Guilt

Being a primary care doctor is a privilege in many ways. It is also a sacred position of trust. What is said in a doctor's office is, very few legal exceptions, never to leave the room. Of course, in the day of the electronic medical record, that is not entirely true, or is it? How much of what a patient tells you belongs in their medical record? Most would argue, effectively I think, that personal information divulged in the course of the encounter may not always belong in the record. Such information might be a personal event -- a child winning a ribbon at a competition, or a vacation story. The electronic medical record is accessed by numerous healthcare providers that care for a patient in the course of time. With the HITECH and HIPAA laws, accessing this information without a direct clinical context is a breach of law. However, what if a primary care provider records information divulged in conversation during the physical or during the office visit with their doctor? What if they record this information as part of the documentation?

Okay, this is a long preamble to what I really want to say in this piece. I have a couple of patients in my (young) practice that have varied medical complaints for which I have not been able to find an organic cause. I may add, it is not for want of looking. Healthcare dollars have been spent in procedures, tests and consults, all with no fruit. In both cases however, each patient has something they have done that they seem guilty about. They don't say they feel guilty. But their body language, the looking down, the averting the gaze, the downturning of the corners of their mouth, the sudden change of expression all say it.

There are numerous stories in literature about guilt affecting peopel in different ways, including symptoms of physical illness. Is this what is wrong here?

I have another patient who was abused as a child and is dealing with multiple phantom pains. I sometimes wonder if forgiveness is the 'cure' rather than the years of continued pain medications and periodic absences from work with physical therapy to achieve recovery.

I shall not leave myself out of this equation: I have guilt too. At the end of an exhausting day of planned and unplanned clinical encounters, phone calls, nurse notes, impromptu meetings with colleagues, residents, allied health providers and teaching, I am spent. I leave my office guiltily, leaving a desktop full of notes to be dictated, phone calls to be returned, requests from colleagues, students and residents for this or that -- things I am too tired to do. Did I do right by my patients that day? What about the one that left frustrated because I was running late and she couldn't wait anymore? Did I miss something? Did I miss the right decision in sending this one home? Should I not have admitted that one?

Guilt.

Is treating this root of medical problems within the scope of my practice? Should it be?