Today we had a small group discussion for on of my classes, and were instructed to talk about possible causes for a patient's heart failure. We came up with the usual ones, like myocardial infarction or congenital abnormalities, but the case description was not totally straightforward, so we tried to come up with some of the more obscure ones as well. In the course of our continual brainstorming, one of my classmates declared: "It could be all in his head. Psychosomatic is always in my differential!"

Whoa. To me, that was an incredibly insensitive thing to say. Yes, I know that these cases do exist, where there is no identifiable medical cause for a patient's symptoms. But to say it's always one of the main possibilities you think of? No way, not for me.

I think as doctors we owe it to the patient to assume that whatever he is describing is real and based on something we can help with. Several years ago, when my mom was going through a period of major medical distress, she was basically told by one of her doctors that she was crazy and to go talk to a psychologist about it. (She wasn't; a different doctor identified the real cause and treated her successfully.) To this day, when she tells me about it, I can tell it was such a hurtful experience. In reality, I doubt that doctor was trying to be mean; he probably did feel like he had exhausted his diagnostic options. Still, I know there must have been a better way to present that conclusion, including keeping options open for a second opinion.

When I am in practice, I will include psychosomatic cause on my differential, but I never want to consider it until I'm sure we've ruled out any other possibilities. Of course, this may change as I get more clinical experience; many of these sort of "when-I'm-a-doctor-I'll..." convictions have already been overturned in the short time I've been in medical school. I hope that this one, at least, will stick with me as I can imagine nothing more devastating to a patient in distress that his doctor has given up on finding out the cause. I'd rather say, "I'm not sure what's going on, but we'll work through it together."