On Needless Words
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《新英格兰医药杂志》
The presentation began. She described a 62-year-old male with a UGIB whose history included CAD S/P CABG x 2, NAFLD, DM, HT, PUD, and BPH. I looked around as the barrage mounted. Four residents and two students were right on track. Clearly, I was the only one struggling to assimilate the letter collage into a portrayal of a sick person, past and present. As I grappled with whether the penultimate "ED" referred to erectile dysfunction or emergency department, a sudden awareness of a hero I'd never met invaded my psyche and displaced all else. How pleased William Strunk, author of The Elements of Style, would be by medical-resident discourse! "Omit needless words," he had admonished. How adept these young people were at doing just that. How bereft I felt at needing words they didn't.
It brought to mind a comic interlude during a presentation to a revered chief of medicine years ago. His teaching opportunities as an attending that month had been thoroughly thwarted by patient after patient admitted for advanced dementia, dehydration, and decubitus ulcers, leading him to lament the apparent reality that our teaching hospital had become a center for terminal care. Soon thereafter, another such patient was presented to him. He was told the woman had come from "Fairhaven NH." Mistaking "nursing home" for "New Hampshire," he exclaimed, "My God, they're referring them in from out of state!"
More recently, in presenting a patient to me, an overworked intern described him as "socially negative times three." When I asked for a translation, he replied, "No tobacco, no alcohol, no drug use."
"What would you think if I described you as `socially negative times three'?" I parried.
His answer was swift and on target. "Given the way the year's been, I'd say that's pretty damn accurate."
Words never seem more needless to a busy resident than those elicited from a somatizing patient during a complete review of systems. All the compulsiveness nurtured in medical school evaporates before the onslaught of bewildering trivial complaints that have presumably found, finally, a sympathetic ear. How to shut off the torrent of words?
The conventional strategy is to ask questions that have simple yes-or-no answers, but this rarely hinders the determined somatizer from expanding a yes response into an intricate account of the details of his or her belly pain or dizziness. Long ago, a creative fellow resident invented the only effective method I know of for dealing with a patient with an all-positive review of systems, though I hesitate to recommend it. We called it the "Corning couplets" in his honor. Typical couplets might be "Have you ever had constipation or syphilis?" and "Do you have headaches or lice?"
My most instructive example of the potential barrenness of questions with dichotomous answers occurred some years ago at a performance of Bruckner's Third Symphony. It was part of the Cambridge series of the Boston Symphony Orchestra, to which many physicians subscribed. As the first movement ended, a small, elderly lady had a prolonged syncopal spell. She was carried out to the lobby, where I joined the throng of my colleagues who had followed her. Once placed on the floor, the woman fluttered her eyelids and gained consciousness. Then the questions began.
"Have you ever had a seizure?" asked a neurologist. "No," she replied. "Do you take insulin?" asked an endocrinologist. "No," she said. "Have you ever had heart palpitations?" came from a cardiologist, and again the answer was "No." Then it was my turn. Not out of shrewdness so much as the lack of any new hypothesis, I blurted out, "Well, what do you think it was?" Her eyes opened wide, and her response was loud and unequivocal. "Bruckner!" she exclaimed.
No needless words there, but a great lesson on what an open-ended question can elicit — and an anecdote that has continued to serve me well in working with medical students.(Stephen E. Goldfinger, M.)
It brought to mind a comic interlude during a presentation to a revered chief of medicine years ago. His teaching opportunities as an attending that month had been thoroughly thwarted by patient after patient admitted for advanced dementia, dehydration, and decubitus ulcers, leading him to lament the apparent reality that our teaching hospital had become a center for terminal care. Soon thereafter, another such patient was presented to him. He was told the woman had come from "Fairhaven NH." Mistaking "nursing home" for "New Hampshire," he exclaimed, "My God, they're referring them in from out of state!"
More recently, in presenting a patient to me, an overworked intern described him as "socially negative times three." When I asked for a translation, he replied, "No tobacco, no alcohol, no drug use."
"What would you think if I described you as `socially negative times three'?" I parried.
His answer was swift and on target. "Given the way the year's been, I'd say that's pretty damn accurate."
Words never seem more needless to a busy resident than those elicited from a somatizing patient during a complete review of systems. All the compulsiveness nurtured in medical school evaporates before the onslaught of bewildering trivial complaints that have presumably found, finally, a sympathetic ear. How to shut off the torrent of words?
The conventional strategy is to ask questions that have simple yes-or-no answers, but this rarely hinders the determined somatizer from expanding a yes response into an intricate account of the details of his or her belly pain or dizziness. Long ago, a creative fellow resident invented the only effective method I know of for dealing with a patient with an all-positive review of systems, though I hesitate to recommend it. We called it the "Corning couplets" in his honor. Typical couplets might be "Have you ever had constipation or syphilis?" and "Do you have headaches or lice?"
My most instructive example of the potential barrenness of questions with dichotomous answers occurred some years ago at a performance of Bruckner's Third Symphony. It was part of the Cambridge series of the Boston Symphony Orchestra, to which many physicians subscribed. As the first movement ended, a small, elderly lady had a prolonged syncopal spell. She was carried out to the lobby, where I joined the throng of my colleagues who had followed her. Once placed on the floor, the woman fluttered her eyelids and gained consciousness. Then the questions began.
"Have you ever had a seizure?" asked a neurologist. "No," she replied. "Do you take insulin?" asked an endocrinologist. "No," she said. "Have you ever had heart palpitations?" came from a cardiologist, and again the answer was "No." Then it was my turn. Not out of shrewdness so much as the lack of any new hypothesis, I blurted out, "Well, what do you think it was?" Her eyes opened wide, and her response was loud and unequivocal. "Bruckner!" she exclaimed.
No needless words there, but a great lesson on what an open-ended question can elicit — and an anecdote that has continued to serve me well in working with medical students.(Stephen E. Goldfinger, M.)