Look behind a patient's words

When symptoms don't make sense or a story doesn't hang together, there's usually a deeper meaning.

By John R. Egerton, MD
Family Practitioner/Friendswood, TX

"Why are you taking an antibiotic?" I asked Mrs. Green on her latest visit. She's a regular patient of ours, and there was no record of such a prescription in her chart.

"Well, I couldn't get an appointment here, so I went to another clinic," she said.

I was puzzled by this. There should have been appointments free at the time. On further questioning, Mrs. Green admitted that there was an appointment available, but only with a locum doctor who was working for us then. She had seen him before and didn't like him.

As doctors, we all know how important it is to listen. But it's not just the words we hear that are important; it's the meaning behind them. Sometimes patients mean far more than they say. Once we found out what Mrs. Green was really trying to tell us, we decided to check with other patients who had seen the locum. Because we found a lack of enthusiasm for his ability and bedside manner, we took Mrs. Green's warning and hired someone else.

Sometimes, a patient's miscommunication is an attempt to mask fear and anxiety.

"I just need a check up," Joe Black told me cheerfully when I asked the reason for his visit. In his late 30s, he looked the picture of health.

"Any particular health problems?" I asked.

"No, just thought I should get checked out. Stress test and all that."

I checked his chart. In the several years he had been a patient, Joe had never shown any interest in routine screening exams, despite my suggestions.

I took a guess. "Has anyone you know had a heart attack recently?" I asked.

Joe looked astonished. "How did you know?"

So often a relative's or friend's sudden heart attack, or diagnosis of cancer, or some other frightening disease prompts such a consultation. The nonchalant request for a "check up" really means, "I'm scared; tell me everything is all right."

Another patient, Brenda White, complained recently, "I'm so short of breath."

When asked to explain in more detail, she said that she just didn't seem to be able to get enough air into her lungs. "I'm sure there's something wrong with my lungs or my heart."

An examination of these organ systems was completely normal. So I took a different approach and asked Brenda how things were at home.

She told me that she was stressed out: Her parents were sick, her kids had been acting up, and there were money problems. So what Brenda was really saying when she said she was short of breath was, "I'm having attacks of hyperventilation."

Sometimes patients leave out a step when they describe their symptoms. It's up to us to ferret out the missing piece.

"How long have you had this pain in your knee?" I asked Fred Gray. "Since I got back to town," he said.

This meant little to me until I asked some more questions and found out that Fred had been on a skiing vacation.

Bill Brown had a sore throat. "I've had it since my daughter left," he said. Again, this made no sense until some further questioning revealed that Bill's granddaughter had been visiting, too, and she'd had a terrible cold.

But sometimes hidden meanings are easy to figure out. "I've no time to exercise," "I'm so busy I can't avoid fast food," "My family takes up all my time," "I smoke because it helps me relax," "My wife won't cook the right things," "My wife won't exercise with me."

They all mean, "I don't want to."

 

John Egerton. Look behind a patient's words. Medical Economics Apr. 25, 2003;80:52.