White coats, drowning horses

June 21, 2002

Does the uniform make the doctor? Perhaps more than you realize.

 

White coats, drowning horses

Does the uniform make the doctor? Perhaps more than you realize.

By Derrick H. Adams, DO
Internal Medicine Resident/San Antonio

My patient's dream of a drowning horse meant nothing more to me than a sign of his underlying anxiety. What else could it mean? After all, this was an otherwise healthy 66-year-old with chronic depression.

As a third-year medical student, I began my psychiatry rotation the same way most of my colleagues did: I left my stethoscope in the car. Before the end of the first week, I'd also shed my white coat in favor of a comfortable sweater. It wasn't until this patient entered my life that I realized how important those simple trappings could be.

Mr. Jones (not his real name) was under an emergency detention order after his son had caught him trying to swallow a handful of antidepressants and pain pills. His chronic depression had been exacerbated by the recent death of his wife.

On our first visit I found nothing unusual. As his family had reported, he had a negative view about his life and admitted to "wanting to die," but he angrily denied ever attempting suicide.

We talked at length about the loss of his wife and about a series of disturbing dreams that were plaguing him. "The horse," he told me. "I see it drowning in the river, struggling to keep its head above the water. I watch its nostrils fill with water." Mr. Jones said he woke up short of breath and gasping for air from these nightmares.

Night after night, the drowning steed haunted his dreams. Each morning, the house staff would reassure him that it was nothing more than anxiety. Medication was adjusted, counseling refocused, and psychotherapy continued. Still, his affect remained flat. His constant complaints of insomnia and fatigue were chalked up to depression.

During lunch a few days after our first encounter, a forkful of lasagna landed on my beige sweater. To hide the stain, I retrieved my white coat from the car, with the stethoscope in the pocket.

When I made rounds, Mr. Jones was surprised to see me in the white coat. "I didn't know you were that kind of doctor," he remarked. Although I had taken a thorough history upon his admission, he hadn't told me about his leg edema because he didn't think it mattered to a "head doctor." The white coat also inspired him to share the fact that he had been taking "water pills" in recent years.

With that history, I actually used the stethoscope. It led me to suspect bibasilar rales, and a chest film revealed pulmonary edema.

Sixty milligrams of a diuretic later, Mr. Jones' chest cleared and he slept well. No more drowning horses plagued his dreams.

The remainder of his stay was unremarkable. Peaceful sleep had brought an abrupt end to his depression. He was referred to an internist for the management of his heart failure, and the antidepressants were discontinued.

Had the cafeteria been serving hamburgers that day instead of lasagna, the diagnosis may have been missed. It had taken the trust evoked by the white coat to draw out this patient's true story. I doubt I'll ever forget Mr. Jones and his drowning horses, nor the comfort and security a physician's white coat cultivates.

 

Derrick Adams. White coats, drowning horses. Medical Economics 2002;12:59.