The Importance of One’s Choice of Words and Keeping to Reality During Patient Encounters

Busy healthcare practitioners often pay too little attention to how their actions and words affect others, particularly ill patients. I have often noted residents and medical students, for example, doing an away elective while wearing a white coat with an insignia from their own hospital or medical school. While they may not have been provided with a white coat to wear from the institution where they were completing an away rotation and perhaps thought that they were not doing any harm by wearing their own coats, they likely did not consider the impact that this could have on a patient who was trying to remain oriented to time, person, and place. One’s choice of words may also at times cause more problems than one might imagine. The same words used in conversation with different patients may have different results, either comforting or anxiety-provoking; what may be considered useful in orienting one patient to reality may result in another patient becoming confused.

I recently saw an elderly woman in consultation who had fallen. The patient had significant periorbital edema that made it difficult for her to open her eyes. Her periorbital edema coupled with her baseline visual impairment from macular degeneration and her inability to wear her usual glasses due to her facial swelling caused her to have a difficult time seeing her surroundings. She also had a baseline hearing impediment that contributed to communication difficulties. While speaking with the patient and performing the physical examination, I was particularly puzzled by the conversation that was occurring between this woman and her doting nurse. There seemed to be a nice bond that had formed, but I could not understand why the patient kept referring to the nurse as her “granddaughter” and commenting to me about the “wonderful care I am receiving from my family” when, in fact, the only other person in the room was the nurse. Was she confused, disoriented, and in need of something more than just verbal cues to maintain reality?

When I was finished with the examination, I spoke to the nurse in private and suggested to her that attempts be made to reorient the patient to reality. I suggested that the patient be corrected when she began referring to the nurse as her “granddaughter,” and the patient be reminded that she was in the hospital after a fall and that, in fact, a nurse was providing her care and not a family member. The nurse thanked me and said that she would do this. A short time later, the nurse came to see me and asked if I thought that it was a bad idea for her to call this patient “granny,” as she admitted to have been doing with all of her older female patients. She seemed to have new insight, and realized that saying the “wrong” word might actually contribute to a patient’s confusion. Although one might wonder if the relationship between the nurse and patient would have been as strong if the patient did not believe that her own granddaughter was the person who was caring for her rather than a stranger, a nurse, I still believe that keeping to reality is always preferable over falsehood, even if the latter is being done with the best of intentions.

Dr. Gambert is Professor of Medicine and Associate Chair for Clinical Program Development, Co-Director, Division of Gerontology and Geriatric Medicine, Department of Medicine, University of Maryland School of Medicine, Director, Geriatric Medicine, University of Maryland Medical Center and R Adams Cowley Shock Trauma Center, and Professor Medicine, Division of Gerontology and Geriatric Medicine, Johns Hopkins University School of Medicine, Baltimore, MD. Send comments to Dr. Gambert at: medwards@hmpcommunications.com