Time to find common ground

It would be for the best that some descriptions doctors give patients are consigned to history

We all have pet hates, don’t we? Leaving our personal ones to one side, what are the pet peeves in your professional life?

Structured history-taking has many merits, but it is not a perfect tool. And the reporting of the patient’s history throws up some curved balls, I reckon.

One of the things that annoys me is the habit of presenting cases with the phrase “patient denies smoking or drinking”. The glaring implication is that the doctor doesn’t believe the patient and neither should those listening to the presentation. How about “the patient reports not drinking and not smoking”? There is no judgement if we do it this way.

A bugbear that annoys some doctors is the use of the term “poor historian”. Writing in STAT recently, two US doctors asked colleagues to consider the following questions:

“Should we pity the ‘poor historians’ – the individuals or family members who can’t give a clear accounting of their illness or symptoms – or embrace them? They have important stories to offer their clinicians, but can’t tell them. Who is really to blame here? And should the term poor historian ever be part of an individual’s permanent record?”

A poor historian designation has at least two functions, they add: It’s an expression of frustration at a lack of diagnostic clarity and a solicitation of forgiveness from their colleagues for lingering clinical ambiguities in the case.

Back in the 1960s and 1970s, the term “poor historian” was widespread enough in medicine that some doctors began to advocate against its use. In 1961, a Kentucky physician suggested that the term implied that the doctor was “himself a poor observer”. A 1970s textbook was far more blunt: “Too often the excuse is made ‘The patient is a poor historian,’ when in fact the physician is at fault.”

But the term continues to be passed down, from one generation of clinicians to the next, and is still alive today.

The STAT authors would like to see the term retired: “We don’t seek to assign blame to individuals on either side of these conversations: Patients offer the stories they can offer, and not getting sufficient information is generally not a sign that clinicians aren’t doing enough, or aren’t effective information gatherers.”

In response to the article one reader said: “A reason I don’t like the label is that the person writing the history is the doctor, hence the doctor is the historian, and as a historian is able to consult many primary sources, such as family members, primary care physicians, nursing home staff… etc.”

In other words, the patient is not the only source of historical information and doctors need to tap all these resources before deciding to use the poor historian label.

In another related piece recently, my narrative-based medicine colleague John Launer, writing a pre-Christmas column in the British Medical Journal, asked: “Which words or phrases would you like to see disappear from doctors’ vocabulary?”

He picked out three: “Lacking insight,” “in denial,” and “manipulative.” For him, they all smack of moral judgment masquerading as diagnosis.

Of “lacking insight,” he says that, although it carries a vague impression of psychiatric precision, it often means simply that the patient isn’t seeing things the same way as their doctor. 

Doctors who use the phrase “in denial” usually have in their mind an imagined set of emotional responses that everyone is meant to feel in a given situation (anger when thwarted, prescribed stages of grief after loss, etc.).

“Doctors seem to apply this kind of thinking especially in the context of bereavement,” he writes. “In these and other circumstances, they may ignore any personality quirks or varieties of human psychology that lead some people to react in their own unique way. The lazy use of the term ‘denial’ also appears to exculpate doctors from – God forbid – demonstrating curiosity about exactly how a particular individual is responding and what’s made them do so.”

As for “manipulative”, Launer says he scarcely knows where to begin: “When doctors describe someone as ‘manipulative’ what they really mean is that a patient wants something that the doctor, rightly or wrongly, believes they don’t deserve. Whether the patient’s request arises from distress, a misunderstanding, or any other cause, it’s no more or less manipulative than the doctor’s disinclination to say yes.”

He concludes with the following: “Please can we retire all these expressions and just talk about having different perceptions, expectations, or wishes from some of our patients – and about finding some common ground when we do?”

I’d be curious to know what readers think.