This lady worked as a consultant archaeologist, but seemed to be abnormally bothered by her Epidermal inclusion cysts - a thing I noted on her initial consultation several weeks ago.
On Friday, she called my nurse while she was driving to her surgical appointment at my office - she was about 10 minutes late, and was extremely agitated and crying while driving. My nurse gently talked her in to the parking lot of my office, and then ushered her into the surgical suite.
I then met her and talked her into a state of calm - all while noticing the fact that the left side of her head seemed to be missing a lot of hair, and that her scalp was terribly excoriated. One of the cysts that I was supposed to excise was missing and the area over top of it was excoriated.
We chatted for a while during the surgery to remove the larger of the scalp cysts, and what I discovered was that this poor, gainfully employed professional had been suffering from severe Trichotillomania (A compulsion to pick at one's skin or hair) since her University years. Prior to that, she had been suffering from a lifelong generalized anxiety disorder. She had a normal, happy childhood with normal relationships and normal parents.
She stated that she had been treated initially by a Physician with Luvox, but that the efficacy of the medication wore off years ago. When her Physician left, she saw various Docs at walk-in clinics that would variably refer her to a Psychiatrist with a years-long waiting list.
She then lost faith in walk-in clinics, and continued to suffer and just "live with her illness" for a number of years. The Doc that referred her to me knew nothing about her illness and did not appear to have made any commentary about her trichotillomania on the referral note.
It was interesting that while technically, I was performing a surgical procedure on her (elliptical incision, cystectomy, rotation advancement flap) - what I was really doing was taking a proper psychiatric history....a medical procedure that would make a far larger difference to this lady's life than the surgery I was performing on her.
Ironically, I was being paid much more to do the surgery than I would have been for the Psychiatric history and diagnosis.
But at length, the surgery was complete and I was able to determine that the lady suffered from Trichotillomania as a compensatory response to a severe ongoing somatic generalized anxiety disorder.
I am not a Psychiatrist. I would have really liked to send this person to a Psychiatrist. But a referral to a Psychiatrist that will see her for an ongoing therapeutic relationship, takes at least 2-3 years in Calgary - if the referral will be accepted at all.
So while I lament that I will be unable to see this patient again (my Family Practice is closed) for the ongoing Psychotherapy that I know she will need, I was able to start her on the Effexor that I think will make a significant positive difference to her life.
I have to see her in two weeks to remove her sutures - and at that time, I will hopefully find out whether or not she is covered for a private Psychologist. If she is covered, I will refer her on to one of the very fine Psychologists that I have been referring to for a number of years.
This case just highlights the suffering of people that fall through the cracks as Family Physicians abandon working in their traditional areas of expertise that depend upon long term Physician Patient relationships.
While walk-in clinics serve a vital and valuable role, I believe that society is slipping slowly but surely into another kinds of "dark ages" of medical care when we accept the limited services that they and the Emergency Rooms can provide as our highest standard of ongoing care.
I would like to teach students to do what I do - and to show them how to thrive financially while they do it...but I've learned that each student costs me a fortune/day to keep in my office (we don't get paid to teach students). The $5000 at least per month a student would cost me would be far better spent on a savings plan for my kids' education as well as my retirement plan.......
So for now...we'll make change one patient at at time.....