Juan C. Alvarez, Jr., is a third-year medical student at the Herbert Wertheim College of Medicine. Here, Juan shares an important lesson for health care professionals dealing with a patient who often “cries wolf.” Juan’s narrative first appeared in Reflective MedEd.
Aesop was a Greek slave and storyteller from the 600s BCE who is accredited with the authorship of many common stories and folklore. One of his most well-known stories is of a Shepherd boy who was well-known throughout his village as a “prankster”. His most well-known prank was to call the entire village to his aid in fighting off a wolf from attacking the town’s flock of sheep. Time and time again the town would gather their weapons and run to the pasture just to find a young boy laughing as he was able to make a fool of the entire town. After continued false alarms, the town eventually caught on to the boy’s foolishness and decided to no longer entertain the “prankster” by rushing to his cry for help. At first, the boy did not give this much thought as he assumed the joke was just overused. Nevertheless, he, unfortunately, learned his lesson at the cost of his life when the town did not rush to his cry for help in the presence of a real wolf. The lesson to be learned from this story is that once someone is marked as a liar, no one would believe them, even if they are telling the truth.
While this is a great life lesson on how to portray yourself to others, I believe the story should have a different meaning for physicians with their patients in the medical field. If just one person, even though the boy was an established liar, had rushed to the boy’s aid, he may have survived his encounter with the Wolf. This is immediately what I began to think of during my emergency medicine rotation when I witness how a bias towards a patient could have potentially come at the cost of their life.
“Frank” was a homeless person suffering from addiction to heroin and opioids who was considered a “frequent flyer” within this particular emergency room. He was well known among the staff as he had visited the emergency room upwards of 50 times in the last year in attempts of obtaining pain medication for a false illness. The patient had “cried wolf” for everything from broken bones to a heart attack to abdominal pain: he apparently had even hit himself and claimed he was attacked. After a while, the medical team started to entertain his complaints less and less as each visit always ended up in a negative work up and the patient would leave when he realized he wasn’t going to “score” some free drugs. This continued until one day Frank came in with severe abdominal pain. My attending physician, knowing Frank was a “frequent flyer” for drugs, thought it would be a great learning experience for me as a 3rd-year medical student to conduct a history and physical. So he asked his colleague who oversaw Frank’s care that day if I may evaluate the patient.
Not yet knowing any information about Frank or his extensive history of drug-seeking behavior, I began to take a full history and perform a physical exam just as I would any patient. As the encounter progressed, I began to rule up and down my differential diagnosis until I believed his presentation was consistent with a bowel obstruction. Feeling confident with my history & physical, I finished up with Frank and return to the doctors to present my findings. Throughout my presentation, based on the look on their faces, I started to realize they knew something I didn’t. Once I finished, they both laughed and said that I had been fooled by a great actor. Still lost I asked for clarification which is when they explained Frank’s history as a frequent flyer with drug-seeking behavior. I followed with questions along the lines of “How do you know he’s faking it?” The colleague replied, “I’ll show you” and had me follow him towards Frank.
During this second encounter, the colleague mostly spoke over, brushed off much of the complaint, and accused Frank of making up his symptoms. It was even stated that he was taking resources away from patients that “actually” need them. We then walked out of the room without conducting another physical exam and I was told “You see, that’s how you can tell they are drug-seeking.” I was then sent back to my attending who asked me about the experience and wanted my honest opinion on the situation. With the freedom to speak my mind, I told him regardless of the patient’s history of drug-seeking behavior, I didn’t think the patient needed to be treated like a dog by the other physician who put little effort into questioning Frank. How could we be sure if he was acting or not, especially since there was no physical exam conducted by the doctor? After some back and forth with my attending, he decided that it was a good idea for us to evaluate “Frank” one more time, this time conducting a physical exam.
In the room for a third time with Frank, his story was consistent again. As my attending performed a physical examination, I could see he was becoming more convinced this may not be another episode of drug-seeking behavior. We then walked out and advised the colleague to order a CT scan which he was reluctant to do until my attending told him “If he isn’t faking it and you refuse to evaluate him, he could die or live and sue you.” To which he replied, “Fine but it’s a waste of our resources plus a drug addict can’t afford a lawyer”. Less than 2 hours later, the surgical team came down and took Frank to immediate surgery for a large bowel obstruction which is a medical emergency.
Reflecting on this situation I realized that as physicians our profession comes down to simply being there for each patient and treating them with dignity and respect regardless of their past. As my attending put it, “Drug addicts get sick too, and there’s no reason why their life and health matter any less than someone else’s”. By being allowed the privilege to practice within an art focused on the healing of others, we carry the responsibility to treat everyone as equals. This means doing everything within our ability to help them improve from their current state as all life is precious, regardless of any label society places upon certain people. As physicians, we need to be prepared to take on the wolf regardless of all the false cries in the past.