godfather of surgery

Chapter 1288 The Real Patient

When Yang Ping saw the expedited report from the testing center, the last trace of doubt in his heart disappeared.

The emetic was clearly administered to Lele intentionally. Yang Ping finally understood. As the head of the pediatrics department at the First Affiliated Hospital of Nanjing Medical University, what rare organic diseases hadn't Director Zhao seen? His decision to refer the case after personally following up for so long indicated that he might have vaguely grasped the truth, but lacked confirmation and, more importantly, a multidisciplinary support system to handle such an extremely sensitive situation. Transferring the case to Yang Ping, known for his innovative thinking and interdisciplinary approach, was both a reluctant but wise choice.

If this diagnosis is confirmed, it will not only concern a child's health, but also the survival of a family, and may even lead to medical disputes. After all, the child has been receiving treatment at the First Affiliated Hospital of Southern Metropolis Hospital for two years. Shouldn't the team at the First Affiliated Hospital have discovered the problem earlier? A direct confrontation would be disastrous, not only for the patient's family, but also for the reputation and relationship between the two hospitals.

He needed a comprehensive plan that would reveal the truth and protect the child, provide the mother with a way to accept help, and also consider the position and reputation of the referral company, the First Affiliated Hospital of Nanjing Medical University. This was no longer just a medical diagnosis, but a complex intervention involving medicine, psychology, ethics, and even sociology.

Yang Ping invited Director Zhao Yongchun again and suggested that a senior psychiatrist or psychologist be involved. The First Affiliated Hospital, upon hearing of a possible breakthrough at Sanbo Hospital, reacted unexpectedly quickly. Not only did Director Zhao come, but Director Sun of the Department of Neurology, who had made the bet earlier, along with two other curious senior professors, also came along, ostensibly for "learning and exchange."

The following afternoon, the atmosphere in the small conference room of Sanbo Hospital was somewhat subtle. Four experts from the First Affiliated Hospital sat around one side of an oval table: Director Zhao Yongchun, his brow furrowed, flipped through the documents before him, his expression complex—a mixture of anticipation for a possible answer and unease about that expected one; Director Sun leaned back in his chair, seemingly relaxed, but his eyes were sharp, a smile playing on his lips; Professor Chen Minghua of the Department of Psychiatry, in his fifties, wore gold-rimmed glasses, his demeanor gentle yet focused; and there was also Professor Wu Zhenhua, a highly respected senior professor from the Department of Pediatrics at the First Affiliated Hospital, nearing retirement, drawn by this difficult case that he had also heard of.

On Sanbo's side, Yang Ping sat in the middle, with Dr. Li Min on his left and Song Ziming, Xu Zhiliang, Xia Shu, Zhang Lin, and Xiao Wu on his right.

"Professor Yang, I heard you've found a breakthrough in Lele's condition?" Director Sun spoke first, smiling broadly. "This child has been a struggle at our First Affiliated Hospital for two years, and Director Zhao's hair has turned quite gray. If you've truly cracked this difficult case that's been scratching our heads, I'll not only give you a bound volume of the inaugural issue of the *Chinese Journal of Neurology* to study for a month, but I'll also give you that rare copy of *A Collection of Difficult Cases of the Nervous System* to study for two months!"

Yang Ping smiled and said calmly, "Director Sun, you flatter me. Solving medical problems often requires timing and collaboration from multiple parties. Director Zhao did a lot of solid preliminary work to eliminate possibilities, which made it possible for us to focus on more specific directions."

He gestured for Li Min to distribute the prepared materials to everyone, then stood up and walked to the whiteboard: "Based on Director Zhao's previous work, we have adjusted the focus of our observations. We have invited you all here today to participate in the final diagnostic reasoning for this case."

He listed the key features one by one on the whiteboard, and finally wrote: "Medical emetic components were detected in the stomach contents."

After writing this, Yang Ping turned to face everyone and gave Director Zhao a special look: "Based on these characteristics, especially the last point of solid toxicological evidence, we dared to conduct this targeted test only after Director Zhao had completely ruled out organic diseases in the early stages. What do you all think is the most likely diagnostic direction?"

A brief silence fell over the meeting room. Several experts from the First Affiliated Hospital quickly flipped through the documents in their hands. Director Zhao's gaze lingered on the toxicology report for a long time. The suspiciously related moments in the surveillance summary screenshots, the meticulously neat, almost obsessive handwriting in the symptom diary, and this toxicology report in black and white—all these fragments, along with the vague "something's not right" he had felt for the past two years, finally pieced together a complete and chilling picture.

Professor Wu Zhenhua took off his reading glasses and sighed deeply: "Munchausen syndrome by proxy?" He looked at Director Zhao, "Yongchun, you actually had a feeling about it a long time ago, didn't you?"

Munchausen syndrome by proxy: Caregivers fabricate various symptoms to get the person they care for to go to the hospital for completely unnecessary treatments, thus satisfying their own pathological psychological need to "care for the patient." The caregiver is the patient, and the person they care for is the victim. Generally, the victim is a child who lacks the ability to act independently.

This disease is associated with severe child abuse, and according to reported data, the mortality rate among affected children is as high as 10%.

Director Zhao nodded slowly, his voice slightly hoarse: "Yes, Dr. Wu. But I... I dare not and do not want to think in that direction. Without solid evidence, who can raise such questions about a mother who has devoted herself so wholeheartedly? Moreover, in our First Affiliated Hospital, the specialties are clearly divided; pediatrics is pediatrics, and psychiatry is psychiatry, lacking a collaborative mechanism for handling such cross-disciplinary cases." He turned to Yang Ping, his eyes complex, "Professor Yang, the observation plan you designed—symptom recording under 24-hour monitoring and correlation analysis of caregiver behavior—is ingenious and necessary. More importantly, you possess cross-disciplinary review knowledge, which is difficult to achieve in other hospitals. Even multidisciplinary consultations in other hospitals often seem very disjointed."

This candid confession changed the atmosphere in the meeting room. Director Sun put away his joking expression, and Professor Chen nodded seriously.

Professor Chen began, “Director Zhao’s dilemma is very real. In the traditional medical framework, unless there are clear psychiatric indications, it is difficult for pediatricians to rashly involve psychiatrists in the diagnosis and treatment of a child with physical symptoms. The most distinctive feature of this case is that its manifestations are entirely within the scope of the non-patient’s physical symptoms. The patient’s psychological problems are hidden very deeply, and the real patient and the so-called patient are separate.”

Yang Ping sat back down: "This is exactly what I wanted to emphasize. The solution to this case is not a question of which hospital is more skilled, but rather a question of diagnostic thinking and collaborative models. The fact that Director Zhao was able to have doubts and choose to refer the patient in the absence of evidence requires great professional insight and courage. Without Director Zhao's extensive preliminary investigations, we might not have been able to find a diagnosis. None of the diseases we could think of fit the criteria, which in itself is a clear guideline."

He turned on the projector: "What we need to face now is how to properly handle this confirmed diagnosis. We need the collaboration of pediatricians, psychiatrists, and social workers, and we may even need legal counsel and police involvement. Communication must be extremely careful and cannot be a simple revelation."

"But how do we present the evidence of toxicology?" Song Ziming asked. "This is the most sensitive part, and this evidence was discovered at our Sanbo Hospital. Won't it make the family feel that no problems were found in the first year or two, but the toxication was discovered as soon as they came to Sanbo?"

This question hit the nail on the head, and for a moment, everyone's eyes were focused on Yang Ping.

Yang Ping had already considered this difficult problem: "In communication, we will downplay the boundaries between hospitals and emphasize that this is a continuous medical process. We will say that the comprehensive screening conducted by the First Affiliated Hospital in the early stage laid the foundation for finally locking in the direction, while the observation environment and interdisciplinary model of Sanbo just provided the conditions for discovering this special behavioral pattern. As for toxic evidence, we will present it as an anomaly found in the comprehensive review of the entire diagnosis and treatment process, rather than new evidence of crime discovered by Sanbo."

He looked at Director Zhao and Professor Chen: "How about the three of us—Director Zhao, Professor Chen, and I—lead the communication? Director Zhao will represent the initial treatment team, I will represent the current team, and Professor Chen will provide a psychological perspective. We'll form a continuous and unified professional front to avoid giving the family the impression that the hospitals' conclusions are inconsistent. Whether or not police intervention is needed depends on how things develop, but we'll file a report beforehand." Director Zhao was somewhat surprised, then gratitude appeared in his eyes. Yang Ping's arrangement not only protected the First Affiliated Hospital's professional reputation but also demonstrated a rare magnanimity; the essence of medicine is solving problems, not vying for credit.

“I agree,” Director Zhao said solemnly. “As Lele’s primary attending physician in the early stages, I have a responsibility to participate in this difficult communication process.”

Director Sun stood up, walked up to Yang Ping, and extended his hand: "Professor Yang, I apologize for my joke earlier. You not only have superb medical skills, but also this magnanimity and wisdom. I will personally deliver the bound volume and the rare copy to you when I get back."

The communication took place the following morning. When Ms. Qiao saw Director Zhao, she was visibly surprised: "Director Zhao, you're here too?"

Director Zhao nodded gently: "I have been keeping Lele's condition in mind. I am very grateful to Professor Yang for inviting me to participate in this important discussion. Our treatment of Lele is a continuous process."

This communication was more difficult than expected.

As Yang Ping gradually presented the evidence, Ms. Qiao reacted extremely strongly: "Are you implying that I'm harming my son? Director Zhao, Lele has been in the first or second year of high school. You know us best. Do you think I'm that kind of person?"

Director Zhao paused for a few seconds before slowly speaking, "Ms. Qiao, over the past two years, I've witnessed firsthand everything you've done for Lele. No mother would intentionally harm her child. But sometimes, excessive love and anxiety, coupled with past trauma, can cause behavioral changes that even the child cannot understand." He flipped through Lele's medical record at the First Affiliated Hospital. "Do you remember? Last March, when Lele was hospitalized at the First Affiliated Hospital, she vomited three times. We routinely examined her stomach contents, but we didn't perform a toxicology screening at the time. If we had considered things more broadly back then..."

He didn't finish speaking, but the implication of his words made Ms. Qiao freeze.

Professor Chen then stepped in, analyzing the possible connection between Ms. Qiao's childhood experiences and her current behavior from the perspective of psychological trauma. When she talked about her experience of caring for her mother with cancer since she was eight years old, Ms. Qiao's defenses finally began to crumble.

“Sometimes… I feel that only when Lele is sick can I feel alive and needed…” she sobbed. “During those two years at the First Affiliated Hospital, every time the doctors gathered around him to discuss his condition, every time the nurses said to me, ‘You are such a great mother,’ I felt that was my only value.”

Director Zhao's eyes reddened slightly. He now fully understood why this case was so challenging. This mother needed not only treatment for her child, but also healing for her own inner trauma. Some people use their childhood to heal their entire lives, while others spend their entire lives healing from their childhood.

Following the consultation, the support team immediately initiated the intervention plan. Thanks to Director Zhao's involvement, the father was more accepting of the plan, trusting the experienced expert who had been following up with him for two years. The plan continued Yang Ping's design: Lele would temporarily be cared for by the father, Ms. Qiao would begin systematic psychotherapy, and family therapy would proceed concurrently.

However, a new issue arose during the legal and ethical review process: As the initial treatment institution, should the First Affiliated Hospital bear any responsibility for failing to detect the problem earlier? Did Lele commit any harmful acts that could have been detected during her time at the First Affiliated Hospital?
Yang Ping proposed holding a joint ethics meeting between the two hospitals. At the meeting, he insisted on one point: "Medicine is a continuous process of cognition. Two years ago, without clear indications, no hospital could have conducted toxicology screening or monitoring on a devoted mother. The First Affiliated Hospital team performed standardized diagnosis and treatment that was in line with the level of understanding at the time. We are able to discover the problem now because we are standing on the shoulders of the First Affiliated Hospital's two years of solid work and have adopted different observation perspectives and collaborative models."

Ultimately, the ethics committees of both hospitals reached a consensus: this was a problem of limitations in medical understanding and treatment models, rather than medical negligence. The joint statement emphasized that the resolution of this case demonstrates the importance of inter-hospital collaboration and multidisciplinary integration in modern medicine.

A week later, Lele was discharged from the hospital. When his father came to pick him up, the child's face showed a long-lost relaxed smile. Ms. Qiao's psychotherapy also officially began. Professor Chen conducted psychotherapy for her twice a week, and Director Zhao would occasionally follow up on the situation by phone. This was beyond the scope of a regular pediatrician's duties, but he said, "This case taught me that a doctor's thinking sometimes needs to transcend the boundaries of specialties."

Director Sun indeed brought over the precious bound volume and the rare copy. "As agreed, I'll lend it to you for two months." He gripped Yang Ping's hand tightly. "However, I think our cooperation will probably last for more than two months in the future."

Director Zhao's feelings were even deeper: "Professor Yang, thank you. Not only for Lele's case, but also for myself. This case has made me reflect a lot. Our First Affiliated Hospital has the best experts and the most advanced equipment, but sometimes it is precisely because of this best that we are prone to professional arrogance and ignore the possibility of interdisciplinary collaboration. Referring Lele to you was the best decision I made this year."

Yang Ping returned to his office, where Song Ziming was organizing Lele's complete medical records. The records were now incredibly thick—containing all the records from the First Affiliated Hospital for two years and the Third Affiliated Hospital for several days, as well as the discussion records of the multidisciplinary teams from both hospitals.

“This could be written into a very good case study,” Song Ziming said. “It’s not just about Munchausen syndrome by proxy, but also about medical collaboration, medical ethics, and humanistic care.”

Zhang Lin looked up and asked, "Professor Yang, when Director Zhao referred the patient, was this the basic direction already determined?"

Yang Ping pondered for a moment: "I think he had strong suspicions, but lacked evidence and a support system for handling such cases. He may have been being cautious."

A month later, Lele's father sent a photo—his son had won third place in the jump rope competition at the school sports meet, and he was all smiles. Ms. Qiao's treatment progressed slowly, but she was beginning to face her problems squarely.

P.S.: This is a case study from DXY.cn, and some readers may have already seen it. It's Munchausen syndrome by proxy. Before seeing this case on DXY.cn, I had only read about it once in a book, so I'm very grateful to the doctor who shared it. This is the first reported case in mainland China, so I'm sharing it here as part of my daily writing. There are two reasons why this disease is so rare: first, it is inherently rare; second, we generally don't value psychology and psychotherapy. Many psychological problems remain unresolved, and people don't seek medical help. This is a consequence of traditional culture. Thank you.