Presenting Complaint – Language in Medicine, Part 1

Truth-Seeking, or: Establishing the History of the Presenting Complaint

I was a student of language long before I became a student of medicine. My grandfather was Polish, my parents travelled widely and studied a range of languages between them, our bookshelves were crammed with dictionaries, grammars, notebooks half-full of handwritten lists of vocabulary.

As a child, my parents moved to France. I remember clearly: being unable to speak and write at all in French on arrival, aged 7. Learning how to speak and being laughed at for making mistakes. Adopting the local accent with grim determination that no one would ever know I wasn’t local. Returning to England to go university, aged 17. Being unable to speak and write at all in academic English. Being teased for pronouncing words the wrong way.

At home, my siblings and I spoke a pidgin tongue. Easily understandable to anyone who spoke both languages, it seemed impenetrable to those who couldn’t. I still remember the look of blank bewilderment on a friend’s face when my baby brother came crying: “I piqu-ed my finger on the compas in my trousse!” (- I pricked my finger on the compass in my pencil case!)

I went to university to study languages. But what I really enjoyed was not so much the structure and acquisition of language, rather: its subtleties. I was drawn to literature, to the etymology of words, to stylistic devices that allowed you to manipulate language, to twist it and turn it and make it serve the point you wished to prove. By the end of my degree, what had been impossible to begin with had become a game. I was good at it, it came instinctively, but it always felt too easy to be meaningful in any serious way.

You write with fluency and conviction, you talk with authority and control. A complex idea here, an abstract proposition there, you juggle with them, play with them, seduce them. There is no movement from doubt to comprehension, no breaking down, no questioning, no excitement. You try to persuade others, never yourself. You recognise patterns, but you rearrange them where you should analyse them. In short, you do not think. You have never thought. You have never said to me anything that you believe to be true, only things which sound true and perhaps ought to be true: things that, for the moment, are in character with whatever persona you have adopted for the afternoon.

Stephen Fry, The Liar

When a patient arrives at hospital, the first thing you seek to establish is the “presenting complaint”. What brought them in? Why are they here? The answer can usually be given in a couple of words: chest pain, cough, shortness of breath, fevers.

What follows next is the “history”. The background to their presentation. How did it all begin? When did it start? What else has been going on? You might think that this is a straightforward thing to extract. It is not. Not in the slightest. Every person who speaks to this patient will be given a different story. Everything hangs on the questions posed, but not just the questions, the way in which they are phrased. “So you came in with chest pain?” begs confirmation, and most will oblige. “Did you come in with chest pain?” on the other hand, can open a flood gate of hereto unspoken details.

At medical school, we are taught to start wide and narrow down. “What brought you in?”, you might ask, before eventually getting to the specifics much much later. In real life, you learn to tailor your first question to the situation at hand. If it is 7pm and there are twenty people waiting to be seen, the way in which you allocate your time becomes a question of ethics. You rarely have the luxury of time in medicine.

So it becomes a game. The overall goal is to establish what you might call “the truth” in as little time as possible. The truth may be very different to what the patient feels is important, so a separate goal is to keep a rapport while you attempt to extract this information. Sometimes this goes disastrously wrong: it is not uncommon to meet a patient furious at the doctor who came before you. “They never let me explain how it really started – ” you might hear, before a patient launches into a story about their childhood that may or may not have any relevance to the potentially cardiac-sounding chest pain that alarmed their GP enough to send them in for a check-up.

The fun, of course, is that there is no single “truth”. It is not the case that if two colleagues asked exactly the same questions in exactly the same way, they would get the same story. It is not the case that if the same person asked exactly the same questions in exactly the same way two days in a row, they would get the same story. I have seen (countless times) a patient be asked the same question by the same person three times in a row and give a different answer every time.

So actually, your role is akin to that of a detective. You are tasked with approaching a tangle of chronologically confused and tangentially related information and deciding what matters. It is then your job to clarify details that might be suggestive of further areas of concern, which you are only able to begin to do with skill once you have enough years of experience to know what the relevant areas of concern might be.

Mostly, the patient is oblivious to what you are trying to establish. If they presented with chest pain and you ask them whether they sleep on a flat surface or with many pillows, it is not uncommon to get an answer such as: “Oh, well I don’t sleep well because my feet are always cold”. That wasn’t really what I asked, you might prompt. “Oh no, well I haven’t slept well for years, now that you ask!”, the patient might reply, brightly.

The issue here is that you are talking at odds. You have asked your patient a question that is trying to establish whether they are able to comfortably lie flat on a flat surface without gasping for breath, as would not be the case for someone with orthopnoea secondary to heart failure. But what the patient heard was a question about pillows, which they equate to comfort, and they’re not quite sure why you’re asking them how well they sleep, but they’re not quite sure why you’re asking most of the questions you’re asking, so they go along with it and give you an answer that, to them, answers the question as they understood it. It is difficult to explain how comically frustrating this type of conversation can be, especially at the end of a long day, or overnight.

Sometimes, the patient realises what you are asking, but has a different agenda. “Did this chest pain come on suddenly?” might be met with, “No, I’ve been feeling unwell since that day I got caught in the rain”. Which needs to be clarified: you’ve been having chest pain since that day you got caught in the rain? Or you’ve been feeling unwell since then, and the chest pain is simply one aspect of this? Here, you are again at odds. The patient does not feel that you are giving appropriate weight to the information that they feel is important, or has not understood why your question really matters.

Other times, the information has simply gone. The patient cannot remember the circumstances in which they fell. They can’t reliably tell you if anything like this has ever happened before. So again, the focus shifts.

No one ever told me how important language was to medicine. I think if I had known, I would have shown an interest in it much sooner. Perhaps it was that period of my life in which I was forcibly rendered mute, perhaps the countless occasions on which I struggled with the frustration of being unable to communicate what I wanted to say, but I find the exercise of truth-hunting, with all its comic moments and exasperation, extremely rewarding.

This is the first post in a series that will focus on illustrating different aspects of the importance of Language in Medicine. My two great loves. Hope you come along for the ride.

-Z