Saturday, June 18, 2011

Munchausen's by Doctor: A Previously Unrecognized Entity

One of the most important jobs of a pediatrician is to imbue parents with self-confidence. Instead, we often confuse them, scare them and fill them with self-doubt. This can have a long-term detrimental effect on the parent-child relationship. Parents whose child experienced an illness early in life can fall prey to the Vulnerable Child Syndrome, where they perceive that their now healthy child is still somehow medically fragile and prone to illness. This not only can result in unnecessary medical interventions; it can lead to behavioral and developmental problems in the child.

Why do doctors create the belief that children are ill when they are not? For starters, with the exception of checkups, every encounter a child has with his physician results in a diagnosis. This is obligatory, as physician visits are compensated by insurance companies based on diagnostic codes that are catalogued in a constantly updated publication known as the International Classification of Disease Manual or ICDM. There is no code for "healthy child" or "normal", though there is code V65.5: "Person with feared complaint in whom no diagnosis was made" or "worried well". But physicians who use this code run the risk of not getting paid for the visit. Insurance companies view such encounters as superfluous. No, it's safer, from a financial standpoint, to report that the child was sick.

So most children are assigned an ersatz diagnosis to justify a medical visit. From the doctor's perspective, the diagnosis is tentative and plays more of a bookkeeping function than a medical one. There is danger in this. Diagnostic labels tend to stick. What was a provisional diagnosis, long discarded by the treating physician, becomes a permanent part of the medical record. And the diagnosis remains cemented in the parent's mind. That perfect little baby is no longer perfect. He has "Reflux". He is sick. He is vulnerable.

The tendency to diagnose illness in healthy children is also driven by the failure of many pediatricians to recognize the wide range of normal when it comes to children's behavior, development, growth, and pattern of expulsion of bodily contents from various orifices. Differences in doctors' confidence in their clinical skills, variations in comfort in dealing with uncertainty, and unique personality traits of the physician all lead to wide discrepancies in how symptoms are interpreted. I have met many a neurotic pediatrician who instinctively sees a tempest when a lonely cloud drifts across a blue sky. These doctors tend to have practices full of high strung parents.

In some instances doctors jump at the chance of making an "interesting diagnosis" to relieve the drudgery of seeing an endless parade of runny noses. In the television coverage of a recent devastating earthquake, I was surprised to learn that in order to keep search and rescue dogs from becoming discouraged, human volunteers hide in the rubble from time to time so that they can be "found". This is essential to keep the dogs keen and it has a salubrious effect on their psychological well-being. I believe doctors have the same need. If a "good find" is not available, a doctor will sometimes just make one up.

I once attended a drug company sponsored lecture featuring a distinguished visiting allergist at a restaurant with gaudy Victorian d├ęcor. Having arrived early, I was invited to dine with the scheduled speaker and a local family practitioner who had also come early for the talk. The family doctor, a kindly gentleman whose long face was exaggerated by his bald pate, started describing a very interesting case he had seen some weeks earlier.

A middle aged man presented to his office with a hacking cough. Further discussion brought to light that the patient owned a parrot. The family doctor paused for effect, smiled, leaned forward as if revealing a secret and said, "The gentleman had Psittacosis".

Psittacosis, also known as "parrot fever", is an infection caused by the bacteria Chlamydiophila Psittacci, which can be inhaled from bird droppings. The diagnosis is suspected based on history and physical and is confirmed by one of several blood tests.

"How interesting", said the allergist. "How did you make the diagnosis?"

The smile vanished from the family doctor's face. He straightened his spine and said, "Sir, he had a parrot!"

The gentleman may have had Psittacosis, but the family doctor fell a little short of proving the diagnosis. And he was offended by the allergist's query which in effect questioned the validity of his diagnosis. The family doctor was proud of having made the diagnosis of psittacosis. To suggest that the diagnosis was wrong was like finding a live person in the rubble of an earthquake, only to be told he is a stooge.

What I am suggesting is that doctors get an emotional high from doctoring. Medical students experience this when they successfully insert their first I.V. Residents are overjoyed when they succeed in performing a spinal tap on an infant on their first try. And many doctors in practice like to boast that they have a high proportion of ill children on their patient panel.

There is nothing wrong in deriving pleasure from helping your fellow man, after all it is a common motivator for pursuing a career in medicine. But we must be sure that the procedure we are doing is in the interest of the patient rather than for our own mental well-being. Along these lines, I believe there is a previously unrecognized phenomenon that I have dubbed "Munchausen's syndrome by doctor".

Munchausen's syndrome, named after Baron Karl Friedrich von Munchausen, an eighteenth century German nobleman with a penchant for telling fantastic tales of his implausible feats and unbelievable exploits, is a condition in which an individual fabricates symptoms in order to receive medical care. It must be distinguished from malingering, which is the feigning of illness in order to gain a surreptitious objective (such as skipping work or defrauding an insurance company) in that the entire goal is to be a patient and assume the role of the infirm. It is also distinct from conversion disorder, an involuntary condition with psychological underpinnings in which an individual perceives symptoms consistent with a morbid condition even when the condition is not present.
Munchausen syndrome by proxy is a form of child abuse in which an adult (usually a parent) fabricates symptoms or induces illness in a child so as to get attention and fulfill a pathologic psychological need. Some parent groups argue that there is no such thing as Munchausen's by proxy, that it is a diagnosis invented by a callous medical establishment that is unsympathetic to the plight of parents whose children have true medical needs. Yet there is ample documentation, including the use of covert video surveillance in the hospital setting, that shows parents suffocating, poisoning and producing fractures in their own children.

I believe that there is a Munchausen Syndrome by doctor, where a perfectly healthy child is diagnosed with, and treated as having a disease for the pure psychological need of the treating physician. The parent becomes an unwitting accomplice, becoming thoroughly convinced that their child is terribly ill, always on the brink of a medical catastrophe, requiring multiple daily medications to allay a crisis. These children tend to be labeled with several diagnoses from a limited pool, most frequently asthma, gastro-esophageal reflux, gluten insensitivity, recurrent infections (bronchitis, sinusitis and ear infections), and allergies to multiple foods and medications. The child frequently presents to the Emergency Room with a shopping bag full of medications, often including Metoclopramide, Lansoprazole, Fluticasone, Montelukast, Levalbuterol, Tacrolimus, antihistamines and the ubiquitous antibiotic. And the child looks completely well despite the parents' and referring doctor's anxiety. And stopping the pharmaceuticals results in no ill effect.

I believe that Munchausen's syndrome by doctor is far more common than Munchausen by proxy, which has been estimated to affect 2 out of 100,000 children. As in Munchausen by proxy, there are, in my opinion, certain personality traits that are more common in those doctors that perpetrate Munchausen syndrome by doctor. These individuals are basically insecure, and try to compensate by interpreting every symptom in its most malicious form, falling victim to a neurotic paranoia which can be kept at bay only through the incessant ordering of laboratory studies and the prescription of treatment upon treatment. The offices of these doctors are almost always full, seeing as each patient requires frequent visits. And they attract ever more individuals who, in their state of anxiety, are oddly reassured by being told that their child is ill; but at least they are in the hands of a doctor that will see them over and over, and who will provide the most aggressive treatments (whereas the other doctor just kept telling them there was nothing wrong with their child).

Convincing a parent that her child is ill is a treacherous threshold to cross. The perception that one's child is ill always alters the way the parent views and treats her child. It can undermine the confidence and sabotage the effectiveness of a parent. Again, one of the most important jobs a pediatrician has is to reassure parents so they can be more effective and self-confident, yet we frequently do the opposite, either as a result of our own insecurity, out of sheer ignorance and, on occasion, because of a pathologic impulse to feel needed, appreciated and valuable.

Dr. Palmieri is a board-certified pediatrician and the author of "Suffer the Children: Flaws, Foibles, Fallacies and the Grave Shortcomings of Pediatric Care".

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