The Secret Language of Doctors

by Brian Goldman

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  Arguably, one of the biggest changes in maternal care inside the hospital has been a near total gender swap.

  I can remember when it was almost impossible to find a female OBGYN. Today, not only do women outnumber men in OBGYN residency programs, it seems strange to see a male physician in the role.

  “Sometimes people have come in and left the hospital when it’s only males on call,” says a male OBGYN resident who is training in the U.S. “They’ll go to another hospital, shopping for a female obstetrician. Or they’ll ask to be transferred out as high risk by ambulance, because there’s only male obstetricians on. Not only do people not want obstetricians anymore, they definitely don’t want male obstetricians. It’s a bit disconcerting, as young residents that are wanting to have a long career, to be rejected like that so flatly.”

  The change has led some to question the role of male physicians in the field altogether.

  “Sometimes people look at them a little funny, like they’re somehow a bit perverted and that they went into the field so that they could look at female vaginas all the time,” says a former female resident in OBGYN. “When I’ve talked to my previous male colleagues, I think that was really hard on them. It reflects a misunderstanding about the field.”

  The female resident thinks there’s a lot less overt sexism in medicine. But she says she’s encountered a more subtle kind of sexism directed by female attending OBGYNs against female residents.

  “I think the OBGYN residency is one of the hardest on the residents, and the least forgiving on pregnant residents,” she says. “I remember one woman went into early labour during a shift when she was a junior resident. She’s thirty-two weeks pregnant and starts to have contractions. She’s afraid to ask to stop working because you just don’t do that. Finally, she’s kind of crippled by these contractions. Some of the other residents who are working with her go to the attending on that night and say that she’s got to go home because she’s in labour.

  “And the attending says she can’t go home because she’s on call. And if she goes home, she’s going to have to make up the shift! We’d never treat a patient that way.”

  The trend towards mostly female OBGYNs appears irreversible. According to a 2008 report by the Society of Obstetricians and Gynaecologists of Canada, 84 percent of OBGYN residents are female, 16 percent male.

  If and when the last man is driven from obstetrics, I seriously doubt that will end the tension between doctor and patient.

  8. Incarceritis

  A 28-year-old man I’ll call Roger is brought to the ER by the police. Roger had been charged with possession of cocaine for the purposes of trafficking. As the charges were being laid, Roger had started complaining of chest pain, which prompted the trip to the ER. Two female police offers brought him to the ER; both were smirking at me as I introduced myself to the patient.

  “What seems to be the trouble today?” I asked Roger.

  “I’ve got pains in my chest. They’re going down my left arm. I think I’m having a heart attack.”

  Roger then proceeded to answer yes to every textbook question related to heart disease: yes to having shortness of breath, yes to having high blood pressure, yes to having a family history of heart disease, and so on. Around the fifth or sixth yes, it dawned on me that Roger had boned up on the symptoms of a heart attack. I decided to ask him one I was sure he hadn’t read about.

  “Do your ears ring when you pass water?” I asked Roger. He looked puzzled and unsure of how to answer. After about twenty seconds, inspiration came to him.

  “Doc, now that you mention it, that’s exactly what’s been happening,” he replied.

  Now it was my turn to smile. Roger had answered yes to something called the positive functional inquiry test, a bit of medical slang an attending physician taught me when I was a student. A functional inquiry—also known as a review of systems—is a series of questions designed to get further details about the presenting symptom and a fuller picture of the patient’s overall health. A functional inquiry is exhaustive, yet useful only when it yields information that is both pertinent and true.

  As my teacher explained, some patients get confused by these questions and answer yes to each one because that’s what they think the doctor wants to hear. The devious ones—patients like Roger—answer yes each time because they think that’s the ticket to receiving a diagnosis. Whenever he became suspicious, my teacher said, he would ask patients if their ears ring when they pass water because this bogus symptom has no basis whatsoever in medical fact.

  “I’m not worried that you’re having a heart attack,” I reassured Roger. “Just to be on the safe side, let’s do an electrocardiogram and get some blood tests.”

  Later, when I finished my night shift and was handing over the ER to a colleague working the day shift, I told him about Roger.

  “I love patients with incarceritis,” he said. “Move ’em in and move ’em out.”

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  Roger’s story is inspired by hundreds of encounters with patients in police custody. Incarceritis is the medical argot my colleague learned as a resident to describe the conditions of people in jails, prisons or any other kind of police custody who fake symptoms to earn a trip to the hospital. The creator of incarceritis took the verb incarcerate, added the suffix –itis—Latin for inflammation—and created a delightful yet totally fictitious noun. As a piece of slang, it’s witty enough to get high marks from The House of God author Dr. Stephen Bergman.

  “Ah, yes, I’ve heard that one,” says Dr. Jeff Keller, a former ER physician who now is the medical director at not one but several jails as well as juvenile facilities in Idaho. “When they’re arrested, before they come to jail, they get it in their heads that if they can be sick enough, we’ll have to release them. They’ll seize upon anything in their pointy little heads that makes them sick enough to get out of jail.

  “Diabetics, especially type 1 diabetics, can manipulate their blood sugars and there’s very little that you can do to stop them if they really want to have their blood sugar go high or low. For example, in the jail we will draw up their insulin and hand it to them to inject. They’ll turn slightly away from us and inject the insulin underneath their clothes or onto the floor, so their blood sugar goes sky high and then we have to take them to the ER. Conversely, they’ll take their shot of insulin and then refuse to eat, causing their blood sugar to crash, which again means a trip to the ER.”

  Keller’s experiences both as a jail doctor and an ER physician have given him a unique understanding of medicine inside and outside of the correctional system. “There are a lot of differences between correctional medicine and regular medicine,” says Keller, who writes the blog Jail Medicine. “In a family practice, and a little less so in the ER, basically you believe everything the patient tells you. But in corrections, we always have to view all of those health claims kind of skeptically. They may be truthful but what they say may also be a means to an end.”

  And that is the essential difference between Keller’s outlook on patients and mine. I assume patients are telling the truth; hard-fought experience has shown Keller and those of his ilk otherwise. In Keller’s world, when it comes to patients who are convicted criminals, truth telling is at best a fifty-fifty proposition. In general, inmates who work a con on the doctors and nurses who work at correctional facilities are looking for one of or a combination of drugs, sex, power and influence.

  Often, though, they’re just looking to make life behind bars a bit more pleasant—like getting out of work detail. ER doctors and nurses may call it incarceritis; the health professionals who work inside those sliding prison doors call it the whine line. That bit of slang, which is listed No. 13 on scrubsmag.com’s “Top 47 Slang Terms Nurses Use,” refers to “inmates who suddenly need to see medical because it’s raining and they don’t want to go to work. In the hospital they are the uninsu
red that show up in the ER with sniffles, etc.”

  Prison inmates work as part of a rehabilitative labour program. The Thirteenth Amendment to the U.S. Constitution permits penal labour as a punishment for a convicted criminal. Detainees who have not been convicted cannot be forced to participate in such programs.

  In the ER where I work, I may get one or two requests a shift for a medical note excusing a patient from work or school. A whine line is that multiplied by twenty or thirty—in a prison no less! You don’t have to remind Dr. Mike Puerini of that particular challenge. Puerini is a physician at the Oregon State Correctional Institute, a medium-security prison in Salem that houses 800 inmates serving sentences of one to fifty years.

  It’s hardly surprising that some prison inmates use illness or disability to get out of work duties. Puerini says the biggest complaint he has with the whine line is not with inmates; it’s with correctional officers who ask doctors to validate claims by inmates for everything from time off work to providing a wheelchair.

  “The officers say they’ve got these fifty guys who don’t want to work today,” says Puerini. “They bring each one up to the doctor, and the doctor has to decide who has to work and who doesn’t have to work. In my opinion, that’s an officer not doing his or her job. Somebody’s got to say no.

  One of the reasons Puerini doesn’t want to validate the health claims of inmates any more than he has to is just how easy it is to get fooled by a good story. If you believe every word prisoners say, you won’t last as a corrections physician.

  “We had this doctor,” Puerini recalls. “I love this guy. He’s one of my favourite people, but he drove me crazy while he was working in the building. He saw working in this prison as an extension of his Christian gospel way of life and I’m the last person to fault that. But he was happy to give away the farm because he saw it like his mission work and other charitable work.”

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  There’s a strong connection between the prison MD who fears giving in to inmates on the whine line and the ER doc who fears giving in to patients who are pretending to be ill to score a prescription for narcotics. But there’s one big difference. Prison docs know what ER staff can only suspect: that their patients are criminals with hidden agendas.

  The polite term we use for this heterogeneous group of patients is drug seekers. But that’s an awfully wide net. They range from people who are addicted to the drugs they covet to criminals in the business of acquiring prescription drugs to sell or barter. Some are bona fide patients who got turned onto narcotics by GPs or specialists with little time to take a proper history and not much else to offer in their therapeutic toolkit.

  The thing is, it doesn’t seem to matter to us what kind of drug seeker a patient happens to be. We treat them all with a dollop of contempt that, to an outside observer, is shocking. The mere act of importuning, wheedling and sometimes pleading for drugs just seems to bring out the worst in us.

  “We use varying degrees of profanity for them,” says the ER nurse at a community hospital in Kansas who blogs under the name Not Nurse Ratched. “We’ll say, ‘Douche bag over here is demanding Percocet again.’ Or ‘We’ve got a bunch of barefoot hillbillies in there that want their hillbilly heroin.’”

  Hood Nurse, the ER nurse who blogs about her experiences at Adventures of Hood Nurse: Hood Hospital, says she and her colleagues call drug seekers trolls.

  “One in particular had a major medical problem at one point but has been out of the woods since,” says Hood Nurse. “She’ll come in for various complaints and want to get [the narcotic pain reliever] Dilaudid for whatever complaint it is, regardless of how ridiculous it is. She’ll say she’s allergic to everything but Dilaudid.”

  Hood Nurse and her colleagues have another slang term for narcotic seekers. They say the patient has ADD—not attention deficit disorder (a legitimate medical condition) but something more on point. “It stands for Acute Dilaudid Deficiency,” says Hood Nurse. “Somebody comes in for various complaints and they keep adding more on top of the pile. And they’ve had a thousand other visits this month for other vague complaints.”

  Dilaudid is one of the most powerful prescription narcotics in the painkilling arsenal. It can be given in pill form. In the ER, I give Dilaudid in its intravenous form to patients with severe pain caused by broken bones, kidney stones, acute abdominal problems and a host of other painful conditions. Dilaudid has long been known among drug seekers as “drugstore heroin” because, when shot intravenously, it produces a heroin-like high.

  “You’ll ask your colleagues what’s wrong with them and it’s like ‘Oh, you know, they’ve got ADD,’” Hood Nurse says, her voice dripping with sarcasm. “They’re coming in just because their ‘serum Dilaudid levels’ are low.”

  That slang is a pun on a bona fide kind of medical treatment. We measure chemicals such as sodium and potassium because your body needs them to run properly. We don’t measure serum Dilaudid levels. If a patient is in severe pain, we just give the patient a shot. The slang term serum Dilaudid level suggests the patient thinks she needs Dilaudid more than we think they do.

  Troll, douche bag, ADD. Not Nurse Ratched says her ER colleagues sometimes say the drug seeker is suffering from percocetopenia—a made-up bit of slang that means the patient is suffering from a lack of Percocet, a narcotic tablet of which addicts and recreational users have long been fond.

  Nurses aren’t the only ones who have it in for drug seekers. Just ask Dr. Donovan Gray, an ER physician and the author of Dude, Where’s My Stethoscope? The book, a collection of stories about Gray’s experiences as a doctor, devotes not one but two chapters to his experiences with drug seekers. “Anyone who’s worked in an ER knows about drug seekers,” writes Gray. “They’re those incredibly annoying chuckleheads who are forever trying to con us into giving them prescriptions for certain drugs. OxyContin is their Holy Grail, but Percocet, Dilaudid, fentanyl patches, or just about any narcotic will do.”

  A colleague who works in another part of Canada recalls a young woman who used to visit an ER complaining of migraine headaches. The thing about migraine is that you can’t see it on a CT scan of the head. Either you believe the patient or you don’t. The woman had visited the ER five times in seven days and each time had received a shot of Demerol—another powerful narcotic. After the fifth time, as she walked out the sliding doors, a nurse shot at her: “Why don’t you come back when you have a real cause for your pain?”

  The woman—who also had a psychiatric history—took the nurse’s suggestion to heart. She left the ER, walked to a nearby second-floor bar with a balcony and jumped, cracking both of her heel bones and two vertebrae in her back. As paramedics wheeled her back into the ER, the woman again demanded Demerol, which she got immediately; unlike a migraine headache, her broken bones gave her an obvious and legitimate source of pain.

  What strikes me about the episode was not just the disdain shown for the patient but the brazen way the doctors and nurses involved in her care laughed as they told the story. They were even chuckling as paramedics wheeled her in—as if delighted not just at having a good story to tell but that the drug seeker took their advice and became a real patient—one with three broken bones, all self-inflicted.

  There are many reasons drug seekers elicit a disdain bordering on hatred. For one thing, they’re seen as freeloaders. “That’s a blanket term that people in my hospital use not just for the drug seeker but the social services seeker or ‘whatever-else’ seeker—the people that come in and immediately make a thousand demands,” says Hood Nurse. “They want a cab voucher. They want footsies [soft foot covers that doctors and nurses wear over their street shoes when they go to the OR]. They want a sandwich. Healthy ambulatory people who are there for a minor complaint can easily provide these things for themselves. But freeloaders know these things are available and they demand them—usually in an obnoxious fashion.”

  ER
nurses are often quicker than doctors to label freeloaders and for a very good reason. I might see the patient only once, so I don’t see the pattern nurses catch because they work more hours than we do. Of course, it helps that, unlike physicians, my nursing colleagues don’t have to make the call and decide whether a patient is legitimate.

  The second reason for all that contempt has to do with the fact that some drug seekers—though not all—have PhDs in lying. The doctor-patient relationship is based on trust. You trust that I have the knowledge and the skill necessary to take care of you. I trust that you’re telling the truth. There’s no scanner that reveals whether you’re really in pain. The fact is, you could be lying about it and I probably wouldn’t know the difference. I have to trust you.

  Like most medical or nursing grads, I entered practice believing every patient tells the truth. When I was just starting out and I saw an ER patient writhing on a stretcher with what she said was terrible pain in her back, I believed her. I ordered a shot of a narcotic to relieve the pain. When she felt better, I sent her home with a prescription for thirty tablets of Dilaudid. As she left, she thanked me for being a kind and caring physician. I felt good about myself. A few weeks later, a police officer paid me a visit. He showed me a list of fifty or so doctors who had given the same woman scripts for narcotics within days of each other. All of us had been duped by a bogus patient—a con artist.

  When that happens, some doctors worry that authorities will take their medical licence away. That seldom happens, unless you’re a total rube who falls for every drug-related scam under the sun. Still, some physicians feel like they’ve been burned. I suspect the thing that gets most of us is the role reversal from the usual doctor-patient relationship. We’re used to having an overwhelming edge on our patients in terms of knowledge and experience. CT or MRI? Chemo or radiation? How the heck is a patient supposed to match wits with us?