Case Description:
As a primary care physician, you have found your relationship with 24-year-old Peter both particularly challenging and particularly rewarding. When Peter first came to you at 18, after aging out of pediatric care, he was sullen and resentful, claiming he hated all doctors and “so- called helpers.” His pediatric records were incomplete and confusing. He has come to trust you over time, referring to you as “my good doc.” Peter is a skilled computer graphic designer with a stable job. Generally healthy, he has struggled with generalized depression and anxiety which you have treated with anti-depressants, with moderate success. Peter has always resisted your consistent advice to seek therapy from a psychologist or social worker to explore reflectively his patterns of depression and anxiety. Your impression of Peter’s family is that while unconventional, it is a loving and supportive family. Peter refers to his family as “my cool crazy family.”
You are beginning to suspect, though you are not certain, that Peter may be experiencing the onset of bi-polar disorder. You do not feel qualified to evaluate, diagnose, or treat serious psychiatric disorders. You try to refer Peter to a psychiatrist for further evaluation, but he refuses. You share your concern that bi-polar disorder is one possibility, and one you would not be qualified to treat. But Peter steadfastly refuses to see a psychiatrist. He says: “You are my good doc. I trust you. You tell me what to do for this.”
What should you do?
Discussion of Case:
Get the facts:
- Are there any primary care guidelines, primary care assessment protocols, or family history intakes that could assist you to further assess the likelihood or unlikelihood of your suspected diagnosis (bi-polar disorder)?
Ethical tensions:
- In this case, one tension is between the role of a primary care doctor and the role of a psychiatric specialist. How much psychiatric evaluation should be considered within the scope of primary care? And is this particular physician—you, in the case—adequately trained for what is required to evaluate Peter?
• You may feel tension between two targets of beneficence. “Doing good” by maintaining patient trust and respecting patient comfort level with practitioners may be in tension with “doing good” by getting the most expert medical care for your patient.
Identify Options:
- Tell Peter that you do not feel comfortable assessing his diagnosis and treatment without further assistance of a specialist and that therefore consultation with a specialist is a precondition for your continuing to be his doctor. At the same time, emphasize you would work with that specialist and continue to be his primary care doctor if he agrees.
- Ask Peter’s permission for you to consult with a psychiatrist about his case, sharing his medical records, so you feel better able to serve as his physician.
- Prescribe Peter a trial period of a common prescription/dosage used to treat bi-polar disorder. Evaluate whether he seems to improve on the protocol.
- Other?
-
Getting permission for you to consult on his case without him could be one way of balancing respect for patient autonomy and your desire to pursue medical beneficence (best standard of care).
-
If you decide to treat presumed bi-polar order as a primary care physician, you could put time or improvement conditions on your willingness to continue to treat without a consulting specialist.
- Support efforts within medical education to improve primary care practitioners’ ability to recognize and assess common psychiatric illnesses.
- Support efforts in medical organization to provide patients with a “patient-centered medical home”-- where any specialty consultation will be relationally integrated with the patient’s primary care doctor.