| | Print | Email

History Taking in Patients who are "Survivors"


Michael Gordon, MD, FRCPC
Vice President, Medicine and Head, Geriatrics and Internal Medicine
Baycrest Centre for Geriatric Care
Professor of Medicine
University of Toronto

Abstract
The approach to taking a medical history from a "survivor" presents certain challenges to physicians. There may be a tendency to ignore the issue in the erroneous belief that it might be upsetting to the patient. Or there may be a cursory comment on the experience that may merely acknowledge it as "part of the history", of a comparable significance with other historical data. Since the holocaust experience is such an important part of a survivor's life and has without doubt a major impact on medical conditions and the ability to deal with them, it is important for the physician to acknowledge the experience, highlight it to the patient as an important part of that person's life, get significant details related to the experience and demonstrate a sensitivity to the impact that the experience provided.

Depending on the situation, the discussions related to the holocaust may take place during one interview or preferably should occur over a period of time to allow the patient to develop a trusting relationship with the physician. If done successfully, it is usually possible, in time, for the physician to discuss many parts of the holocaust experience with the patient which engenders enormous trust and intimacy between the patient and the physician. It may also allow certain clinically important psycho-social and physical factors to be explored which otherwise might not be the case.

Paper
The holocaust is not like most events experienced by most patients that physicians and other health care providers care for. Though many of our patients experience various personal tragedies in life, and many Canadian immigrants have had traumatic experiences prior to their arrival in Canada, there are relatively few groups of patients that physicians see in large numbers that have been through genocidal experiences. It is true that there are contemporary political situations that are similar to what occurred during the holocaust, most Canadian physicians do not have a congregation of patients, many of whom have survived such experiences and whose families have been affected by the results of family members being holocaust survivors.

At Baycrest Centre, the holocaust is everywhere as part of a collective experience of the patients and residents we care for and the families and many of the caretakers, formal and informal who are entrusted with their with their welfare. Therefore, as a physician it is important to take into consideration, the impact of the holocaust experience on the patient as well as the impact on caretakers when assessments and decisions are being made.

Examples of issues that must be considered are the following:

When taking a history, reference to a family history may be traumatic, but has to be addressed- especially when trying to discover possible causes of contemporary illnesses (i.e. family history of heart disease, Alzheimer's etc.)

Past history might include illnesses that occurred during an internment when there was little in the way of medical care. Exposure to TB for example was very common in concentration camps and must be considered as diagnostic entities. Traumatic injuries that were not adequately treated should also be considered as a cause of late onset disability.

One important issue that must always be considered is the effect of physical and psychological trauma not just from internment but from some specific experiences. Some survivors experienced medical experimentation during the holocaust experience. Therefore, they may have a very different view of doctors, nurses and therapeutic interventions, especially surgery. They may be particularly suspicious of research activities are the use of new medications or anything that is unknown. One of our patients refused to have a life-saving pace-maker inserted because of her vivisection experience, even though the procedure was explained to her by all of her caregivers and the Rabbi, which eventually resulted in her sudden death- her pathological association of "surgery" could not be overcome even 50 years after the event.

We must be very aware of associations that may have special meanings to holocaust survivors for which the association to us is unclear. Certain times of year, or words, or music may bring up associations that can be frightening or painful. While a patient myself at a general hospital, I heard the cries of fear of a neighboring patients when he was told by nurses that he was "just being taken to the shower". It was a recurring event, which I only figured out after I understood who he was and that he was a survivor. Having the message changed to "being bathed" had a dramatic impact on his reaction to the explanations of the nurses caring for him, for whom his association did not make sense in terms of their world experience or framework of associations.

Many survivors have particularly difficult times during holidays or other periods of importance which have major emotional significance. I have found for example that during the high holiday period, may of my patients seek appointments and some may express medical problems that may be related to their emotional state and special loss that they feel.

When speaking to patients about their experiences, it is important to let them take the lead but let them know that you are interested in hearing their experiences if they wish to talk about them. I have found that giving indirect openings to talking or touching on the subject in various ways (mentioning a book that I read or a movie that I saw) may allow them to have "permission" to talk. Sometimes I have had patients who did not speak about things for the years that I knew them, suddenly tell me terribly painful tales with great vividness that clearly has permanent meaning for them. It is helpful to let them know that you can handle their feelings and will let them tell you whatever they want when they want to.

Just because someone is a holocaust survivor does not mean that they suffer from clinical depression. Likewise, because someone was a holocaust survivor and has "done well" for years does not mean that they cannot develop of late onset depression like any one else. It may be that when a depressive illness manifests itself, much of the content of talk may be related to loss and their holocaust experience.

Some issues related to medical care may be impacted on by their holocaust experience. There are many for whom food plays a very important symbolic role reflecting something in their experience. There are those who always eat fast or cannot bring themselves to eat a lot, or who in contrast always eat a lot or for whom certain foods have great symbolism- will never eat cabbage because that was the basis of the thin soup they had to eat or for whom bread has an extraordinary symbolic meaning. With such people, it may be very difficult to discuss therapeutic diets in a meaningful way.

There are some patients who have many somatic symptoms which they attribute to their holocaust experience and for which the complaint is valid. Whether it is chronic bowel dysfunction related to untreated infections, bone deformities due to poorly treated fractures, loss of digits due to cold exposure, the meaning of these disabilities goes beyond the illness alone. Interventions must take into account the real and symbolic meaning of the disability.

Although, holocaust survivors, many patients with that background experience want to be part of the "real" world of non-survivors. They do not want everything attributed to their holocaust experience because they feel it "taints" them or "labels" them. A physician must be careful to take complaints in all domains at face value and respond to them objectively with full diligence before attributing the complaint to the holocaust experience.

Taking care of Holocaust survivors for a physician is at the same time a humbling and satisfying experience. It is sometimes unbelievable to talk to someone who has had the kinds of experience that is related and at the same time express humour, warmth and caring. As a physician, it is incumbent upon us to take the time and be thorough and caring so that we can serve the needs of this very special patient population.