Friday Reflection 48: Linguistics, Diagnosis, and Medical Error

FH is a 66-year-old woman who comes in for an urgent visit because she has been feeling woozy for two days. She is very anxious, almost distraught, because she thinks these symptoms are the same as the ones that her sister had before she died of a hemorrhagic stroke.

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A few years ago, a team building exercise was proposed at a meeting I was attending. To say I hate team building exercises is a gross understatement. I usually run for the door when these are suggested. On this day, I was too slow. For the exercise, I sat back-to-back with a partner who looked at a picture projected onto a screen. I could not see the picture. He described the image, and I had to draw what he described. After 5 minutes, I shared my drawing, and we discussed what worked and what didn’t.

Recently, I was at the Art Institute of Chicago, one of my favorite places on Earth, preparing to help lead a group of medical students around the museum. Our guide described a similar exercise while looking at a painting of a woman in mourning. Because my mind was on medicine, it struck me how similar this exercise is to what I do in clinic.

All diagnostic inquiries start with a patient experiencing a symptom. The symptom is a kind of platonic truth. What can make the search for an accurate diagnosis difficult is that a doctor seldom really has access to this truth. The doctor does not see or feel the symptom. Instead, the patient is asked to translate a sensation into language. Sometimes, the patient’s linguistic abilities are inadequate for describing the symptoms. Sometimes, our language itself is not up to the task.

Often there are issues working against the patient accurately describing his or her symptoms. The patient is anxious, in pain, exaggerating or minimizing symptoms, being rushed, or distracted.

No one can say if a patient is poorly describing his or her symptoms; that would be like telling someone that their description of red is incorrect.

FH describes her symptoms as wooziness. The doctor seeing her, Dr. S, not having a differential diagnosis for wooziness, asks her, “What do you mean woozy. FH says, “I feel floaty, foggy, out of it, off kilter.” FH is already getting a little exasperated. She is worried she might be having a fatal stroke.

To make a diagnosis, a doctor must characterize the concern, translating the patient’s words into a symptom with an established differential diagnosis and an associated diagnostic approach. This is where many diagnostic errors occur. This might happen if the doctor is not listening. But it also might happen if the doctor mischaracterizes what the patient is feeling because of how the patient reports the symptom. When that happens, the doctor begins evaluating a symptom that is not actually present.

The approach to the dizzy patient should begin with the doctor asking, “What do you mean dizzy?” and then just sitting quietly while the patient describes the dizziness. This question is supposed to force the patient to characterize the dizziness as vertigo, orthostasis, disequilibrium, or non-specific dizziness. When Dr. S asked, “What do you mean by woozy?” she had decided that woozy meant dizzy and proceeded as if FH had complained of dizziness.

The clinical interchange has just started and already the patient has translated her symptom into language and Dr. S has translated that into a medically useful symptom.

After hearing wooziness described as “floaty, foggy, out of it, off kilter,” Dr. S. had had it with ope