Doctors spend their days labelling people. Depending on which speciality we work in, we all have slightly different ways of doing so. For example, my mom’s physician would label her like this:
62 year old female #kidney donor 2018 with #mild renal impairment
Or my sister’s gynaecologist would label her this way:
29 year old female G2P2 #previous caesarian x 2 #asthmatic
(True stories – my mom donated her kidney to a friend; she’s a hero. And my sister is a mom of two; also a hero.)
It’s the first thing we do before we start seeing a patient. Actually, it is probably the second. The first is to assign societal labels based on appearances from which we then draw conclusions about their medical labels.
The young guy with all the tattoos and scars who looks a little scary? Must be a gangster or a drug addict or both. Then the hashtags “substance user” and “drug-induced liver injury” hang around in the backs of our minds.
The middle-aged obese woman with swollen legs? #diabetic #hypertensive #sedentery lifestyle #heart failure
The little old lady mumbling to herself in the corner? #dementia
We do this all the time. And then once we’ve formulated our own highly prejudiced labels we check their medical history on previous hospital encounters. What labels did the doctor before us assign this patient? We see #previous defaulter ARVs and are immediately annoyed by this person that we haven’t met yet, whose story we don’t know. We read the label assigned by the triage nurse “chest pain” and go into full heart attack mode, forgetting that there are plenty of reasons for someone to have chest pain, if they even have chest pain at all.
Before we have even interacted with a patient we have given them a list of labels, sometimes ten hashtags long. Ten labels and we might not even have processed the patient’s name yet.
The problem with this is we allow these labels to skew our clinical judgement. We trust all these hashtags more than we trust our own acumen. We are quick to duplicate them and slow to question them. It has happened so many times that a person with COPD (emphysema) has been labelled asthmatic. Or a person who has one abnormal kidney function result on the system has been labelled chronic kidney disease. I’ve even seen a patient labelled HIV positive when in fact someone else’s positive result had erroneously been uploaded on their folder number.
We assume the doctor who has made notes before us, especially when we consider them a senior, has got all his hashtags in a row. This has major implications for how we enter the patient encounter. Because these labels (however true or false they may be) blind us. We have a whole bunch of hashtags swimming before for our eyes and we miss things.
I’ve been caught out so many times. Just the other night I read the label “stroke” next to a patient’s name and thought “yes a stroke, I can do this, it will be simple”. (It was two o’clock in the morning – simple is all I want to handle at that time.) When I found her she was in severe respiratory distress. Yes, she had had a stroke but that was the least of her problems. Not so simple.
I also recently took over a patient in the ward whom the preceding doctor had labelled heart failure. Turns out her liver was causing all the problems and I almost missed it. I read #cardiac failure and that was that. Luckily my senior colleague has learnt the label lesson:
Don’t trust the hashtags. It is far better to go in with a blank page, maybe just a patient’s age and sex as a guide, and then formulate an unbiased set of labels.
What is even worse is that I can take all the medical jargon out of this post, apply it to the world at large and be left with the same truths. Young guy with all the tattoos and scars who looks a little scary? Must be a gangster or a drug addict or both.
The irony is that I too have all the tattoos and scars.