Munchausen or not – To suspend the judgment and to seek to understand

Alhamdulillah, all praises be to Allah SWT for His blessings upon us and the time He gives as an opportunity to design the kind of end we aspire in this life. Remembrance and praise be to Muhammad saw, our beloved Messenger of Allah, his family and companions, may Allah grants them peace and happiness and may we be among them as well in our dreams, aspirations and our end insyaAllah.

Medicine is really interesting and I find it really eye-opening. In its complexity, there is simplicity, in its simplicity, there is an unread message. It is complex not only because it deals with general biological sciences but also individualised challenges in each individual patient. Hardly is patient like a single textbook. The best way to learn is to learn around patients because it involves bio-psycho-socio-spirituo-culturo and behavioural dynamics. It is complex because it deals with managing human being who has not got any single fixed rules regarding anything. SubhanAllah, while it teaches you to be sharp in mind, supposedly professional and flash in attitude, it also teaches and reminds us everyday about the value of humbleness.

Everyday we are seeing patients. If we are to be asked about the profession that can bring us closest to the reality of human being, it is indeed any profession that resembles this approach or profession, listening, being close, lending ears and humbly negotiate approach and means of how to save human being. In saying that, it is aware that this applies much much more when doctors/ anybody comes from within the society rich dynamics, having difficulties, challenges and hardships they go through in their lives.

It is an answer today, as time will always provide with every uncertainty and hence why the prophet was asked to wait when the unbelievers rejected the message. I have this one interesting patient with unbearable background history of breast ca bilaterally Rx with bilateral mastectomy. She also had Hodgkin lymphoma Rx with mental radiotherapy and chemotherapy. Splenectomy was also done as part of Rx pathway. Twenty years down the track, this woman developed chronic chest pain diagnosed as chronic pain syndrome secondary to radiotherapy effect managed on-goingly with Amitryptyline, Carbamazepine, Gabapentin, Methadone and Fentanyl patch. In short, max management of pain but with unsatisfactory effectiveness.

She presented to the hospital 10 days ago complaining of worsening chest pain, with what described as anginic picture. Series of investigations showed impossibility of Acute Coronary Syndrome, making us wonder could this be secondary to limited microvascular reserve giving syndrome X-like pattern but on the background of re-stented coronary artery because of occluded artery previously. Tachyphylaxis and limited tolerance from chronic pain syndrome would then possibly amplify patient's intolerance and hence why she is suffering in pain nearly each hour.

9 days passed with the team exhausted all the means to control her pain, subhanAllah, this really amplifies the fact that medicine is limited and what amplifies and expands it is by the grace of Allah, teaching human being through their thoughts, discussions, research to find answers to problems they face. It also sends the message clearly that without His help, you can load all possible medications but the pain is not gonna ease itself.

Anyway, throughout the 9 days, due to severe pain and escalating fentanyl IV dose( reaching 100 mcg PRN given every hourly), we started to think is this really a true pain or is this acutally attention-seeking behaviour. Munchausen's syndrome, a term I still remember since my second year in the college, reading a book, The Art of Healing, written by one American MD doctor, talking in one chapter about kind of patients who pretended sick in a really excellent manner to seek attention. They would damage themselves, pretending sick and even harming themselves to seek attention. This came across my mind and the reason being the fact that she really looked like wanting attention especially from the registrar. It is very hard when you don't know someone enough but to formulate what could be the possibility.

Anyway, cutting the story short. Repeat angiogram today showed re-stenosed stent artery. This patient had mental radiotherapy on the chest which causes radiotherapy-induced coronary artery disease over time. It is easy to formulate a judgment and to judge people without first trying to understand patient's perspective. It is also easy to take subsequent actions based on presumptive idea. Not that the team does not know this possibility, but the index of suspicion that it could be re-stenosis this time after several other visits has been really low. To keep an open mind and to first seek to understand before being understood would really be an important element in maintaining human and therapeutic relationship.

-gambar hiasan-

In our daily lives, the same applies. It can be easy to label others and to lose intellectual humility, understanding others' backgrounds. When spiritual therapeutical relationship fails, then people will build barrier against the message, not really because of the message itself, but it can just be because the people who carry the message fail this rapport and reading others very dogmatically. Quran gives an extreme example how the art of advising towards Allah should be done. Musa as and his cousin Harun as were asked to go to Fir'aun and advised him in a very respectful and full of wisdom. This was despite the fact that Fir'aun claimed himself as God.

May Allah SWT enlighten us with things that we are dealing with daily insyaAllah.

Question for medical students : How is Munchausen syndrome differs from Hypochondriasis?