What I did before
Before this incident in the emergency room, I had no established teaching practice that focused consciously on checking the veracity of a trainees’ use and understanding of medical terminology. This challenged my assumption that the medical student comprehended such composite terms accurately.
What Changed My Teaching Practice
The telephone rang again – it was Julie, the new medical student who had joined the ward a few weeks earlier. In a tense voice she implored, “Doctor Veerapen, can you please come down and meet me at the Emergency, I am driving my father in – he is having hemoptysis, I think he has brought out several cupfuls and it is not stopping. I will be there in ten minutes”. I made my way down thinking about hemoptysis, about the possible underlying causes, wondering if her father was a smoker. Had he been unwell? Was this the first episode? By the time I got there, Mr. Chan was already on a trolley having an intravenous line inserted and his vital signs taken. An anxious looking Julie was talking about how massive the hemoptysis had been. The front of Mr. Chan’s shirt was soaked in bright red blood. Every now and then he spat out more fresh looking blood but he did not look distressed. I did not hear him cough. There was something incongruent about this clinical picture and the story of hemoptysis. Asking Julie to sit aside momentarily, we proceeded to question Mr. Chan about what had happened. In between spitting out more fresh blood, he explained that he was fine until an hour ago when in the middle of his meal his mouth started to well up with blood and it just had not stopped since. “No”, he had not coughed, he felt no pain and “Yes”, this was the first time. Further inquiry revealed that he was eating a meal of fish and it was a rather bony one at that. A quick examination of his tongue after mopping the blood revealed a clean horizontal cut measuring about 4 cm that was still oozing blood. Sustained local pressure took care of the problem.
What I Do Now
Without a clear history in Mr. Chan’s words, his diagnosis and treatment could have been delayed or misguided. This incident has been a forceful reminder of the need to teach our students to report the chief complaint and history of the presenting illness in the patient’s own words. Furthermore, as teachers, we need to remain mindful of making assumptions that a medical trainee means and understands medical terms as we do. Now, an unqualified use of a composite term like hemoptysis or hemetemesis prompts me to probe further with questions like: “What does that look like?” “What are associated features in the history or physical examination that you would look for?” and “What other conditions present in a similar way or can be mistaken for hemoptysis (or hemetemesis etc)?” If appropriate, these questions may be followed up by a discussion about the implications of labelling a patient with one of these terms without clear understanding and reasoning.
This incident has provided me with a poignant and striking tale that highlights the risks of inappropriate or inaccurate use of medical terminology. It has also made me more vigilant in my communications with practitioners and trainees from other healthcare professions who may have a different understanding of medical terms we use routinely.
Further Reading
Bourhis, R. Y., Roth, S., & MacQueen, G. (1989). Communication in the hospital setting: a survey of medical and everyday language use amongst patients, nurses and doctors. Social Science & Medicine, 28(4), 339-346.
Cole, Steven A. (2000). History of Present Illness (Problem Exploration). In Steven A. Cole and Julian Bird (Eds.) The Medical Interview: The Three-Function Approach (pp. 77-86). St. Louis, MO: Mosby.
Hadlow, Jan, and Marian Pitts. “The understanding of common health terms by doctors, nurses and patients.” Social science & medicine 32.2 (1991): 193-196.
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