Eighty percent of diagnoses can be made based on the history and physical.  Take the subjective and objective; throw in some medical history, family history, social history and you can figure out your assessment and plan. Doctors are the detectives of the body and the more facts, the easier it is to solve the mystery.

This is the fictional note that I wrote in my head concerning a fellow physician friend when she approached me in confidence a few weeks ago.

Subjective

Depressed mood, anxiety, insomnia, anhedonia, weight loss present, abdominal pain. Symptoms per patient have been present for one week.  May have been present earlier but seemed to significantly worsen in the past week.

The patient is talking to her friend (me) about how she is feeling.  Walking daily when her friend (again, me) drags her outside. No other exercise.

Managing to go to work and see patients.  Took one day off because of not “feeling herself.”

Suicidal ideations: Not asked (because I honestly didn’t think she was suicidal).

Does not want to do counseling.  Hesitant to do medications and accept that this is depression because of the stigmata in medicine.

Medical history

Two bouts of depression in past that were thought to be strictly situational, treated short-term with medication which was stopped afterward.

Family history

Positive for mental illness of depression and anxiety in first-degree relatives.

Social history

Married, children.  Appears happy with family life. Appears to have social support (including me).

Objective

Weight loss noted.  Mood is quiet, somber. Anxiety present but no delusions or hallucinations. Still showing insight and adequate train of thought.

Basic labs normal.

Assessment and plan

Depression. Convince her that this is depression and recommend medication, counseling and taking some time off from work.  Will check in daily to convince her slowly.  Will continue to be a good friend and offer support.  Will tread slowly so as not to scare her away. Will try to convince her to abandon the stigmata of depression in medicine. Will be honest about my own battle with depression and let her know it is OK for doctors to struggle.

I was wrong. I know she was not my patient, but she was my friend.  We were both doctors, and we had known each other for twenty years. The true diagnosis was major depression with imminent suicide one week after she started expressing her symptoms to me. Hindsight is always 20/20.

Normally with a confusing medical case, you can do an informal morbidity and mortality rounds with your colleagues to discuss the finer points and what could have been done differently.  When your friend commits suicide, it is the opposite.  Out of respect to my friend and her family I keep quiet and do not speak about the details because doctors are in the business of saving lives not taking their own.

I reread the details of my SOAP note over and over in my head trying to fill in the blank spaces.  I stay up at night thinking of words I should have said, questions I should have asked. I read about how female physicians are three to four times more likely than the general population to commit suicide.  Three to four!  That might have been helpful to know a few weeks ago. Four hundred physicians commit suicide annually. And my friend was one of them.

Eighty percent of diagnoses can be made by the history and physical alone, but it is the one that I did not make that will haunt me.

The author is an anonymous physician.

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