On the Nature of the Patient-Physician Relationship: A Case Study

Of the three fields, medicine, law, and divinity, the practitioner most widely esteemed and valued by society is the physician. In small towns across rural America it is not surprising to find an eminent physician virtually running local politics and affairs associated with his vocation. Though many times unwarranted, it is human nature to have such an innate respect for the leech. This sprit of admiration was much the case in the fictional New England town of Mount Ephraim, New York in February of 1976, when one physician was called, in the midst of a crisis, to do his duty, according to the novel, We Were the Mulvaneys, by Joyce Carol Oates. A female, age seventeen, attended the high school prom and afterwards attended two post- prom parties, during the course of which she had become intoxicated. A male, approximately one to two years older than the female, raped her after the second party (Oates 135). Medical attention for the victim was not pursued for several days following the assault (136). Proceeding such a traumatic event the most appropriate treatment, which, given that no irrevocable physical harm had been inflicted (135-6), should have centered on professional counseling for both the female and her family, was not achieved. The situation, once placed in the hands of the family physician, was terribly mishandled. As a complete result of not knowing how to handle the situation the family is ultimately unraveled. They are the type that put up a nice facade, but behind it they are weak and miserable. Much of what should have occurred in the physician’s office did not occur and what did occur was woefully inadequate, thus ineffective, in securing the goals to restore and repair what had been damaged. First, it is apparent that the physician was capable of attending to the girl’s current mental state. His reaction was initially compassionate, yet very characteristic of the ideal physician. “[…] [The doctor] urged her to sit, offered her a tissue, and spoke comfortingly to her, ” (134). He also demonstrated that he could be firm with the mother.

[The doctor]’s nurse escorted [her] into an examining room, and [the mother] would have followed them, but [he] suggested that it might be better is she waited [in the consulting room] […]. (135)

Second, from the girl’s reaction to being in the consultation room one can infer that she neither needed her mother, nor felt uncomfortable being in the presence of the physician. “In [The doctor]'s consulting room, […] [the girl] grew calmer. It was a familiar place,” (134). He should have promptly excused the mother, but possibly not to the waiting room as the mother, too, was emotionally unstable. Rather he should have let the mother remain in the consulting room with the nurse to tend her needs, and the physician should have taken the girl into an examining room where they would have been able to talk unhindered by the presence of two extra people, the nurse and the girl’s mother. Although, the physician eventually removes the mother from the equation when, at the girl’s suggestion (135), they go into an examining room finally, but the nurse accompanies them. Neither do they leave the consulting room and the mother with the intention of talking about the situation, but simply to give the physician an opportunity to determine what physical harm has been done. This assessment is not contradicting the notion that a nurse should have been present when the physical examination was preformed; rather, it is to emphasize the fact that in interviewing and counseling the girl the physician should have sought accomplish this in a more confidential manner. Third, he unfortunately further compounded the situation when he physically, thus psychologically, distanced himself from the girl and her mother and used his desk as a barricade.

“She could not bring herself to look at [the doctor] behind his desk, nor at [her mother]. […] [The mother] hugged her, herself in tears, as [the doctor] looked on, and [The mother] wept, wept as if her heart had bro­ken. And [the girl] sat stiff yet unresisting, allowing her mother to embrace her but not returning the embrace. (134)

The description alludes not only to the notion that the mother’s presence not only impeded the openness of the dialogue, and had a detrimental affect on the girl’s state, but that the physician has not done enough, and in fact has created more barriers than just the natural notion of being a medical doctor, to tare apart his image as the old unapproachable stoic clinical physician. From observation, the impression of feeling inferior to a clinical man is quite commonly manifested in children, adolescents, and adults alike as an automatic reaction, and this behavior does not need to be qualified by the presence of an uncompromisingly cold clinician to be exhibited. Therefore, it is the primary obligation of the physician to rectify the situation whenever and wherever it exists in order to establish an open; meaningful; and, ultimately, a successful patient-physician relationship, where success is measured by how much good can be done to aid the patient. This sacred alliance is explained in the American Medical Association’s “Fundamental Elements of the Patient-Physician Relationship” of the Medical Ethics Code number E-10.01.

From ancient times, physicians have recognized that the health and well-being of patients depends upon a collaborative effort between physician and patient. Patients share with physicians the responsibility for their own health care. The patient-physician relationship is of greatest benefit to patients when they bring medical problems to the attention of their physicians in a timely fashion, provide information about their medical condition to the best of their ability, and work with their physicians in a mutually respectful alliance.

Fourthly, the physician’s demeanor is contrary to what it should have been. Instead of confidently, yet compassionately and understandingly, addressing the matter he becomes visibly flustered. He allows it to be known how uncomfortable he is in handling the matter, thus, sacrificing the confidence of the family, chiefly the mother, as is inferred in the following passage:

He held a sheet of paper in his tremulous hands and frowned at it, as if his own handwriting perplexed him. […] “It's been several days since the assault and so there wouldn't be—I'm sure-“ and here [the doctor], the most gentlemanly of elder men, faltered, “-any traces of semen remaining.” […] [The doctor] was shaking his head, visibly nervous, frowning at the report in his fingers. He was a man whose courtly, warmly gra­cious manner could sometimes shade into awkwardness. (135-6)

The girl does not open up and permit herself to ventilate to the doctor partly because of his disposition and partly because of the mother’s presence, but instead sees him only as one concerned with physical injuries and not emotional ones. That is the picture that he paints by inquiring only about what physical harm has been committed, who has committed it, and where it was committed.

“Hurt [Jane]?” [The doctor] asked. […] “And where did this happen, Marianne?” […] “Who was the boy, [Jane]?" [The doctor] asked quietly. “What did he do to you?” […] [The doctor] said, frowning, “But something was done to you. [Jane]? You've been---hurt?” […] (134)

[…] [Jane] said calmly, looking now at [the doctor], “I am ready to be examined now, Dr. [Doe], I guess.” (135)

The physician demonstrates clearly that he is of the old Austrian (Central-European) school; that is to say his personality is condescending and autocratic in nature. The notion that a patient, or in this case her mother, would question him, the physician, is completely out of the realm of all possibility. As the physician, he welded absolute autonomy regarding the treatment of his patients according to this manner of thinking. (Chamberlain)

"It appears that your daughter has been sexually abused."

[The mother] was on her feet, anguished. “Oh God. Oh Jesus. She's been raped?” (135) […]

“There is evidence of 'forcible penile penetration,' yes. The hymen has been ruptured and there are bruises and lacerations in the vaginal and pelvic area and bruises elsewhere—thighs, abdomen, breasts.” […] (135-6)

“Raped? Marianne?”

“[Ma’am], she doesn't say-that. She hasn't said that, dear, you see.”

“But of course that's what it is, Dr. [Doe]! Rape.”

He said, carefully, “I've prescribed painkillers for your daughter, and something to help her sleep. She's a brave young woman, and it may be that you and [John] need to listen to her, and not,” again he paused, with a fastidious licking of his lips, “do anything rash.” (136)

Their "old" family physician foresaw the future for them, and, though he was in a position powerful enough to circumvent most, if not all of the coming tragedy, he did not. Much what he did was fine; although his manner was awkward, feeble, and, in a few instances, dictatorial in nature. It is rather what he did not do that permitted the emotional imbalance to exist. Works Cited: American Medical Association. “Fundamental Elements of the Patient-Physician Relationship” E-10.01. . 1990. Chamberlain, Dr. Robert. Lecture/Personal Interview. medical ethics and ethnic tendencies in medicine. Monday, February 2, 2004. Oates, Joyce Carol. We Were the Mulvaneys. New York: NY. Plume, Dutton Signet, Penguin Putnam. 1997.

Cysts of the Pineal Gland: a Review of the Literature Concerning the Incidence, Classifications, Diagnosis, Treatment, Physiology, and Anatomy

Family Practice Clerkship Summer 2005 Anatomy and Physiology. The pineal gland, situated at the, “posteriodorsal aspect of the diencephalons, [with] proximal portion […] invaginated by the pineal recess of the third ventricle, (Rowland, 2000)” and weighing ~130 mg, with a length of ~1 cm, is also a highly vascularized organ, served by the, “posterior choroidal branches of posterior cerebral arteries (Rowland, 2000).” The pineal gland functions both as an endocrine and neural organ and acts either directly or indirectly to impact all organs of the human body (Rowland, 2000). The pineal gland, acted on by norepinephrin, yields pineal indoleamines (Rowland, 2000). Innervation is by axons from brain via the pineal stalk, in addition to sympathetic innervation by: postganglionic axons perikarya from the superior cervical ganglia (Rowland, 2000). Cell bodies of the pineal gland communicate with the preganglionic fibers ending in ganglia of the intermediolateral cell column upper thoracic of spinal cord (Rowland, 2000). The neurons of intermediolateral cell column of spinal cord end in terminals from perikarya, hypothalamus, and paraventricular nuclei are connected suprachiasmatic nuclei that receive signals from ganglion cells of retinas via retinohypothalamic neural tract (Rowland, 2000). Incidence. Sawamura et al. (1996) found, in discounting cysts less than 0.5 mm, in their review of 6023 patients and 8623 MRI studies, an overall frequency of 1.3% of pineal region cysts. They speculate that pineal cysts begin forming, in women during adolescence, as its use wanes. Sawamura et al. (1996) noted pineal cysts are most frequent 5.82% amongst young (21-70) women, and using the chi square analysis found that young women had a p value of <0.001>Diagnosis Sagittal MRI to evaluate for the possibility of obstruction or occlusion of the proximal aqueduct and anatomical relationships relative to the pineal gland is indicated either when otherwise unexplained clinical symptoms are manifested, or previous CAT scan or MRI warrants such (Fetell et al., 1986). Clinical symptoms associated with pineal cysts represent both neural and endocrine function of the pineal gland. Rowland (2000) delineated (Appendix A, Table 1.) three symptom categories based on impairment and type of involvement, which include: increased intracranial pressure resultant of hydrocephalus, brainstem and cerebellar compression, and endocrine abnormalities. The following clinical symptoms have been most frequently found in association with pineal cysts and may occur in widely varying degrees and configurations, with regard to one another: Parinaud’s syndrome; headache, migraine without aura, migraine with aura, chronic migraine, hemicrania continna, unilateral headache; scotoma and transient inferior field deficit; paroxysmal papillary dilatations and contractions; mass effect; mesencephalic; diplopia; vertige; ataxia; long pathways deficit (Peres et al., 2004; Michielsen et al., 2002; Tartara et al., 1999; Konovalov et al., 1998). Imaging. Fleege, et al. (1995), via CAT and MRI studies, examined nineteen patients presenting with symptomatic pineal cysts, aged 15-46 years, comprising five male and fourteen women. Fleege et al. (1995) concluded, citing the broad spectrum of configurations observed regarding the pineal cysts, distinction could not be made, via MRI or CAT studies of the pineal cyst in question, between a benign cyst and a pineal region neoplasm. Barboriak et al. (2001) showed 75% of pineal cysts changed <2>Pathophysiology and Anatomy of Pineal Region Cysts. Todo et al. (1991) noted three primary defining characteristics of large benign pineal cysts in a study of two middle-aged patients in whom the cysts were an incidental MRI finding. These characteristics include: a three-layered cyst wall, including: (1) collagen fibrous layer, (2) gliaic layer, (3) and pineal cell layer; cysts walls typically measure 100-300 microns; calcification was found associated with the first layer of cyst walls. Tamaki et al. (1989) found pineal cysts have greater opacification than cerebrospinal fluid and less than other regional anatomical structures using T1-weighted images were used in MRI, and smooth margins and homogenous contents were observed using T2-weighted images in MRI. Fain et al. (1994) redefined the second layers as follows: (2) pineal parenchymal cells with calcifications possible, (3) hypocellular glial tissue with or without Rosenthal fibers including, or occurring individually, granulations. It was also observed the cyst walls ranged from 0.5-2.0 mm (Fain et al., 1994). Lee et al. (1987) noted that in their fifteen patients cysts were midline, with flattening of the superior colliculi and no mass effect. Hardy (1996) notes intracystic bleeding is a major contributory factor in cyst growth. Mario et al. (2004) speculates that dysfunction in melatonin production and secretion may be associated with pineal region cysts. Treatment. In the literature the two most frequently addressed interventions are “open-surgical” and stereotactic methods and likewise are most prominently addressed here with regards to the other currently employed procedures. Treatment can include: radiotherapy; chemotherapy; open surgical resection via infratentorial, supracerebellar, suboccipital craniotomy, or occipital-transtentorial; endoscopicopy, via either free-hand method, or stereotactic biopsy, with possible shunt placement in patients with recurrence, or in asymptomatic patients, cautious clinical monitoring, with no intervention until symptoms present. Although 33.3% of pineal region tumors are benign and curable with complete surgical resection, rarely are symptomatic pineal region cysts benign (Rowland, 2000). Prognosis for such patients is heavily contingent upon the histopathology of the cystic tumor (Rowland, 2000). Radiotherapy, 5,500 cGy total focused on the cranium, and partially in the pineal region, is standard for all pineal region malignancies (Rowland, 2000). Unless metastasis is indicated radiographically, the vertebral column is generally not targeted in such therapeutic interventions (Rowland, 2000). Chemotherapy of pineal region malignancies is employed often in concert with radiotherapy regarding nongerminomatous malignant GCTs, using variations of cisplatin, vinblastine, and bleomycin or cisplatin and etoposide (Rowland, 2000). Musolino et al. (1987) cites the possible risks of surgical intervention, but as demonstrated by Konovalov et al. (1998) and Maurer et al (1990), these views are largely unfounded; whereas, there is a significant risk of recurrence and complication from such associated with stereotactic diagnosis and treatment method. With complete surgical resection, both complete diagnostic studies and one-time complete treatment is achieved, without the possibility of follow-up measures, the exception being chemotherapy and radiotherapy of malignant cysts. Mena et al. (1997) provided evidence in support of surgical resection of pineal cysts, showing that one patient who had stereotactic treatment, suffered recurrence and another who had no treatment died of associated cystic complications. Konovlov et al. noted that surgical outcomes for resection could be very good in the above noted approaches and made recommendations accordingly. Tartara et al. (2000) recommend the infratentorial-supracerebellar approach, which allows the best and safest entry. Fetell et al. (1991) reports on nine patients who underwent uneventful suboccipital craniotomy and suffered no mentioned complications. MacKey et al. reported on a 7-year-old-boy who underwent occipital-transtentorial resection of a pineal cyst. The authors make strong recommendations for surgical intervention for the following reasons: (1) resect with wide margins, (2) mitigate recurrence, (3) limit other future cystic complications, (4) mitigate need for shunt placement in patients with hydrocephalus, (5) increase sample size for testing, including histoimmuniochemical and biocytopathologic analysis. They especially point to the potential for stereotactic biopsy to not meet the above-noted criteria; thereby, necessitating further invasive intervention. Michielsen et al. (2002) makes recommendations for rigid endoscopic treatment of pineal cysts. In review of seven symptomatic patients, of which four were treated endoscopically, three free-handed and one stereotactically. Two patients underwent ‘open surgical resection.’ The mean follow-up period was 29 months, with the endoscopic patients were asymptomatic and the other two patients symptomatic. Musolino et al. (1993) noted stereotactic biopsy is effective in diagnosis and treatment of pineal cysts and they point out that is does so without many of the risks associated with conventional surgery or radiotherapy. Stern and Ross (1993) describe the stereotactic treatment of two patients, in which a shunt was employed in the one after recurrence and the other remained well for the 30-month follow-up period. Both patients had benign cysts, of which was comprised ‘brown-yellowish’ fluid. Cytologic and histoimmuniochemical studies confirmed the nature of the cysts. Behrems and Ostertag (1993) retrospectively reviewed seven patients who underwent stereotactic biopsy, five of whom had, ‘clinical recovery or marked improvement,’ over the 20-month mean follow-up period. The authors make recommendations for stereotactic treatment based on the notion confirmatory diagnostic tests can be conducted with sample aspirated, in a minimally invasive procedure. References. Baboriak, D. P., Lee, L., Provenzale, J. M.: Serial MR imaging of pineal cysts: implications for natural history and follow-up. AJR. 176:737-743, 2001. Behrens, P., Ostertag, C. B.: [Stereotactic procedure in pineal cysts] [Article in German] Fortschr Neurol Psychiatr. 61(8):284-9, 1993. Fain, J. S., Tomlinson, F. H., Scheithauser, B. W., Parisi, J. E., Fletcher, G. P., Kelly, P. J., Miller, G. M.: Symptomatic glail cysts of the pineal gland. Neurosurgy. 32(2):315-20; discussion 320-321, 1993. Fetell, M. R., Bruce, J. N., Burke, A. M., Cross, D. T., Torres, R. A., Powers J. M., Stein B. M.: Non-neoplastic pineal cysts. American Journal of Neuroradiology, 7(6):1081-1086, 1986. Fleege, M. A., Miller, G. M., Fletcher, G. P., Fain, J. S., Scheithauser, B. W.: Benign glial cysts of the pineal gland: unusual imaging characteristics with histologic correlation. Pediatr Radiol. 25(4): 254-248, 1995. Konovalov, A. N., Spallone, A., Pitzkhelauri, D. I.: Pineal epidermoid cysts: diagnosis and management. J Neurosurg. 91(3):370-4, 1999. Lee, D. H., Norman, D., Newton, T. H.: MR imaging of pineal cysts. J Comput Assist Tomogr. 11(4):586-90, 1987. MacKay, C. I., Baeesa, S. S., Ventureyra, E. C. G.: Epidermoid cysts of the pineal region. Mena, H., Armonda, R. A., Ribas, J. L., Ondra, S. L., Rushing, E. J.: Nonneoplastic pineal cystics: a clinicopathologic study of twenty-one cases. Journal of Neurology, Neurosurgy, & Psychiatry. 56:207-208, 1993. Michielsen, G., Benoit, Y., Baert, E., Meire, F., Caemaert, J.: Symptomatic Pineal Cysts: Clinical Manifestations and Management. Acta Neurochirurgica. 144(3):233-242, 2002. Mondera, M., Marcol, W., ska-Macyszyn, G. B., Kluczewska, E.: Pineal cysts in childhood. 2003. Musolino, A., Cambria, S., Rizzo, G., Cambria, M.: Symptomatic cysts of the pineal gland: stereotactic diagnosis and treatment of two cases and review of the literature. J Comput Assist Tomogr. 11(4):586-590, 1987. Peres, M. F. P., Zukerman, E., Porto, P. P., Brandt, R. A.: Headaches and Pineal Cyst: A (More Than) Coincidental Relationship? Headache: The Journal of Head and Face Pain. 44(9):929 2004. Petiteolin, V., Garcier, J. M., Mohammedi, R., Ravel, A., Mofid, R., Viallet, J. F., Vanneuville, G., Boyer, L.: [Prevalence and morphology of pineal cysts discovered on pituitary MRI: review of 1844 examinations] [Article in French] Neurosurgy. 32(2):310-314, 1993. Rowland, L. P.: Merritt’s Neurology (10th ed.). Lippincott Wiliams & Wilkins, 2000. Pp. 99-103; 342-347. Sawamura, Y., Ikeda, J., Ozawa, M., Minoshima, Y., Saito, H., Abe, H.: Magnetic resonance images reveal a high incidence of asymptomatic pineal cysts in young women. Journal of Clinical Pathology. 49:267-269, 1996. Stern, J. D., Ross, D. A.: Stereotactic management of benign pineal region cysts: report of two cases. Neurosurgery. 32(2):310-4, 1993. Tamaki, N., Shirataki, K., Lin, T. K., Masumura, M., Katayama, S., Matsumoto, S.: Cysts of the pineal gland. A new clinical entity to be distinguished from tumors of the pineal region. Childs Nerv Syst. 5(3):172-6, 1989. Tartara, F., Regolo, P., Terreni, M. R., Giovanelli, M.: Glial cyst of the pineal gland: case report and considerations about surgical management. J Neurosurg Sci. 44(2):89-93, 2000. Todo T., Kondo, T., Shinoura, N., Yamada, R.: Large cysts of the pineal gland: report of two cases. Neurosurgery. 29(1):101-5, 1991. Vajtai, I., Bodosi, M., Vargaa, Z., Ormos, J., Varos, E. [Symptomatic glial cysts of the pineal gland: report of two cases and review of the literature.] [Article in Hungarian] J Neurosurg. 80(3):454-460, 1994.