Reducing the essence of a human being to a single sentence is impossible, but in taking care of patients, we doctors do it all the time
The one-liner attempts to summarize an individual and an illness into a single, typically run-on, sentence to expedite communication. It is a thesis statement for your diagnosis. Word choice and omission are critical. By the end of this thesis statement, your audience, in spite of the known perils of anchoring and premature closure, has already placed the patient into a familiar box.
Take, for example, my 62-year-old patient who was an IV drug user and developed an infection of his tricuspid valve. Thus framed, the audience is prone to labeling him as “shooter with a fever.” In so doing, they partially blame him for his present illness. The one-liner doesn’t permit me as a presenter to explain that he suffered a back injury while working construction in the 1980s, was given a lifetime supply of opioids, and then started using heroin when his scripts ran out. With its limited words and content, the one-liner can generate bias.
This is a 55-year-old woman with a history of diabetes and hypertension presenting with crushing substernal chest pain that radiates to the left arm.
This is a 55-year-old woman with a history of fibromyalgia and anxiety presenting with squeezing substernal chest pain in the setting of recent divorce.
This is a 55-year-old woman with a history of sickle cell disease presenting with stabbing substernal chest pain.
The one-liner has evolved over the years to include only what is truly medically relevant. For instance, when my grandfather started internship in 1958, he was taught to always include race because it is an important determinant of disease. My father, 30 years later, still placed race in the one-liner but only so that “you could picture the patient.” When I was taught oral presentations a few years ago, the dogma was to almost never include it. Evidence had emerged that ethnicity inappropriately influences how physicians treat pain from long bone fractures and choose chemotherapy regimens for ovarian cancer.
As I started my intern year, an admission called into question my own perceptions of the idiosyncratic one-liner. I was admitting a patient for a complicated urinary tract infection. While walking back from the ED, I wondered where and how to include that she was a trans woman. If this were a CHF exacerbation, perhaps I wouldn’t include it at all or simply mention it in passing with other routine data.
I thought of my team members trying to “picture” the patient and how “trans” would affect those images. Ultimately, with the hope that it wouldn’t influence her care, I said “trans woman” in the one-liner because it seemed relevant to a complicated UTI.
We have just finished a year that has made the divisions in our society more palpable than ever. As a medical community, we should be more cognizant of the labels we assign to our patients. The one-liner can engender premature closure and anchoring by placing patients in inflexible boxes right at the beginning of the presentation. But I believe we can avoid the bias through conscious scrutiny of the words we put into that single critical sentence.
Ethan L. Bernstein is an internal medicine resident.
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