Summary

One of my otherwise healthy patients went through a severe family crisis. My patient, N, suffered a deep depression, triggered by post-surgical impotence. My desire to help him, together with an unique relationship between a trainee of mine and the patient’s family, became a triangle of a healing team with a happy ending. My story prompts me to reflect upon physician-patient relationship that has much meaningful results in family practice. As family physicians, we often treasure these unique stories in our memory.

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The “Clalit” health maintenance organization (HMO) is a large medical insurance scheme plan in Israel covering more than 60% of the population. Its health care coverage is roughly similar to that of prepaid HMOs in the United States. For a monthly premium, comprehensive medical care is provided either directly through the HMO itself or indirectly through contracts with the government. All visits to the family physician are free of charge and there are only few co-payments. A typical primary care clinic serves a population of about 8000. The patients are registered in the GP’s list and usually patients need to see a GP or the family doctor before seeing a specialist. They can choose whichever HMOs’GP they want, but they have to be registered in his list as their family physician. This usually creates long term relationships between GPs and patients especially in the rural areas.

N was a 68 years old man living with his wife in a small town in northern Israel. He retired from work seven years ago.

He was born in Iraq, and he came to Israel as a child. Because of financial difficulties in the family, he had to leave school early and to go out to work. He married young and had nine children. Four of his children had progressive degenerative muscular disease. Two of his children were living in a care institution.

I was N's family doctor for many years. He was a hard working and supportive man whose time was mostly spe nt at tending to his family's need or at work. Concerning religious beliefs, he was a traditional Jew. He adjusted easily to retirement. In the morning he enjoyed attending a day centre for retired people and during the rest of the day he spent his time with his family. He was the only breadwinner of his family during his working life. From a young age up to retirement, he worked in a physically demanding job. N saw his family as being central to his life, and most meaningful to him was the loving relationship with his wife.

For many years I served as N’s family doctor and was warmly accepted as if I was a family member. I can remember helping one of N’s sons who suffered from severe obsessive-compulsive disorder. The disorder presented as recurrent cleaning rituals of different body parts, and progressed to reluctance to eat any food offered to him, which caused much tension in the family. My frequent home visits supported N and his wife very much and helped them to cope with the problem. Their son agreed to receive psychological treatment as well as pharmacological treatment that helped him feel very much better and led to better functioning.

N had not suffered from specific health problems in the past. Four years ago he started complaining of increasing difficulties in micturition . He was diagnosed with benign prostate hypertrophy. When he consulted me I advised him to treat this problem with medication and to avoid surgery, if possible. However, N did not follow my advice and decided to consult an urologist who suggested an operation. He was told that the operation was a simple procedure, usually without significant side effects. In addition, his urologist sh owe d h im a vid eot ape abou t the ope ra tio n and potential side effects. After that he discussed with his wife and decided to undergo the operation.

I only came to know about the operation indirectly from his wife. He had not visited me since the operation, about 8 months ago, which was unusual for him. I asked his wife who came to me and asked about personal matters including her husband’s well-being. She was feeling uneasy when she answered me and seemed embarrassed and confused. My impression was that she was reluctant to talk about him during the visit.

On her next visit, I asked again about N, trying to create an empathetic and supportive atmosphere. She burst into tears and told me that N was not the same man after the operation. He tended to stay at home, hardly spoke with her or other family members, and did not want to see anybody. He even became hostile towards her and she could not understand why. She said in tears that she had had a hard time with him, and felt helpless since she did not know what was wrong with him or how she could help him. She added that she and other family members were trying to persuade him to see me but he refused. I asked her to tell N that I personally asked him to visit my clinic. N decided not to come but I did not give up and kept sending invitations through his wife. At last, N agreed to come with his wife to my clinic. N looked neglected, skinnier than ever, walked slowly and hardly spoke. He did not direct his gaze at me, looked embarrassed and did not want to answer my questions. In a weak voice he told his wife: “Let’s go home. I have had enough of this”.

About this time, I had a 6th year medical student, called Boaz, (he later became a psychiatrist at the nearby hospital) who was attending my clinic as a trainee. I introduced Boaz to N, and asked N if it was alright for me to come with Boaz to visit him the next day at N’s home. Surprisingly enough, N agreed and his wife was very glad about my initiative. It was clear to me that within the framework of a home visit N could feel more comfortable and that might be the best setting for a therapeutic conversation.

The meeting went on for several hours. At the beginning, N hardly spoke and moaned a lot. He repeated several times that his “world has fallen apart and nothing can help”. I explained that I was here to be with him and to support him wholeheartedly. I promised to do whatever I could in order to help him. Gradually, N felt more relaxed and told his story. The problems started immediately after the operation. It started with sexual function problems. He was informed that one of the rare side effects of the operation was a reduction in sexual function. He was given this information prior to his operation both by his doctor and on audiotape.

But he did not believe that this side effect could happen to him. Two months after the operation, the sexual problem had still not resolved and his mood deteriorated. He sought advice from the urologist. The urologist asked N if he had had improvement with his urinary symptoms. There was an improvement. But N told the urologist about his impotence problem. The urologist did not take him seriously. He said to him, “Tell me, do you want more children at your age?”. N told me he was very offended and was hurt by the urologist’s response. These words from the urologist continuously went around in his mind. He felt embarrassed, ashamed and helpless. His mental condition deteriorated. He was in a very low mood, with lack of motivation and a total loss of interest in life. He stopped taking an interest in his family and would not leave the house. N neglected his personal hygiene. He would only wash every few days under pressure from his wife. He would hardly speak, confined himself to the bedroom, drank large amounts of coffee and smoked heavily. Due to lack of appetite, he lost 15 kg in two months. At night he hardly slept and when he did, his sleep was interrupted. He awoke early in the morning. N’s suffering increased. He felt desperate. He had low self-esteem, and a feeling of no hope. He had suicidal thoughts although without a concrete plan to commit suicide. In addition, he had continuous intruding thoughts in his mind that his wife was being unfaithful to him with his neighbour. Although his wife strongly denied these accusations, he refused to believe her.

N said that on one hand he was angry with her because he felt she was dishonoring the family. On the other hand he said he could understand her behaviour “because who needs an impotent husband”. His wife was very distressed by his accusations and screamed back at him. “How dare you. All my life I have been faithful to you and I will continue to be. I am a wife, a mother and a grandmother. You say that I am unfaithful to you with a man who is younger than our son? What has happened to you? You should be ashamed of yourself”. In spite of her words, N said he decided to leave home. “I am not worthy of being a husband or a father. I feel I am a burden on my family”. His wife found it very difficult to come to terms with how her husband felt. She begged him to believe her. The family was facing a serious crisis.

I saw before me a neglected man. He hardly spoke, was paranoid and not focused. He was suffering from a deep clinical depression. He said, “Everything is over. I am not a human being anymore. My head is empty and blood is not flowing through my body”. N’s wife told me that he had changed beyond recognition. She cried and said that the family was falling apart. She did not know how to reach N because he rejected all attempts of help.

At the end of the meeting, N said he felt a sense of relief. The student was able to build a relationship through asking empathetic questions and listening to his answers. In spite of the suffering and distress, a part of N was now able to reach out and accept help. We suggested to N that the student would make several home visits. The offer was willingly accepted and N was very satisfied with the visits.

N had a comprehensive physical examination including blood tests, brain scan and psychological cognitive assessment. The results were all within the normal range . He was referred for a psychiatric examination. He was diagnosed with major depressive disorder and psychotic features. He was offered admission to a psychiatric hospital. He refused admission but started outpatient treatment instead. N was given drug treatment and psychotherapy together with his wife. N gradually improved over three months. He tried d rugs for impotence without success and then an operation was performed to insert a penile prosthesis. The operation had a positive outcome for N.

At that time, I moved to another clinic and was no longer treating N and his family. I continued, however, to hear about him from Boaz who three years later became his psychiatrist at the nearby outpatient clinic. After I left the clinic, I was not able to contact N and his family. On the one hand I felt guilty that I left him in the middle of his crisis when he still needed my support, but on the other hand I was slightly angry with him for not heeding my advice and choosing the operative option.

Boaz told me about the great progress in N’s condition. He recovered very well and the relationship with his wife returned to its previous good state. He started taking care of his children and family.

This story moved me a lot and showed me the powerful and meaningful relationship that can be formed between a doctor and his patient. On the one hand, this relationship can have a devastating effect as demonstrated in this story. On the other hand, it can be a constructive and healing experience . This emphasizes our responsibility as family physicians for the patient’s wellbeing, even if he might not be reaching out to us. Taking an active persisting role in encountering patients’ hidden problems is a necessity for us in our family practice. Implementing an empathetic approach and with creative methods to bring out such concealed problems can be of great help.

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