned to Mary’s room and learned that my preceptor’s inquiry was especially important in our visit. I observed the connection that he made with Mary, gathering key information and using her responses to create a treatment plan. We discussed our options and decided to prescribe Mary a different medication. Although the conversation was difficult and personal for Mary, my preceptor’s kind but direct questioning inspired me to better obtain a more complete medical history out of each of my patients.
Someday I may encounter a sister, brother, friend or neighbor sitting in the corner of my examination room. In spite of the familiarity, I need to work towards gaining an unbiased and more complete understanding of the information which could impact their health. Like with Mary, I look forward to understanding who my future patients are, and how best to treat them, through asking the right questions. This will probably not be the last time I walk into a room, and see my sister.
*The patient’s name has been changed to ensure privacy.