There used to be a habit of documenting personal comments in medical notes.
Pick up any letter from 20 years ago and it will invariably start with :
"Thank you for asking me to see this delightful 57 year old retired lady who presents with . . . "
"Thank you for referring this disgruntled 84 year old married lady who presents with . . . "
"Thank you for asking me to see this difficult 36 year old divorced teacher who presents with . . . "
"I reviewed this charming 71 year old widowed gentleman who presents with . . . "
And so forth.
In General Practice, such details were commonplace in correspondence. When training in psychiatry, the vogue was to purge such details from all letters, censorship that still intrudes in to my consciousness today.
This struck me when, this morning, I reviewed a lady's care with nursing, social work and occupational therapy staff. We'd found her to be perfectly normal, her care home found her problematic so had asked her GP to refer her on to me.
The GP's referral letter asked us to see, " . . . this stubborn lady."
Through my background indoctrination of objective, factual correspondence this piqued me, initially. My, that's a rather judgemental comment, no? She's not firm, she's not assertive, no, she's stubborn. That rather colours perceptions of her, doesn't it?
On meeting her, her daughter and the home carers (in a regular nursing home, not an EMI unit) things became clearer. She's in her room a lot of the time because she favours her own company. She happily attends for meals and medication and the like, she just prefers not to socialise all the time with the other residents. Physically she's reasonably well, mobility's poor after a fractured hip (and surgery that's been undertaken a couple times to sort this, unsuccessfully) but otherwise is pretty well. She's a very warm lady, you can't help but smile and be charmed by her ways. Despite what the staff say about her, she's very likeable.
She does indeed like things her way. She wants to be on her own but then buzzes for nurses to attend to her needs. Nurses want her sitting in the day room so they can sort her needs more conveniently for them, rather than going to her room. Too, they're worried she's not showing compliance with the "social stimulation" they need to document they do. She wants none of that, thank you very much. Her daughter says she's always been like this, they had a major falling out 'cause she's been so opinionated and assertive in determining what she wanted and how she wanted it.
She wasn't depressed. She wasn't anxious. She wasn't demented. She was perfectly well.
Her GP had the truth of it. She is, indeed, simply a stubborn lady. It was the right information to share, it was succinct, it was meaningful and useful in the assessment (knowing she's always been like this, rather than labelling her with some random psychiatric diagnosis to explain her current behaviour).
In future I'll just reframe subjective comment as "premorbid personality" and welcome it. It's got meaning and it helps patient care.