This month we look at a case where the physician remembered things differently than the patient. This is a common scenario, and again highlights the importance of thoroughly documenting conversations with patients.

Dr. B, 45, was a general practitioner working in a clinic in a low-income neighborhood. He had been working at the clinic for close to 10 years and was starting to feel burned out. The clinic handled a variety of patients, some of whom had emotional or other issues, some who had not had access to medical care in many years, and some who were accompanied by social workers.

One patient who came in frequently, with and without a social worker, was Ms. W, 28. Ms. W lived in a nearby residence for women who were getting back on their feet. Her early life had been challenging, and she had been homeless for a brief period in her early 20’s when she was abusing drugs. After getting help for her drug problem and getting clean, she became pregnant. She had recently given birth and was struggling with the responsibilities of being a single mother. 

When Dr. B saw her in the waiting room with a social worker, he sighed to himself. Ms. W was a “slow talker” – she spoke very slowly and tended to veer off topic during appointments. He still had a full waiting room of patients to see, and it was already afternoon. He called Ms. W (with her social worker) into the exam room and asked her what the problem was. She began telling him about the recent birth of her child and how she felt overwhelmed and was crying all the time and felt hopeless and unable to cope with the baby on her own. 

Ms. W began talking about the tribulations of being a new mother again, and how grim everything seemed, and Dr. B interrupted her.

“This seems to be postpartum depression,” he told her. “It’s common and affects many women. I will prescribe something that should help you.”

He wrote her a prescription for lamotrigine to treat the condition, told her he hoped she would feel more positive very soon, and ushered her out.