So this is an encore performance Clinical Problems in Consultation Psychiatry (CPCP) presentation by Dr. Aubrey Chan, who authored the one on catatonia recently. It’s also his internal medicine noon conference talk. He’s an R2 in the UIHC Internal Medicine-Psychiatry combined residency program and these presentations are given in the William B. Bean Conference Room, which is named after Dr. Bean, who was the head of internal medicine here at Iowa decades ago. As a side note, Dr. Bean had a connection to what we now call the Somatic Symptom and Related Disorders category in the Diagnostic and Statistical Manual of Mental Disorders, 5th Ed. One of the changes in the DSM-5 was to subsume Factitious Disorder under the somatic symptom disorder category.
It turns out Dr. Bean wrote a very long poem about Factitious Disorder, entitled “The Munchausen Saga,” published in 1959 in three journals that I know of, Perspectives in Biology and medicine, Perspectives of Biological Medicine, and Transactions of the American Clinical and Climatological Association. It goes on for several pages about a patient known as the Indiana Cyclone who was admitted to our hospital in 1954 and who had a florid case of Factitious Disorder…and who was also probably a malingerer. Bean’s poem was based on the case report by Chapman, published in JAMA in 1957:
Chapman, J. S. (1957). “PEREGRINATING PROBLEM PATIENTS-MUNCHAUSEN’S SYNDROME.” J Am Med Assoc 165(8): 927-933.
Physicians in the United States may be unaware of the patient who spends his time going from place to place, resulting in wide travels, and presenting himself to hospitals, with a fanciful history and extraordinary complaints. It is not uncommon for these patients to have many surgical scars crisscrossing their abdomens, and willingly to allow further surgical procedures to be performed, regardless of the dangers. Publicizing case histories of such patients seems to be the only way of coping with the problem, which exploits medical services that could be put to better use.
Dr. Bean was renowned as a brilliant and colorful speaker and “…a masterful teller of tales…,” although not a teller of tall tales as are those with Factitious Disorder. In fact, we flatter ourselves as psychiatrists for our ability to distinguish between somatic symptom disorder, factitious behavior patterns, malingering, and conversion reactions–which would necessarily entail a miraculous talent for divining the motivation for each of these problems, a debatable presumption at best.
However, Dr. Chan tells us his story about somatoform illness with practicality, humility, and empathy–which are probably among the best attributes of all doctors, regardless of their erudition.
Returning to his R2 talk to the other internal medicine residents I mentioned earlier, I was happy to have an opportunity today to attend it. Of course I’m biased because I’m one of his teachers, but I think he did an outstanding job. When he finished, I noticed that his peers had excellent questions, most of them centering on how to communicate the diagnosis to the patient (especially in the era of the electronic health record to which the patient may have access) or how to tell them “no” when they ask for medications or other treatments which may not be indicated and not in their long-term best interests.
Aubrey had very good answers focusing on emphasizing a return to greater functional ability while validating concerns and instilling hope while eschewing the delivery of diagnostic labels that send mixed messages about whether or not the patient’s concerns are “real.”
At times, as his teacher, I felt like adding a comment or two but I stifled myself, not just because time was limited–but because Aubrey will be a leader and I needed to let him lead to allow him to grow in that role. Aubrey already has his own words for kindly telling the truth to patients and how to convey to his colleagues the importance of saying “no” to patients in order to ensure their safety, even at the possible cost of incurring their displeasure. He already knows how to tell residents and faculty that telling patients in plain language what is both wrong and right with them is hard but is a learnable skill and a powerful art.
Aubrey also tells me he doesn’t smile well for the camera. Judge for yourselves.
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