Case Scenario

SCENARIO 1

A mother brought her 11-year-old son to my office because he was having recurrent severe colicky midabdominal pains. She had taken him to the emergency department the day before but was not satisfied because “they did nothing for him.” I, too, found nothing physically wrong with the child and was sure his problem was functional. The mother could not accept this, even as a possibility. “There is no reason—everything is fine except for the pain,” she said. After she and her son left the clinic, I learned that the boy was about to leave home for a three-month competitive ski training course in northern Italy. Although he was a talented skier and wanted to participate, it was likely he was concerned about being away from his family and about the pressure of the course.

SCENARIO 2

A 44-year-old man was seen because his generally stable and easily controlled hypertension had recently become labile. He insisted on repeated questioning that all was fine in his life other than the nuisance of his inadequately controlled blood pressure. I had been forewarned by the clinic nurse that the patient's wife had run off with his best friend, he had lost his job and he had decided to relocate and find work elsewhere; however, I had been unable to elicit any of this information from him.

Commentary

Why is such critical information about patients and their lives so frequently left unsaid? There are a myriad of possible explanations.

One is that the physical symptoms may arise in some persons precisely because they are unable to express their distress in words. Sometimes what remains unsaid can be ascribed to a language barrier, inarticulateness, a limited or compromised mental capacity or the deliberate withholding of information (e.g., to protect a third party or for secondary gain).

Many people are unaware of the “mind-body connection” and may simply not realize that certain information is relevant. Information that may seem obviously pertinent to the physician may seem irrelevant to the patient, just as information that may seem clearly important to the patient may be regarded by the physician as a mere distraction.

Certain unconscious defense mechanisms used in an attempt to cope with an overly painful reality may interfere with the process of sharing information. The painful experience may be repressed. The more extreme defense of denial may be at work out of a fear of what might be discovered or a hope that if one does not name something, it does not exist; a degree of denial can be adaptive in dealing with a serious illness.

Isolation of affect may occur, in which an idea or event is separated from the affect that accompanies it. Other patients may fail to mention an obviously important piece of information because they wish to make a favorable impression on the physician or wish to avoid feelings of shame or weakness. Some patients may rely on an external locus of control and thus seek a pill as a solution rather than having to engage in painful introspection.

Much of what remains unsaid is the physician's fault; the information was simply not elicited or the history that was taken was rushed, superficial, not open-ended or not patient-directed. The patient never had a chance to say what needed to be said. In this era of managed care and seven-minute office visits, it is essential to recognize that time can be a crucial element in avoiding these pitfalls and in overcoming at least some of the barriers to communication. Even the most skillful psychotherapist cannot facilitate open communication without time to develop a rapport with the patient. For many physicians, working in the context of increasingly condensed schedules, it may become even more difficult to discover the hidden truths and issues that often underlie presenting physical symptoms. The physician must be able to spend enough time with the person who is suffering to build a trusting relationship, allow for natural flow of communication and synthesize an overall understanding of the person's unique situation.

Inadequate time worsens the problem, but it would be disingenuous to assert that adequate time is all that it takes to achieve full disclosure. In neither of the case scenarios above was lack of time the explanation for the hidden truths. Indeed, the truth came out in both cases as a consequence of gossip, of people talking about one another and the information reaching the clinic office and nursing staff. Often, a patient's illness can be understood only because it is seen within the context of what is going on in the community. Access to critical undisclosed information is directly proportional to the physician's involvement with that community. The more that he or she is part of the community and shares the lives of his or her patients, the less that remains hidden. This is bad news for the subspecialist, because there is no way to uncover what can only be known by a sharing of lives over a period of years.