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To Us It's a Normal Day, to a Patient It's the Worst Day

It's not unusual for my mother to call me at work, but I still answered quickly last August when my phone rang. She had texted me earlier that she was going to the ER because of terrible vertigo and nausea. "I have to stay in the hospital another day. They saw something on my CT angiography. They said it’s an aneurysm or a pseudoaneurysm or an artifact. I don’t know what that means," she said. "I’m really scared." Imagining my healthy and resilient mother hospitalized was disarming, though I knew that the experience of going to the doctor and being overwhelmed and confused was common, having seen plenty of the same in my patients.

She went on to tell me that the radiologist and ER doctor had disagreed on the scan results, so they needed to keep her for another test. I asked what test, but they hadn't told her. "They said the aneurysm might be in the V2 segment, behind my ear," she said. "What does that mean?" Although I was only two months into my residency in psychiatry, both of those months had been in neurology. I tried my best to reassure her, realizing as I did so that her fears and worries must mirror the patients I'd seen earlier in the day, who had also looked to me for reassurance. 

In the day-to-day of medicine, we see so many patients, frequently with similar stories, and we deliver so many messages that it's easy to forget the impact that any one message has on any one patient. On an inpatient service I might see eight patients in a day, but for each patient, it is a day of their life spent in the hospital. How we explain to them what is happening becomes utterly important to their own understanding of their illness, yet we so often don't take the time to do it correctly. At the very least, we don't give the depth of thought we should to how we say what we say, and how it might be received. We must remember this every time we tell a patient anything, but particularly when delivering a diagnosis. We forget this potential of something we say to alter the course of someone's life. Because of this, we must give each conversation its due diligence.

I am now several months removed from neurology, but my months of inpatient psychiatry have only strengthened my conviction that we must take our diagnostic conversations seriously. One of my patients was a young woman, recently graduated from college, with changes in behavior; after gathering all the information and talking with the patient — a very guarded and suspicious person — all the signs pointed toward a first episode of psychosis, and possibly mania as well. The medical student and I thought carefully each day about how we would talk to the patient about it. We wanted to be sure we were being precise and forthcoming, but also tread lightly around the things that were still unknown; including, for example, her actual specific diagnosis. Further, the patient's mother was a professional psychologist. When I spoke with her, I could hear the concern in her voice; I could feel that it was somehow different for her as it was her own child. I answered her questions and assuaged her as best I could, but I was still forced to cut the conversation short, as I had three other patients who also required my attention. 

Our words are layered with meaning and connotation for our patients. Any diagnostic word evokes emotions, perhaps calls images or memories to mind, and only then might take the form of definitions or rational explanations. This is how language works, and the effect is increased when the words are more serious — words like aneurysm or bipolar disorder or schizophrenia. The seriousness, and the resulting connotations, are shaped by cultural factors as well as personal history. My mother may have been thinking, that day in the hospital, of another local woman — the mother of a girl who had graduated high school with me, and very close to her age — who had died unexpectedly of an aneurysm just a few years ago. This contextual aspect of diagnoses is why we must be very careful in how we discuss it. We use these words all the time, and so we forget what it's like not to know them. They carry connotations for us, too, but these are tempered by the years of schooling and studying and not simply by general cultural usage. 

Even my patient whose mother was a mental health professional did not necessarily share the same connotations, and terms like "psychosis" mean one thing in the abstract but quite another when applied, especially to one's child. When I spoke with the family, I allowed them to lead with their questions and concerns, rather than administer my own judgments in my own words. Our treatment team did the same with the patient, and we allowed her to describe what was happening. She worried that she was going crazy, so we talked about what that meant to her now and what that would mean for her in the future, and she was agreeable to trying quetiapine. We explained that the medication is called an "antipsychotic," which carries a number of connotations of its own, and I feared that if we didn't address those directly, her paranoia would prevent her from giving it a try. Conversely, we were concerned about destabilizing her by trying to lay out all the diagnostic criteria for bipolar disorder or schizoaffective disorder, especially without a clear picture of what was going on.

This careful attention to diagnostic conversations is essential in psychiatry, but all physicians must carefully consider what exactly they say when they talk to a patient about their diagnoses. Nearly anything that a patient can be diagnosed with has layers of meaning to it, and so we should try to address those. We should support models that involve meeting a patient on their own turf, asking first: what do you think is going on? Why are you here now? What are you hoping for? What are you most concerned this might be? What is your understanding of your disease? How did you come by that understanding? Only after gaining insight into who the patient is (their cultural background, their familiarity with medical jargon, their insight, their social structures, and more) can we try to use their own language to help them.

My mother turned out to have completely normal cerebral vasculature. Erring on the side of caution, the doctors kept her overnight for a cerebral angiogram, which confirmed the CT angiography finding to be an artifact. Her vertigo improved with meclizine and there have been no problems since. My patient with unspecified psychosis improved with medication and was ultimately able to go home with close outpatient follow up, seeing a psychiatrist who would hopefully be able to clarify for her the exact diagnosis and continue those diagnostic conversations. Both of those stories sound neat when written in plain language, but the lived experience is always so much more. What I hope to resist is the tendency to believe that just because I can articulate a diagnosis in medical jargon means the patient will understand. It is difficult and laborious to translate our words into a shared language, but if we want to have any real impact as physicians, we have to keep trying.

Brent Schnipke, MD is a writer based in Dayton, OH. He received his MD from Wright State University in 2018 and is a first-year Psychiatry resident at Wright State. His professional interests include writing, medical humanities, and medical education. He is also a 2018–2019 Doximity Author.

Illustration by April Brust

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