Oct. 29, 2007

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Looking Past the Patient Label

Graham Ramsay Nicole Martin

I was profiled at the airport last week.

As I stepped through the metal detector and handed my boarding pass to the TSA agent, he smiled and asked, “Are you traveling alone today?”

I affirmed that I was, and he continued, “Do you know how to find your gate?”

Why would he ask me these questions? I wondered. No one had ever bothered in the past. Then it occurred to me: I’m a young woman. And I’m blonde to boot.

I reassured the agent that I knew where to go, collected my things from the conveyor belt, and briskly walked toward the concourse. Then I began to stew. Of course, he assumes I have no idea what I’m doing, I thought—most of my patients think I’m not old enough to have graduated from college, let alone medical school. On the other hand, I figured, he was just trying to be helpful in case I was nervous. But I didn’t feel nervous, since I fly alone nearly once a month. I wanted to give him the benefit of the doubt. Still, I couldn’t stifle the uppity voice in my head that cried, “He has no idea he’s dealing with a Harvard-educated doctor!”

OK, so maybe I was a little oversensitive. This was partly because my family used to tease me about my absent-minded nature. I was the kid who earned straight As but got lost on the way to gym class. Adolescent insecurities aside, I’m strongly independent by nature, and I don’t like it when people assume that I need help. I especially don’t like it when people discount my brains because of my appearance.

Like me, most people become offended when pigeonholed. But as I mulled over my interaction with the agent, it occurred to me that doctors pigeonhole patients on a daily basis. Of course, we don’t meet patients and make instantaneous assessments, except in those few instances when a “subway diagnosis” is possible. A physician generally has the benefit of the medical interview and the physical exam to gather information and, on a more intangible level, to become familiar with a patient’s personality. At the end of the appointment, though, the patient has to have a label—if not a diagnosis, then at least a defined problem.

On the billing forms that we use, we check all diagnoses and problems that apply. Some of the vaguer selections are handy for patients with new, undiagnosed problems. I find myself using “fatigue,” “anemia not otherwise specified (NOS),” and “limb pain” fairly frequently. Despite these wastebasket terms, some patients still resist classification. One of my patients recently complained of a “trickling” sensation in her ear, without hearing loss, ringing, or discomfort. Figuring that the insurance company wouldn’t appreciate creativity, I billed for “ear pain” and moved on.

Billing procedures haven’t forced us to practice this way. Rather, the act of classification is deeply entrenched in medical culture. A doctor elicits a patient’s signs and symptoms, then sorts them on the shelves of his or her mental library. If a finding doesn’t fit precisely with its neighbors, it’s a cue to reshuffle the facts or rethink the outlier.

Many of the clinical pearls we learn in medical school—and use daily in clinical practice—can be encapsulated in sound bytes. Often, a phrase consisting of merely two or three words is enough to make a certain “synapse fire,” as many instructors are fond of saying. For example, “fat, female, and forty” makes us think of gallbladder disease. “Iron-deficiency anemia in a middle-aged man” is colon cancer until proven otherwise. “The worst headache of my life” is code for subarachnoid hemorrhage and an imperative to act quickly.

As physicians-in-training, we’re encouraged to maximize use of these stock phrases in order to “paint a picture” for our medical audience. The intern or resident who admits a patient has a wealth of data available, but it’s up to him or her to analyze that data and use it to build convincing arguments. Two patients could walk in the door with similar illness histories, yet each history of the current illness as presented on rounds may sound entirely different.

Let’s say that I complained of heartburn. I would be a “27-year-old woman with little past medical history presenting with burning and pressure in the chest and epigastrium, worse with meals, relieved somewhat by antacids.” If an elderly diabetic woman had the same complaint, she would be an “80-year-old woman with poorly controlled diabetes and no known history of coronary artery disease presenting with substernal chest pressure and epigastric burning, occurring at rest and with exertion, worse with meals, not entirely relieved by antacids and not associated with palpitations.”

It’s a good thing we’re taught to be persuasive—I don’t want to be whisked off to the cardiac stress lab anytime soon. By attaching labels to patients, we avoid missing important diagnoses in at-risk individuals. We also make life easier for ourselves. When you’re on call and it’s 3 a.m., it’s nice not to have to think too hard. The patient with the worst headache of her life should automatically get a head CT and perhaps a lumbar puncture. If the results of those tests are normal, the urgent portion of the workup is usually complete—the physician’s next priority is symptom management, then perhaps a little shuteye. Naturally, one relaxes a bit when the worst-case scenario is off the table.

Our assumptions can work against us, though. I took care of a middle-aged man from Greece who presented with chest pain that occurred after he drank wine at a wedding. When my team went to meet him on morning rounds, he welcomed us warmly and appeared very healthy. Initially, his symptoms sounded like heartburn (even though he had palpitations, which didn’t really fit), but we admitted him for “rule out myocardial infarction (MI, or heart attack)”—he was in the right demographic for heart disease.

It was only after I spoke to him for a third or fourth time that I began to get a more complete sense of his problem. He had had several similar episodes in the past, which he had downplayed during our previous conversations. When I pressed him, though, I learned that they had all occurred when he was stuck in traffic. It turned out that at the wedding, the guests at the next table had been arguing loudly. I asked him whether he had been feeling anxious or nervous in these situations, and he freely admitted that he had.

Although his English was reasonably good, I’m sure some subtleties were lost in translation. If he hadn’t seemed so socially confident, I might have picked up on the anxiety component sooner. If he were the “classic” panic attack patient often found on board exams—a young woman—I would have placed that diagnosis near the top of my list. Ultimately, I was able to reassure the patient that he didn’t have a life-threatening medical problem. Just as importantly, I let him and his primary care doctor know that his anxiety should be explored further. But it took me a little extra time to figure this out.

After thinking over my habits as a physician, I’ve made my peace with the TSA agent. I still think he jumped to conclusions about me. Rationally speaking, though, it’s hard to fault someone for offering extra assistance. He was just trying to provide what he thought I needed. I do the same for my patients. But once in a while, I need to remind myself to look more deeply and listen more carefully.

—Nicole Martin, HMS ’06, is a resident in internal medicine
at Massachusetts General Hospital.

The opinions expressed in this column are not necessarily those of Harvard Medical School, its affiliated institutions, or Harvard University.

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Copyright 2007 by the President and Fellows of Harvard College