Focus
Student Scene
September 16, 2002
Words: The Most Potent Drug
 Renee Hsia Photo by Jeff Cleary |
At that first visit, the newly minted physician did the history, a physical, and a basic workup: a complete blood count, electrolytes, a urine analysis, and an electrocardiogram. The physical was unexceptional--stable vital signs with good oxygen saturations, pupils equally responsive and reactive to light, clear lungs, normal heart sounds with regular rate and rhythm, no abdominal tenderness, normal strength in the upper and lower extremities. The lab results were slightly abnormal--mildly hypernatremic, hypokalemic with elevated blood, urea, and nitrogen levels. Normal glucose--Jean's weakness was, at least, not attributable to that. The EKG showed a normal sinus rhythm and no acute ST changes.
In the ED, the weakness did not seem to be progressing and was judged in no way to be threatening to respiratory function. Since Jean did not seem to be in acute distress and his vital signs were absolutely stable, he was sent home from the emergency department with instructions to follow up with his primary care physician for an outpatient workup of his weakness.
Eureka
A week later, Jean appeared in the ED again. This time, he came with films. Films of his brain. He had, indeed, followed up with his primary care physician, who had for some reason, perhaps because of a better history, decided to send him for an MRI of his brain. The radiologist reading the MRI that day sent him immediately to the emergency room. Jean didn't quite understand what was going on.At that time, as a beginning third-year medical student with no strict responsibilities and time pressures, I wandered over and asked Jean what had been going on.
And then it all came together: "J'ai le vertige."
Which made it all make sense.
The whole time, he had been feeling dizzy, not just weak. And I realized then that not knowing the English word for dizzy, he had substituted the word weak. The limits of his English allowed him to communicate the fact that he was not feeling his normal self, but only to a certain point.
Unfortunately, the difference between those two words--weak and dizzy--is dramatic from the perspective of the workup and physicianÕs inclination toward the diagnosis. Both words have almost infinite differential diagnoses. Weak conjures up a picture of neuromuscular dysfunction, such as myasthenia gravis, tetanus, Guillain-Barré syndrome, electrolyte imbalance, or even just simple fatigue or hypoglycemia. Dizziness might be a symptom of these disorders as well, but it is an alarm to the medically seasoned ear to focus more closely on dysfunction of a particular part of the central nervous system.
The MRI showed a cerebellar hematoma. Evidently, Jean had suffered a stroke the week before. One that had probably bled slowly and had stopped on its own. At this point, however, there was no treatment. In fact, even if it had been diagnosed a week earlier, it is not certain the patient's management would have changed. Most likely, he would have been admitted for inpatient observation and neurology and neurosurgery consults. We were lucky that the bleed had resolved spontaneously. Jean would only have a mild, residual change in gait and lack of balance, which might even disappear if new blood vessels found their way to the site of injury, as they often do.
The Wrong Turn
But what if we--or more importantly, Jean--had not been so lucky? What if the bleed had continued and we missed an opportunity for a life-saving intervention? Where did we go wrong?It was, very simply, an issue of words. There was a lack of understanding between the physician and the patient. It was no one's fault. The physician did not speak French or Haitian Creole. And the patient's ability to speak English enabled him to explain his symptoms but in an imprecise way.
Are these mistakes unavoidable? According to the Institute of Medicine's widely publicized report on health care disparities earlier this year, racial and ethnic minorities receive worse health care than whites, even when socioeconomic factors, including insurance status, are taken into account. Clearly, for ethnic minorities, language is an enormous component.
The Office of Minority Health of the Department of Health and Human Services published a series of recommendations in December 2000 that speak to this point: health care organizations should "ensure that staff at all levels and across all disciplines receive ongoing education and training in culturally and linguistically appropriate service delivery." In addition, the report states that health care organizations "must offer and provide language assistance services, including bilingual staff and interpreter services, at no cost to each patient/consumer with limited English proficiency at all points of contact, in a timely manner during all hours of operation."
The report's requirements seem somewhat unrealistic--is it really possible to provide all patients, regardless of language, access to bilingual staff and interpreters at all hours of operation? Large hospitals often attempt to provide such services, but is it reasonable to expect small community physicians to be able to do this? If so, who will finance it?
While these questions are undoubtedly legitimate and, unfortunately, too often unanswered, perhaps even more basic is the question of whether the importance of communicating to the patient has been devalued by advances in technology. We have been persuaded to believe that what the patient tells us is of secondary importance because our clinical exam and sophisticated laboratory tests can reveal the truth. This misconception may lead us to ignore the most important part of the clinical encounter: reliable communication. And a further consequence is that we sometimes think that language services are too inconvenient or costly--or both--to aid in diagnosis or patient care.
A paradigm shift is critical. Translation services and the language facility of health care providers must be seen for what they are--indispensable resources. In fact, the increasing diversity of America calls for a parallel growth in language services. Nearly 14 million Americans--yes, Americans, not just people living in the States--are not fluent in English.
When it comes to the question of who will pay for these services, it is clear that insurance companies do not want the extra cost, nor do hospitals or the government. But until we begin to appreciate the true value of communication, can we even begin to tackle more feasible solutions to the problem? Necessities are built into the budget as basic costs of doing business. Language--the vehicle of communication--is a necessity.
Almost certainly Rudyard Kipling did not appreciate how fitting his observation about the importance of words is to the patient-doctor relationship; but in these times, his declaration never rang more true: "Words are, of course, the most powerful drug used by mankind."
--Renee Hsia, a fourth-year medical student at HMS
The opinions expressed in this column are not necessarily those of Harvard Medical School, its affiliated institutions, or Harvard University.