The Inappropriate Use of Quotes in Healthcare
On my Christmas wish list this year, I have just added another item…that health care professionals reduce their use of putting what patient's say in quotations without any explanation as to what the content of the quotes mean. This practice can be very misleading. For example, I recently reviewed records of patient who was collided into during a sports game. The records state that after she was hit, she did a "back flip." Now, what do you think of when you hear the word "back flip?" I think of someone who literally flipped over backwards, which would be quite a traumatic event and indicate that the person was hit with a significant amount of force. These are important things for me to know when I am trying the determine the nature of the injury. So when interviewing the patient and discussing this event she again used the term "back flip." So I asked her "Did you literally flip over backwards?" She said no, that was just her term for landing on her back. Big difference! But you would never know that if you just relied on the note that said "back flip" without an explanation.
Another recent case I reviewed said that after a head injury that the patient "saw Tweety birds flying above her head." Sounds funny and like something out of a cartoon but I was left wondering, was the patient just joking or was she hallucinating? Again, an important distinction and one with diagnostic implications, but it was not clarified in the note.
While the above example may not seem a crucial matter, there are times when putting terms in quotes can lead to misdiagnosis. A common area where this occurs in the area of mild traumatic brain injury (i.e., concussion). To meet the criteria set forth by the American Congress of Rehabilitation Medicine for concussion diagnosis, one needs to have evidence of an alteration in mental status such as loss of consciousness, disorientation, memory loss surrounding the event, etc. A focal neurological symptom would also count but we won't go over that here. So I was reviewing the records of a person who suffered a head injury while the patient was in front of me. Turns out, he had been diagnosed with a mild traumatic brain injury because he told the provider that he was "dazed" after the accident. The provider took this as an indication of altered mental status. However, when I spoke with the patient he denied any loss of consciousness, any disorientation, or any memory loss surrounding the event. So I turned to him and said "Well, what did you mean when you said you were dazed?" He said he meant that he was surprised about what happened but had no alteration in his thinking abilities. In actuality, he never suffered a mild traumatic brain injury but was told that he had. That's a problem folks.
Lastly, there are times when use of quotes is appropriate. Examples include when the patient cannot clarify what he/she means beyond saying whatever was said in quotes. In this case, I would put what was said in quotes but also mention that it is unclear exactly what was meant. There are other times when patients say something truly bizarre that you can only capture in a quote but in that case it will be clear to the reader why you are using quotes. The key point to ask yourself when using quotes is "Am I leaving things unclear for whoever who may read this in the future?" If the answer is yes, ditch the quotes.
posted by MedFriendly | 7:28 PM
4 Comments:
Interesting post and good points.
Off topic slightly but I am often unsure about correct sentence structure, punctuation, etc. I should get a book on it. :)
Also...I think of dazed as foggy, stunned and cognizant after a minute or so.
Another thing to consider when using quotes or reading them in the patient's record is whether the doctor is actually quoting something the patient said verbatim, or is he merely injecting his own bias into the situation by paraphrasing what he thinks the patient said and then using quotes as if this those exact words came out of the patient's mouth.
As a chronic pain patient, I have frequently found that doctors, particularly in the VA system where there is both a strong institutional bias against people claiming to be in "pain" (note the quotes) and also a pervasive CYA culture, will frequently quote me out of context and will take something I said and distort it to the point they have me saying something else, usually something that is self-incriminatory or inflammatory in some way. For example I reported that I had a lot of severe adverse reactions to certain drugs and have a bit of a phobia because of it. I specifically said that I wanted to keep my drug use to the minimum and that "less is more when it comes to drugs." This was reported as "patient claims to be 'allergic to everything' and states: 'I refuse to take multiple drugs.' Patient then persisted in his repeated requests for narcotics," even though I had not mentioned narcotics in that appointment but had done so previously.
Another problem is the persistent use of "scare quotes," which are a not so subtle way of casting doubt or aspersions on what a patient is saying. For example, there is a world of difference between a doctor writing "the patient is requesting treatment for his pain," and writing "the patient is requesting 'treatment" for his 'pain,' " with the latter using scare quotes to imply that the doctor thinks the "pain" might not be real and the "treatment" being requested is probably some kind of controlled substance. I have seen doctors on medblogs discussing the difference between migraine patients and "migraine" patients, with the latter indicating people who are pretending to have migraines or exaggerating their pain to get drugs. The subtle nuance here may not be discernible to the casual observer, but is crystal clear to anyone who understands how and why these quotes are used, so it becomes an easy way to libel someone and yet maintain plausible denial that the intent of the quotes was libelous.
In my opinion, unless the doctor is 100 percent certain (he was using a tape recorder) that a patient said a particular thing, he should avoid the use of quotes altogether. If he is paraphrasing what the patient said, he should make that clear, and should not take things out of context. This is particularly true when the material in question may be of an inflammatory or easily misunderstood nature.
When I was a psych resident, I had a co-resident who put all of the patients' chief complaints, verbatim, in quotes, although I think some were embellished. Of course, you'd never know, with some of the patients coming through our ER. I'd read things like:
"I came to the hospital because Ronald McDonald told me to come, after I had a Big Mac with Dan Rather."
"The police took me for a ride, and here I am!!"
"I'm drunk."
"The other doctors put a sensor in my teeth and I want you to take it out."
"AAAARRRRRGGGGGHHHHHH"
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