Terrorism and the Physician-Patient Relationship

By Tom Walsh
The woman, a regular patient in her early 50s and a breast cancer survivor, showed up without an appointment on Sept. 12 -- the day after terrorist airline hijackings rocked the United States.

"She told me she was here in my office because she felt insecure after the attacks," recalled Bruce Karlin, M.D., a Worcester internist. "It was panic disorder. She just wanted to talk."

Dr. Karlin did his best to calm his patient. "I just tried to tell her she was not in harm's way, that it was an indiscriminate act." He wasn't sure that his counsel had helped. "Some patients you just have to get back to a counselor or start them on appropriate medications."

At Massachusetts General Hospital in Boston, a woman arrived at the Emergency Department with angina. "The onset was soon after the terrorist attacks," recalled Frederick J. Stoddard, M.D., clinical professor of psychiatry at Harvard Medical School and immediate past president of the Massachusetts Psychiatric Society. "It was clear that there was a psychosomatic connection between the two," Dr. Stoddard said. "She was doing all right, but she seemed to react more positively with an empathic medical student who did a fine interview with the patient. That was an important intervention."

"Nothing is the Same"
News commentators, sociologists, and many others across the country sounded a similar theme in the aftermath of the worst terrorist attack in U.S. history: Nothing in American life is the same after Sept. 11.

It is also apparent that the country's war on terrorism will be measured not in days, weeks, or months, but in years. There will almost surely be more violent events on the world and national stage. Some of these will be military. But there is also a strong chance that some future violence may again involve innocent American civilian victims. Physicians and their patients will be mindful of this and they will experience heightened levels of stress, fear, and anxiety because of this for a long time as well.

Vital Signs asked numerous Massachusetts physicians what they were experiencing in their patient relationships since Sept. 11. All said the terrorist violence has had a significant impact on the physician-patient relationship, the cornerstone of health care delivery.

"I do think everything has changed," Dr. Stoddard said. "It is accurate to say we have entered a new world." Physicians, he said, are no different from their patients in their feelings about the attacks. At a recent meeting of his psychiatry colleagues, Dr. Stoddard said one doctor told him, "I just feel sad all the time. I don't think we'll ever feel the same."

Like Learning That Someone Has Cancer
Across the Commonwealth, physicians report they are encountering patients who tell them the terrorist attack on U.S. soil has heightened their stress and made them constantly fearful and sad -- characteristics of post-traumatic stress disorder.

PTSD, of course, is not new. What is new is that virtually everyone in America has experienced this at some level since Sept. 11. What is also new is that physicians must now be prepared to deal with it every time a patient walks through the door. "Not everyone has it, but most have symptoms," Dr. Stoddard said.

Jack T. Evjy, M.D., an oncologist and past MMS president, said the intensity of the terrorist situation is what makes this different for every doctor.

"What's different is the cause, the number of people affected, and the overall intensity," Dr. Evjy said. "Experienced, confident, well-trained physicians already have the tools they need to help with the human part of what is happening. We have to make sure we use the understanding we already have from other medical experiences. Post-traumatic stress disorder . . . terrorism, this is familiar territory. What's not familiar is that America has never had to face these things quite on this scale before."

Emphasizing his point about the new level of intensity being brought to the physician-patient relationship, Dr. Evjy likened the terror situation to hearing of a patient newly diagnosed with cancer. "You know it could be you some day," he said. "You've got it, you can't escape it without surgery, radiation, months and weeks of uncertainty. You grieve, you feel like you're under siege. All the things that people who have cancer feel, we feel with terrorism."

Terror Now Routine Doctor-Patient Dialogue
Many physicians have reacted to the terror strikes as an opportunity to become more verbally engaged with their patients.

Thomas A. Raskauskas, M.D., of Swampscott, who practices obstetrics/gynecology on the North Shore, said he has begun to routinely ask all his patients how they have been affected by the terror attacks.

"Since I only take care of women, the conversations have been interesting," he said. "My patients express a concern for the whole family. They talk about their fears for husbands who travel for work, fears for their school-age children. Where to get advice for their children? How much television should their kids watch?"

More than anything, Dr. Raskauskas said, "My patients have indicated a generalized fear of the randomness of the violence. That seems to be the most unnerving part." He added that he has patients who were so shaken by the terrorist events that they have abruptly changed their minds about whether or not to have more children. Some of those choices, he said, have been affected by a new fear that husbands or children might be lost to new acts of violence.

Mark D. Pearlmutter, M.D., who specializes in emergency and internal medicine, said he's found that it is now essential to inquire whether terror is a contributing factor to a patient's physical symptoms. "We've been taught that a certain number of women who come in have been involved in domestic violence. Now we universally screen for that," he said.

"Now this has happened, and it is a new universal screen. I've never been involved in something as great as this that you have to consider for every patient who comes in the door," he said.

Words Take On Added Importance
It is one thing to prompt reluctant or troubled patients to discuss their feelings. It is quite another to know what to say to them when they've finished. For physicians, not knowing what to say in this case is not an option.

Physicians who spoke to Vital Signs praised organizations such as the MMS for making information available about how to interact with patients on the terror issue. And yet, they said, there is no set of talking points that fully prepares a physician for many of the intense physician-patient dialogues spawned by terror.

Dr. Stoddard described a conversation in which a woman told him, "I feel like I've been cerebrally erased."

"People are seeking words to describe the feelings and the mental states they are experiencing," Dr. Stoddard said. "But in many ways there are no words to describe them."

He said some of his patients have been thoughtful enough to ask him how he was doing. "It's now a whole different interaction with patients," he said. "It's not business as usual."

The Psychology of War
Dr. Raskauskas, a military veteran, said he has fallen back on his military training. "The psychology of war is relevant now," he said.

"It [the terror attacks] goes to the whole fabric of patient care," Dr. Karlin said. "It's a very individual thing, a per-patient, per-visit thing."

Dr. Pearlmutter said there is new pressure on physicians to retain "a façade of calmness" with troubled patients. And, he said he and other physicians have noticed that patients with children often seem most worried. A parent himself, Dr. Pearlmutter said, "For those of us with children, it will have implications for a long time to come."