I am a Pediatrician, a mother of four, and I have Bipolar 2. I was hospitalized this year for something that had nothing to do with my bipolar. Yet, when I saw my records after my stay, I noticed that every note from every staff member started out “XX-year old woman with bipolar presents with ….” I would like to discuss why I feel this wording caused mental health bias and possibly compromised my care.
The Importance of The First Sentence
The first sentence of a patient’s note is called the chief complaint. It is meant to be a brief concise title to the rest of the note. Medical personnel make a list of possible diagnoses based on it to help them figure out what the patient has. The first part introduces the patient and gives a medical history that is relevant to the complaint. For example, “Eight-year-old boy with a history of asthma…” The second half of the note is a list of the most salient symptoms. For example, “…presents with four days of fever and cough.” However, it would be inappropriate to put down, “Eight-year-old boy with ADHD presents with four days of fever and cough.” What business does ADHD have in steering a diagnosis? Therefore, putting a mental health diagnosis in the chief complaint when it has nothing to do with the symptoms is not only inappropriate but could bias a provider’s thinking in determining the proper diagnosis and possibly compromise the patient’s care. I would like to share my experience and examples where I felt bias was a part of it due to my bipolar being put in the chief complaint.
Examples of Bias
One day, I noticed my eyes looked puffy. I was encouraged to go to the emergency room by my nephrologist, but before I went, I didn’t want to be perceived as a hypochondriac, so I asked every nurse in my building if my eyes were puffy. Even my boss (a physician) said she saw it the day before. But the ER staff simply declared they did not notice any puffiness and sent me home.
A few days later, not only my eyes but my whole face became grotesquely swollen, so I returned to the ER. This time they did a CT scan and came back with a diagnosis of multiple lymph nodes.
I kept asking for an infectious disease consult to evaluate the large lymph nodes, but they kept refusing. In the end, I went straight to one of the best infectious disease specialists on my day off. He took me seriously and ordered a bunch of tests, and no good doctor will order unnecessary tests. As a pediatrician, I see enlarged lymph nodes all the time, and I have a good idea of what to do for them, so I don’t know why the doctor in the ER didn’t take me seriously unless my bipolar biased them. (Of course, there’s a saying that “doctors make the worse patients.”)
Because of the large lymph nodes, the medical staff on my case had an initial working diagnosis of lymphoma (a type of cancer). They actually did not tell me this; they did not tell me about some malignant findings on my CT scan, nor that they were consulting oncology. The funny thing is when I saw the oncologist in my room the next morning, I didn’t think anything of it because he is my regular hematologist. (These are cancer doctors. They are called “Heme/Onc” for short because they also do blood disorders.) By the way, my final diagnosis was blood clots and I feel well now.
My other example that I feel might have had an element of bias or at least a discomfort for any mental health patient was the off-timing of my meds. While hospitals may be notorious for this, as patients, we tend to be more sensitive. One night it was 8:00 already and I usually take my meds early. I asked the nurse when was I going to get my meds and he said I was set for 10:00, so I foolishly said, “If I don’t get them soon, I might get all bipolar on you.” He just left the room without saying a word.
Then my worse fear came true. They took a lithium level and they probably didn’t time it right. So it was in the toxic range, and they called psych and lowered the dose. Luckily, I have a super nice psychiatrist who I was able to get on speakerphone and explain the proper dosage to them. We redid the levels and returned to the original dose when I got home.
The reality is we can’t control what medical professionals put on our charts (unless maybe we lobby against mental health bias). If possible, having an advocate with you is always helpful. I was told once in residency that you can’t control what others think or do, only how you react toward it. I know that bipolar doesn’t define me. So, yes, be on the lookout for bias, but at the same time, don’t let it affect you.
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