(South African Medical Journal 2009;99(7):508.)
Recently a student commented that she had seen two patients in our clinic who presented with symptoms, ‘but they were not the real reason for them coming to see the doctor’. They had used the symptoms as what has been called ‘entry tickets’ into the consultation. Although common in practice, these camouflaged messages are often not consciously registered by the doctor. Similar ‘door-handle symptoms’ (1) may arise at the end of a consultation when the real reason for the encounter may eventually be raised.
Patients (and all of us) clothe many encounters in veils and metaphors, used as carriers of Morse code-like messages which we hope the receiver can decipher. Thus entry tickets can come encoded under the cover of an allusion or a slew of euphemisms, especially when discussing the great social taboos of urinary and bowel function, sex and death.
Visiting the doctor is often unsettling and most of us rehearse what we are going to say on the way to the doctor’s office. Our words and sentences may be formulated into conditions that are socially acceptable in the context of a patient seeing a doctor. No one wants to be seen in a bad light, and our fears, guilt feelings and personal beliefs somehow become more acceptable as fatigue (2) and dizziness and that ‘strange’ pain.
We seldom come straight out with our troubling problem, but break the ice with the small talk about the traffic and the weather. This phatic communion (from the Greek ‘spoken’) refers to non-medical preamble that helps us establish rapport. The main complaint may then follow, but even so ‘I am depressed’ is not usually presented as the first complaint. We often offer physical complaints in preference to mental health issues owing to embarrassment or shyness.
This communication involves the complex transition between how people experience their illnesses and how they talk about them. For instance, a commonly encoded entry statement is ‘I want a check-up’, which later reveals a worry initiated by the recent illness or death of someone known to the patient, which has prompted the visit to the doctor.
Idioms and hidden agendas vary with age, sex, culture and context, but some form of pain (e.g. abdominal, backache or headache) is universally accepted, as are many expressions for fatigue and loss of energy. The headache may be real, but its relative weight and significance fades on revelation of the underlying alcohol abuse. In fact almost any physical or mental symptom can be used as the messenger for the infinite varieties of human distress. Balint (3) called them offers or a proposition of a symptom or illness that the patient makes to the doctor, who may accept it or make a counter-offer that may be followed by a negotiation. Much of this may be to do with ‘face’, such as the noble symptom-bearer ‘putting on of a brave face’ (4) or the ‘saving face’ when the patient uses another subject to divert the doctor’s attention away from an uncomfortable circumstance.
Entry-ticket symptoms may be intentional or unintentional due to anxiety or uncertainty about how to express oneself. Traditional people use many metaphors and entry-ticket symptoms both out of respect for the doctor and in their normal forms of address. Many cultures do not come to the point straight away but have circumlocutions before addressing the main subject. For instance, amaZulu men present with ‘kidneys’ (izinso) when worried about erectile dysfunction or if feeling contaminated after crossing a taboo such as finding out that they have slept with a menstruating woman. AmaZulu women may present with ‘stomach’ (isisu) as an initial symptom when they come in with infertility problems or to find out if they are pregnant. The amaZulu use a surrogate language when addressing people whom they respect (called hlonipha) and substitute words and names that are more appropriate for the situation. (5) Abdominal pain may be one of the commonest expressions of a hidden agenda in all cultures and can represent anything from fear of sexually transmitted disease to homesickness to the more common request for a sick certificate.
In a way, during a consultation both the doctor and the patient are fishing from opposite banks of a river. Entry-ticket symptoms at the beginning of medical consultations and door-handle symptoms at the end, and the whole mosaic of presentations in between, offer cues for the doctor to pick up. It is salutary to think that we may never know about those that we miss.
1. Ellis C. Door-handle symptoms. S Afr Med J 2004; 94: 95-96.
2. Ridsdale L, Mandalia S. Tiredness as a ticket of entry. Scand J Prim Health Care 1999; 17: 72-74.
3. Balint M. The Doctor, His Patient and the Illness. London : Pitman Books, 1957.
4. Ellis C. The noble symptom bearer. SA Family Practice 2008; 50(4): 76.
5. Ellis C. Communicating with the African Patient. Scottsville: University of KwaZulu-Natal Press, 2004