The Words We Choose, the Stories We Tell

I met "Jimmy," an octogenarian with large, blue rings around dry, weathered eyes, on a January afternoon in the emergency department bay. He had come in to see his primary care physician for a regular checkup earlier that day. When physical and laboratory exam findings from the clinic suggested that he was dehydrated, he was promptly referred to the emergency department for evaluation.

Jimmy received intravenous fluids in the emergency department and had repeat laboratory tests performed. He was mildly anxious on examination, and when asked about a scar on his abdomen, he replied that he had been "kidnapped and forced into having surgery" by two doctors a decade ago. Because of this unusual admission, I was asked to see Jimmy and determine whether he needed psychiatric treatment.

Apparent delusional belief aside, Jimmy did not exhibit any alterations in mental status. His cognitive testing was intact. He was oriented to place and time and understood why he had been sent to the emergency department. Although his laboratory tests demonstrated improvement several hours later, his belief of being kidnapped remained stable. Puzzled by this incongruity, I continued to delve deeper into his story.

Although I spoke with Jimmy for over an hour, he never described being forcibly taken against his will. I repeatedly questioned him to recreate the minute-by-minute account of the incident. He had originally undergone surgery because his physician told him that he had a cancerous tumor that needed immediate resection. In retrospect, however, he felt he had insufficient information about his condition and was pressured into the surgery. When the tumor turned out to be benign, he felt betrayed and exploited—like the subject of a "medical experiment."

"What happened was a 'hostage situation’ because the doctor did not explain I might not have a cancer," he stated. "He made it seem as if I had the cancer." Jimmy blamed the consulting surgeon as much as his own doctor for engaging in "deceit." "They never told me there was no cancer," he exclaimed. He argued that he had essentially been held hostage in his own body, forced to undergo a surgery for which he had insufficient knowledge and understanding. He superficially appeared to manifest false beliefs of being kidnapped and held hostage. Although unusual, Jimmy’s belief that he was held hostage represented a more nuanced framing of his illness experience as a result of a potentially poor informed-consent process.

Physicians are adept at recognizing representative signs and symptoms that have diagnostic and prognostic significance. And while these heuristics (or mental shortcuts) are useful in the setting of acute illness or disorder, they are often insensitive to subtleties in language and expression. As I learned from caring for Jimmy, effective communication and patient care involves more than posing the right questions; it also requires that we question our assumptions. Certainly, physicians bring a vast array of skills and experiences in treating each patient. But we also bring many assumptions and beliefs that may alter our clinical judgment. By placing our assumptions under scrutiny, we can more readily frame our patients’ experiences in an appropriate context.