I believe inter-collegial courtesy is of the highest importance in medical practice. If it is not observed it may have unfortunate consequences for the patient, as well as for the professionals involved. ‘Unfortunate’ is putting it mildly – it could have been fatal in the case I shall relate.
Some years ago a patient came to see me with massive bruising all down one side of his body. He was also suffering from symptoms of depression. In those days I was very busy with my general practice and didn’t have time to take on another patient for regular hour-long psychotherapy sessions. Therefore I referred him to a colleague, a woman lay therapist whom I knew and who had, I thought, quite a good reputation among the foreign population of Tokyo.
I heard nothing further until this patient turned up again three weeks later with the bruising. The story was as follows: the psychotherapist to whom I had referred him turned out not to have confidence enough to treat him herself; she referred him on to another practitioner, a Japanese psychiatrist. The psychiatrist, in the way that psychiatrists do, prescribed him an antidepressant. Unfortunately he omitted to take a work history, that is, to ask the patient what he did for a living. Or maybe he did ask but failed to take this information into account in his prescribing.
The patient was a professional racing driver. I have known several racing drivers in my career; they were all rather interesting, introverted people. The job requires athletic physical fitness combined with intense concentration; you need the ability to make split-second decisions. Yet it is quite a lonely sport – you are most of the time strapped into the cockpit of the car with little direct human interaction. The 1966 film Grand Prix shows this rather well, I think.
What is absolutely clear is that when you are driving at speeds which may exceed 300kph (186mh) there is no margin for error. Your mind must be unclouded – or the results could be fatal to yourself or to other people on the track.
Under the circumstance the antidepressant was ill-advised. Such drugs all have side effects which can include drowsiness. This may not matter too much in ordinary life but they are absolutely contraindicated (must not be used) in a racing driver! Before this treatment he was fine in the car even though he was depressed; it is in a way a meditation – when racing you cannot think of anything else than the job in hand.
The patient had been in a crash and nothing worse had happened than the severe bruising; he was lucky.
Why, oh why, did the psychotherapist take it upon herself to refer the patient on to someone else without conferring with me? Did she think, because of my well-known reluctance to use mind-drugs, so-called antidepressants, the patient was not safe in my hands? Apart from the potentially fatal outcome indirectly due to her failure to refer back to me, this was a lapse of common courtesy. Needless to say I never referred her another patient.
This incident highlights another problem that is especially evident in Japan: the lack of a general practitioner who is recognised as being in overall charge of the patient’s medical situation. What often happens is that a person independently consults specialists at different hospitals; there may be little or no communication between them. This fragmentation of care can result in reduplication of tests and treatment or inappropriate prescribing. Also, hospital doctors often work in rotating training schemes and the patient may not see the same doctor twice. If there is a query, whom should the patient approach? If there is no general practitioner, who will provide continuity of care?
Text © Gabriel Symonds