I really do not understand the way my patients think.
This one lady, for instance, had surgery. She has pain from the surgery. So for the last two days, she’s been asking every doctor who walks into the room why her right side hurts more than her left side. We’ve all given her, repeatedly, essentially the same explanation: there’s a larger laparoscopic incision on that side, and a little more manipulation was done there.
This morning, the same question again: Why does the right side hurt? I mentioned that there had been a larger trocar there, and she said, what’s a trocar? Well, I guess that’s a fair question; I have no idea of the etymology, myself. So, having not much to do this morning, I stopped and explained the mechanics of laparoscopic surgery in some detail: one site, in this case supra-umbilical, for the camera to go through, and several others, spread around the abdomen, for various instruments. Her surgery had required a stapler, so a larger port had been needed on the left. Thus the larger incision, and more pain from the acrobatics needed to get the stapler oriented correctly. I thought I did a pretty good job: no words longer than two syllables (except “laparoscopic”), layman’s terms, openings for questions, and so on.
Half an hour later, the attending walks in. Same question: Why does the right side hurt more? I couldn’t believe it. What did I miss? Did I give her too much information? Doubtful, since for her elective surgery, I knew she had received several explanations of the precise anatomy, including diagrams. Was it too early in the morning? But it was 6:45am; that’s not horribly early (is it?). Did I use more technical terms than I recognized?
It seemed to go on all morning. I had an attending covering, so the patients weren’t really his. On such occasions, the attendings expect the residents to have everything neatly bundled up before they arrive. When covering on weekends, the attending cares even less for the details than usual. But my patients seemed determined to quiz him about all the minor details that I’d already addressed on pre-rounds. I guess some of them think that the big tall male attending will give them a different explanation than the small female intern. Maybe. But by their conversation, a lot of them seem to think I’m a partner with the attendings; so rank differences can’t be the only thing.
I am coming to suspect that people in the hospital are never very close to rational. Perhaps it’s the narcotics. Perhaps the element of irrationality in almost every patient I’ve had all year (even the nicest still seem to fixate on some irrelevant point here and there) is due to the drugs, and I’ve just never recognized it before. Either that, or the American non-education system has truly succeeded beyond Dewey’s wildest dreams, producing a populace incapable of proceeding from A and B to C. But outside of the hospital, once properly dressed, and returning for follow-up visits, most of these people seem much easier to talk to. Nevertheless, I’m starting to think that it really doesn’t matter how carefully I explain things, because so much of the time none of it seems to stick. The fact that I did stop to talk does seem to remain though, so perhaps simply the lingering impression of friendliness and helpfulness is worth the efforts at coherence and simplicity which seem to fall so flat.
February 9, 2008 at 3:16 pm
I am not entirely sure that it is just the hospital. My son Evan has a heart defect and I would explain thing about it to my husband. He would then turn around and ask the same question to the doctor and get the same exact answer. It was rather annoying, so I feel your pain.
February 9, 2008 at 4:41 pm
Have you considered a neurological defect in this woman?
February 9, 2008 at 6:35 pm
Perhaps this woman is just really really scared and needs lots of reassurance?
February 10, 2008 at 4:16 pm
Awesome – Lol, that could get frustrating.
Jill – There are no other signs of neurological problems. If I did CTs on every patient who seems not to understand simple statements, we would need two new scanners.
Fat Gal – Yes, maybe, but she seemed comfortable and doing well, in fact better than most people who have that operation. And we were all being reassuring. No one said anything the least bit scary in their explanations.
February 10, 2008 at 6:32 pm
Agreed, but I didn’t mean a CT scan. There are certainly patients who need to be told something a couple of times in order to really hear it, but what you’re saying seems a couple standard deviations beyond that. A quick MMSE wouldn’t be out of line, and then consultation if appropriate. No, it’s not a surgical problem, but we’ve been known take OTHER services to task for not being doctors first and specialists second.
February 10, 2008 at 10:38 pm
I think it is just stress related. Even when we medical people are hospitalized, or have a loved one hospitalized, repetition enhances retention. And very often, when questions are repeated, I find it is the particular area that the patient or parent finds most concerning–whether “when can she eat” to “what did that xray show, again?”
February 11, 2008 at 7:39 am
a typical patient. she doesn’t so much want information. she wants attention. if you were to hold her hand and say such things as, ‘don’t worry it will get better.’ and ‘shame! you poor thing’ you’d get a better result.
ct not indicated at all. even outright stupidity is not an indication for ct unless you know it is acute onset
February 11, 2008 at 7:40 pm
Jill – I see what you’re saying, but the rest of the picture didn’t fit. She was up ambulating, actually using her incentive spirometer, eating in moderate amounts, getting washed – doing everything you could hope for from a post-op patient. In fact, perhaps that should be taken as a bad sign?
Susan – Hopefully just stress. But I really think the narcotics have something to do with it, because the patients make less sense than their family does – usually.
Bongi – I love it: “acute onset stupidity.”
February 12, 2008 at 5:00 pm
When people keep asking something like this, often it means there’s some specific concern on their mind that you’re not addressing – i.e., she may have got it into her head that such-and-such might be the *reason* that one side hurts more than the other, and, unless that reason is specifically addressed, she won’t feel content with her answer. Of course, the logical thing to wonder is why people can’t just ask straight out about what’s on their mind, but I guess the answer is that people aren’t rational.
Hence, one of the things that gets drummed into us as GPs is to consider the patients ideas, concerns, and expectations – that’s a catchphrase in training to the point of being trite.
In this case, if the patient is still around by now, or if you get a similar case in future, what would be worthwhile is to say something like “You seem quite concerned about the fact that the right side hurts more, and it seems you don’t quite believe my explanation. Was there something in particular on your mind here?”
Having said all that – if she is still on narcotics, then that could be having an effect on her ability to remember and concentrate. I didn’t realise how much sedation could affect someone’s ability to take things in until my father had a minor procedure done under benzodiazepine sedation and my mother told me afterwards that when the doctor came round to explain the findings to him after the procedure, he clearly wasn’t processing or remembering information as normal – except that this was only clear to *her*, because she knows him so well. He was responding to things the doctor said and holding some kind of conversation and she could tell that the doctor just wasn’t picking up on the fact that he was still impaired by the sedation. Which is worrying for me when I think back on all the times when this was probably the case for many of the patients I spoke to post-op and they just didn’t take in what I told them about the operation findings!
February 12, 2008 at 7:20 pm
Sarah – Thanks, that’s a good point. We were assuming that since four of us had been in there at different times to talk with her, surely she would have mentioned it if there was a particular concern. But you’re right, often just opportunity isn’t enough. Patients have to be encouraged to ask that one nagging question.