Dinah, ClinkShrink, & Roy produce Shrink Rap: a blog by Psychiatrists for Psychiatrists, interested bystanders are also welcome. A place to talk; no one has to listen.
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.
Posted by Dinah on Wednesday, November 26, 2008
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So, if I'm reading this correctly, it is not OK for me to think that Obama delivered his victory speech specifically to me? Are you serious? Because I was moved to tears. We have a connection, that president elect and I. You just don't understand.
"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."
When you say, "It is sometimes felt . . .", who feels it? The patient or other doctors? Also, do you mean that it *is* a different statement or that it can be construed as a different statement when it is not really? Does it just depend on the doctor whether he or she writes no hallucinations vs. denies hallucinations?
I know I am being nitpicky, but it is because I am curious.
I like the word "denies" for many reasons. Often, I may have a paranoid patient, who I believe is minimizing symptoms, or simply denying them, when I see some evidence that the symptoms may, in fact be there. For example, if a patient denies experiencing auditory hallucinations, but is clearly speaking to someone that is not there, or is looking around the room, as if someone is there (who isn't), or something is happening (that I can't see), "denies' is a helpful word. It doesn't state unequivocally that the patient is experiencing the symptoms, but leaves room for the clinician's observations, and opinions.
I remember that as a med student I was really amazed at how many people hear voices too - in the context like you said, someone calling them for a minute or something. At first I sort of shifted into "admission gear" when I heard it and then learned that quite a bit of that is considered normal, that there's a big difference between psychosis and just hearing some voices. And I was really surprised, again, at how common it was, especially in some cultures or in places where history of drug use during sometime in life is common.
When writing up an H&P, there are three places where the presence or absence of hallucinations should be indicated.
1-History. This is the Subjective part...it's what the pt tells you.
Q: Have you had any hallucinations? Seeing things that aren't there? Hearing voices? Your mind playing tricks on you? A: No. You write: "Pt denies hallucinations." Not "No hallucinations", which would be a statement of fact, of certainty.
2-Mental status exam. This is the Objective part...it's what you as a clinician observe about the patient at that moment in time. Here, I would write either "No evidence of hallucinations," or something like "Pt observed holding what appears to be a 2-way conversation, but there is no one else there," or "Pt seen to pick at the air, apparently grabbing things that are not there."
3-Assessment. This is your conclusion. You conclude they do or do not have hallucinations, and characterize them, or you indicate you cannot conclude one way or the other.
And I often tell people "Just because you have hallucinations doesn't mean you're crazy."
In Spanish, the verb negar is used, lit. "to negate[/deny]" so all one is really reporting is that the patient answered "in the negative" to a direct question about such-and-such. I simply think it's a semantic nuance which when viewed from a broader scope becomes less contentious.
That said, I know psychiatry has (necessarily) its own unique paradigm and POV on many topics, and I've nothing to say or add to that. ;)
What about "reports no hallucinations?"
"reports no hallucinations" implies the clinician never probed for the presence of the symptom.
I disagree. If I state "reports no hallucinations", it means I asked and the pt reported that there were none -- to report is an active process.
However, "no reported hallucinations" means that the pt did not spontaneously report them, but I probably did not specifically ask -- a passive process. Seems like a subtle point, but to me it is very clear. Am I the only one to split this hair?
I am merely an English teacher, but he is correct in the active vs passive process and what each one implies.
In my setting (correctional), I try to imagine myself defending the note I'm writing a year from now in a courtroom. With this in mind, my personal preference is using "denied", which leaves no room to question whether or not I inquired about the symptom. That being said, different strokes, and all that. ;-)
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