Shirah Vollmer MD

The Musings of Dr. Vollmer

Closing Ranks

Posted by Dr. Vollmer on May 2, 2012

Lesley,fifteen  is “anorexic” according to three physicians she has seen at a well-respected institution. They have documented their clinical judgment and her diagnosis follows her. She then sees a fourth physician, Dr. Lee,  who determines that her lack of appetite is secondary to her family issues, and she does not have a body image distortion. She wants to gain weight, but she has lost her appetite due to the stress she experiences from her family. Lesley’s family, her parents in particular, do not understand the family stressors at home, so they agree with the three physicians that Lesley has anorexia nervosa. Dr. Lee is insistent that the critical intervention is family therapy, in order to help Lesley understand that although she is the identified patient, the issues she faces come from how her family members treat each other. Lesley’s parents disagree with Dr. Lee, so they take Lesley to a fourth physician at this well-respected institution. The fourth physician has no interest in gathering a history from Dr. Lee, but he reviews the records from his three colleagues and concludes, as they did, that Lesley has a severe eating disorder, requiring inpatient treatment. Dr. Lee says to Lesley’s parents, “they are closing ranks. They have to agree with each other in order to work together. The problem is that this is at Lesley’s personal expense.” The parents are not convinced. They agree with an inpatient program and they communicate to Lesley that she has a major psychiatric disorder. They do not acknowledge or believe that their behavior has contributed to Lesley’s issues. They believe, as they have been told, that Lesley is suffering from a disorder which is hard to understand, but requires individualized behavior therapy to treat. Family intervention has no role, according to these physicians. The parents fire Dr. Lee, and proceed with Lesley’s treatment. Psychiatry is a messy field. There are no objective findings. Lesley might get better, or she might have a persistent problem, given her family dynamics are not changing. The answers are not clear.

4 Responses to “Closing Ranks”

  1. Shelly said

    Of course the parents will agree with the doctors and will fire Dr. Lee. What parent wants to be blamed for their child’s dysfunction? What parent likes to be known as the cause of the child’s stress disorder? And doctors, knowing who pay their salary, choose the quick fix: hospitalize the child instead of focusing on the stressors in the home environment (not you, Shirah!)

    • Hi Shelly,
      Thank you for expanding on this fictional vignette. As you say, without objective findings, diagnosis is subject to unconscious and conscious behaviors which may or may not ultimately benefit the patient. When the patient is a minor, there are even more complications. Thanks again.

  2. This is the sort of thing that really ticks me off…(need to metabolize my anger first so I can answer reasonably ;-)! Shoddy medical politics and parental denial at it’s worst and the child is left to flounder in the middle. This ought to go to a medical review board but with three docs “agreeing” along with parental refusal to see “a rational option” for the warfare of the child, that won’t happen. I’m sure these messy diagnostic dynamics go on in every respected medical institution across the country and how to “fix” this is beyond me. I again say “this is where you blog brings attention to this problem”…thankfully.

    • Hi Eleanor,
      Of course, I appreciate you incorporating a previous post about metabolizing anger as that is necessary in this fictional vignette. Thank you for joining this conversation.

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