Take-home Message

Identifying social prejudice

(Fictional narrative by the doctor)

James Fleck, MD, PhD & João A de Andrade, MD

Anticancerweb 11 (04), 2019

Edgar arrived at the University Hospital.

For security reasons, he had been kept in a room under continuous police surveillance. 

It was not the first time we cared for a prison patient, and I always joined my trainees during the initial visit to ensure that the clinical assessment was as comprehensive as possible. 

Usually, we did not have direct access to one’s criminal records, but we could contact the prison psychology service whenever necessary. Edgar had committed a heinous crime, and was expected to serve a very long sentence. That said, he had a spotless record in prison and always had excellent behavior. It was noted in his file that there was a recent deterioration in his behavior that had finally been attributed to pain. 

As I headed to Edgar's room, I was joined by Peter, my clinical oncology fellow-in-training. Peter had been in training for about five years now. He went through three years of internal medicine training in one of the prestigious institutions in the country and was starting his senior year in our clinical oncology fellowship program. He was a bright and emotionally stable young man who had superior communication and technical skills.

As we met, Peter seemed tense and a bit uncomfortable.

Five years ago, his older brother had been a victim of a brief kidnapping. This was a type of crime common in large Brazilian cities where the victim was held for a few hours as a hostage while bank withdrawals were made using their debit cards. His brother was released unhurt about three hours after being kidnapped, but the episode caused a deep emotional tow in the family.

Peter told me that knowing that the patient had killed someone brought back bad memories and he was having a hard time reconciling his feelings with his professional obligation to care for him.  

Peter was facing a dilemma.

I was also having mixed feelings! I could dismiss Peter from this duty and ask another fellow to help me in taking care of Edgar. On the other hand, if I did that, I would be allowing Peter to pick and choose the patients he took care of. That would be contrary to the principles of medical ethics and a disservice to his education. At the end, I felt that he should be the one making the decision. 

In medical practice there is no room for ambivalence.

I solved my ambivalence by giving Peter the opportunity to decide.

I took him to one of the working rooms so we would have some privacy. He was trying to process his feelings and seemed determined to uphold his professional oath. 

Peter finally told me that he did not have to think about it any longer. He would join me for the clinical assessment and we both went to see Edgar. 

We found him handcuffed and being watched by a police officer. He seemed resigned to the fact that he had a serious illness and knew that his future was uncertain. 

I introduced myself as the attending physician who would take care of him and introduced Peter as member of his care team. I sat down beside his bed and, looking into his eyes, explained that I needed to hear his story.

Edgar began to speak compulsively.

He was hastily reporting everything that has happened in recent months. There was a bit of confusion in the language and there was unrestricted anxiety. He was trying to gesture, but his movements were limited by the handcuffs. 

I informed him that I was not there to judge him, that I was not in a hurry, and that he could take all the time the he needed to freely and calmly express his symptoms and feelings.

Edgar slowed, slightly improving the clarity of his language.

However, his speech was often interrupted by rhythmic and stereotyped spasm-like movements on the left side of his face, resembling a chronic motor tic disorder, which was often accompanied by vocal blast expressing some obscene words. He could not control that behavior and unusual attitude. He was aware of its autonomous nature, which had been a source of many misunderstandings and conflicts since his childhood.

When asked about the problem, he revealed that his father used to hit him in the face to “correct” the defect. As he was often bullied and mocked in school, he became more and more withdrawn and anti-social. Sadly, his first contact with illicit drugs was motivated by a hope to achieve better social acceptance. He said drugs helped him feel uninhibited and self-confident. Unfortunately, he only realized that this was an illusion after killing a man.

He went on justifying himself by saying that he was in an altered state of consciousness. Edgar was beaten by a group of junkies that dared him to commit the crime. He regretted it, but it was late. He never used drugs again, learning to live with his physical defect and staying away from conflicts. He accepted his sentence of 30 years in prison with resignation and a sense that justice had been served.

I was about to begin Edgar’s physical exam when I glanced at Peter.

He was quiet and showing no expression in his face. He stepped forward to better follow the exam, but did not interact with Edgar, always keeping a distance of at least 4 feet. 

Without saying anything, I returned my attention to the patient, and resumed the physical exam…

To be continued in PLOT 3…

Attention: The story 3 will be published sequentially from PLOT 1 to PLOT 6 and you will always see the most recent posting. To read Story 3 from the beginning, just click in the numbered links located at the bottom of the homepage 

© Copyright 2019 Anticancerweb

 James Fleck, MD, PhD: Full Professor of Clinical Oncology at the Federal University of Rio Grande do Sul, RS, Brazil 2019 (Editor)

Joao A. de Andrade, MD: Professor of Medicine and Chief Medical Officer, Vanderbilt Lung Institute, Vanderbilt University Medical Center, Nashville, TN – USA 2019 (Associate Editor)