In the dungeons of the hospital, when the nights were interminable, the sofa broken and the bread stale, I got to know a fellow resident who made the nights bearable by regaling us with the details of patients he had to see. Bed two: LOL at risk of AHF (little old lady at risk of an acute hissy fit). ICU: Peek and shriek (the ICU harboured a patient whose diseased abdomen the surgeons had just opened and shut). Bed 29: TEETH, check out TTR (Tested Everything Else, Try Homeopathy. TTR referred, of course, to the tattoo to teeth ratio, his favourite number).
But behind the mischievous words lay a sensitive and capable doctor who went on to become a favourite among patients because he always knew his boundaries, unlike for example, our surgical tutor who once threw bare a man’s abdomen and asked a gaggle of students to examine “this elephant”. Twenty years later, I still remember that surgeon’s callousness with unease.
Changing times have delivered a distinct etiquette about how doctors talk to and about patients – we are by and large polite, in public and private. But on the brink of starting another stretch of service on the medical wards, I find myself pondering the language that I and my residents and students will use to describe the patients under our care, and importantly, whether we do harm in the process.
Words that crop up a lot include “cute”, “demanding”, “cranky”, “stressful” – the list goes on, interspersed generously, I have to say, with descriptions like “generous”, “thoughtful”, and “inspiring” as so many patients really are. But if I were a patient here is one label I would try hard to avoid: “anxious”.
Anxious is a word that pervades routine conversation – we feel anxious about finding parking, getting the heating repaired, selecting a primary school for our children and getting enough sleep.
But in the hospital, anxious takes on an entirely new meaning. Rather than a mere descriptor of a patient’s affect it fast becomes the prism through which the whole patient is viewed, and alas, often dismissed. An anxious patient can have a host of visible problems but the term anxious overshadows them all, detracting from better care of the ailments that may well have created the invisible anguish.
In an era where generalised anxiety disorder accounts for as much as 40% of mental illness I don’t want to diminish the crippling anxiety of sufferers who need professional help to improve.
I am speaking about the average patient in hospital who is vulnerable, usually ill-informed, steeped in well-intentioned but fragmented medical care, who sheds a disconsolate tear or looks upset and is quick to be labelled anxious. And before you know it, the label is tossed from doctor to nurse (or the other way around), from one handover to the next, until the occupant of Bed 17 becomes “that anxious man” instead of the human being whose hip is broken, whose pain is mounting, who doesn’t speak English and whose family is out of sight.
Every seasoned doctor can recall a time when an anxious patient had an excellent reason to be anxious – an evolving infarct, unsuspected internal bleeding, a pulmonary embolus or more commonly, doctor-patient communication gone awry, so that the space which reason and understanding should have filled is instead taken up by dread.
The insidious way in which being labelled anxious can harm patients was recently brought home to me by a former cancer patient who has spent years trying to disprove a diagnosis of anxiety in order to obtain income protection. His hospital discharge summary had carelessly listed anxiety as a diagnosis after he had sobbed one night at the uncertainty of his situation.
“Try insisting you’re not anxious – it’s an invitation to be labelled anxious,” he said wryly.
On the rounds I am about to begin, our patients will be mostly very ill. I will teach my residents that as benign as we might seem to each other, everything about us, and the hospital environment, creates anxiety. This anxiety isn’t pathological but normal. What’s more, it’s usually eased with better communication, empathy and acknowledgement that if we were in the patient’s shoes, we too would feel the same way.
When patients apologetically dismiss their concerns by saying, “I guess I’m just anxious,” we should ask them to name what’s making them anxious because they will often venture a thoughtful explanation, which will give us something to work with.
Some years ago, after losing a twin pregnancy, I was back in hospital at risk of a very premature birth that had everyone on the obstetric ward sweating. Every day of my prolonged admission was injected with acute anxiety, so I was surprised to hear a midwife recall many years later that unlike other women, I wasn’t anxious.
“I could feel the baby’s head descending but you were so calm,” she praised me.
No, I wanted to reply, as a doctor turned high-risk patient, I had simply figured out the down side of labels. I’d rather be seen as calm and even philosophical about an impending loss than anxious.
I knew by then the high cost of being labelled an anxious patient.
