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Thursday, May 18, 2000No law against lack of concern
HAILEYBURY - It was during a discussion of a psychiatrist's obligations to his most troubled patients yesterday that Dr. Basil Orchard may have put his finger on the real issue that is before the jury in Courtroom No. 1.
He had just been asked by lawyer Owen Smith if a psychiatrist who learns that a patient has attempted suicide is required by professional standards to be concerned, to ask probing questions about it.
Dr. Orchard, looking pained, shrugged his big shoulders and said, "That's the reason for 'being' a doctor, isn't it?"
Mr. Smith asked, "Can you legislate concern?"
"No," said Dr. Orchard, "but you can legislate the things you must do to take more care."
This was no hypothetical chat.
Mr. Smith represents Debora McNamara, a 49-year-old Hamilton woman who is now suing her family doctor and two psychiatrists, claiming they should have known she was so gravely depressed back in the spring of 1990 that she was potentially dangerous.
Dr. Orchard, a leading forensic psychiatrist based in Mississauga, is testifying on her behalf as an expert witness here in this small town about 150 km north of North Bay, where Ms. McNamara was then living.
Ms. McNamara was dangerous, too -- about two months after her fourth, and last, session with Dr. Alexander Bell, she woke up early one morning, placed a pillow over the face of her nine-year-old daughter, Shauna, and over the course of the next 20 minutes or so, smothered her to death.
Dr. Orchard said yesterday this sort of violence is so predictable that psychiatry students have been taught "since 1970" to "look for homicide-suicide" in depressed patients, especially "where there are two people who are very close."
Ms. McNamara, who was the following year found not guilty of first-degree murder by reason of insanity and then confined to a mental hospital for five years, alleges that her medical team failed to recognize how sick she was.
The doctors -- Dr. Bell, his colleague at a North Bay mental health clinic, Dr. Patricia Achiume, and general practitioner Dr. Phyllis Hanley -- strongly deny the allegations.
They say Ms. McNamara didn't disclose all her symptoms, refused to sign the consents that would allow them to share critical information and didn't keep all her appointments or take the drugs they prescribed.
But Dr. Orchard, while agreeing that patients such as Ms. McNamara require more work, said that such difficulties are typical of people in the grips of serious mental illness and that psychiatrists must go the extra mile to help them.
Asked by Mr. Smith about particular actions Dr. Bell apparently failed to take -- such as take a detailed history from Ms. McNamara, ask for details of her suicide attempt in April, 1990, and phone Dr. Hanley for information that Ms. McNamara herself may have refused to tell him -- Dr. Orchard repeatedly said Dr. Bell had been outright "negligent," the quality of his care below accepted medical standards, and at other times, Dr. Orchard suggested, merely perfunctory.
The lack of questions about Ms. McNamara's suicide attempt -- she had overdosed on antidepressants, taking what Dr. Orchard described as a potentially lethal dose -- appeared to especially disturb him.
"If you have any concern for the patient," he said, "you have to look at it ... you can't brush it off or treat it lightly ... this was a very serious attempt to 'die.' "
However problematic the patient, Dr. Orchard said, the doctor has to try.
"There's no standard which says I have to like all my patients, but that does not relieve me of having to do my very best; at least I have to put some effort into it."
He scoffed at the notion that Dr. Bell would have been precluded from phoning Ms. McNamara's family doctor, Dr. Hanley. Dr. Hanley had referred Ms. McNamara to Dr. Bell, he said, and that meant they were free to exchange case notes and records without Ms. McNamara's OK.
As for Dr. Bell's earlier claim -- he has not yet testified here -- that he had only "limited time" to explore the "depths" of Ms. McNamara's ongoing depression, Dr. Orchard said he should have made time.
"The doctor's time is not the main matter here," he snapped.
"The main matter is that the patient is suffering, and what are we going to do about it. What matters is the patient!"
At her criminal trial, the court accepted Dr. Orchard's diagnosis that Ms. McNamara had been suffering from a major psychotic depression at the time she smothered her only child.
The taking of her daughter's life came at the end of a troubling year that saw Ms. McNamara go for help 18 times to her local mental health clinic, see a psychologist, and be prescribed anti-depressants. She will likely be on medication the rest of her life, Dr. Orchard said, because now, in addition to the original illness, "She has to face every day without her daughter, and that she's the reason."
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