Wednesday, November 26, 2008

Can I Have a Word With You?


A while back, one of our commenters took issue with the fact that I referred to a patient's complaint. It got me thinking about the way doctors word things, sometimes in ways that may sound pejorative.

So the standard format of medical notes opens with the "Chief Complaint." If the patient comes in saying things are great, the medical note begins, "patient has no complaints." Often the patient's exact words are quoted. To a physician, this isn't whining, it doesn't have a pejorative edge. The patient's problem is what we are taught to focus on, though a complete medical evaluation includes a review of systems (that's the term) where patients are asked, in a systematic way, about symptoms that may be indicative of a health problem apart from those pertaining to the chief complaint.

In describing patient symptoms, doctors also will sometimes use the statement "patient denies" symptoms. It's sometimes felt that this implies the physician doesn't believe the patient-- patient denies hallucinations is a different statement than no hallucinations.

And then, of course, there are the subtleties of sorting out how people interpret our rather unusual questions in psychiatry. We ask if people hear voices, and when I started doing this I was surprised at how many people say Yes. I soon realized that it's not at all unusual for people to occasionally hear the voice of a dead relative calling their name--- this is, I believe, a cultural phenomena, and in the absence of other voices or symptoms of psychosis, it's not necessarily a psychiatric symptom or a marker of psychopathology. And we ask people if they ever have the sense that the TV is talking to directly to them-- a symptom we call Ideas of Reference from the media. People sometimes think I'm asking if something said on TV feels like something they can identify with strongly, which is a different phenomena (one that's not a psychiatric symptom) when what I literally mean is--- is someone on the TV speaking specifically and only to you? And assessing paranoia in a city with a mind-boggling crime rate is a task of it's own. The questions have to get pretty specific, and if you're not a little worried, well, that's a little odd.