The right words

It was a pretty simple story: their 3-year old had had fever and lethargy for three days. She was fussier than usual, but consolable. On the second day of the fever, her cautious doctor had done some blood tests and an x-ray, and although neither confirmed a bacterial infection, he'd started antibiotics. The medicine hadn't helped her much, and now they were in the emergency room on Easter Sunday, both furrowing their brows as I looked in her eyes, her mouth, her ears.

They were worried, but not worry-crazed, and they seemed cool--like the kind of people I'd sit down with for a beer. We repeated their daughter's tests, and because the level of her infection-fighting cells was very normal, we felt reassured that she didn't have a bacterial infection. She probably had a virus, maybe the flu, I said. With fluids, ibuprofen, and time, she'd get better on her own within a couple of days.

They asked a lot of questions--normal questions for worried, cool parents, about what warning signs to look for, and how best to treat her fever, and how long it would last. I answered them all. And yet as they stood there holding her, ready to sign their discharge paperwork, I felt that there was a question I hadn't answered. The mother was nodding, rocking back and forth on her heels, and making a face that said she understood me, but her brow was still furrowed.

I remembered a snippet from an hour beforehand, when I'd been taking the girl's medical history, and had asked about a family history of childhood illnesses: the mother's sister had had acute lymphocytic leukemia (ALL) as a child. I hadn't thought much of it--there's no hereditary component to ALL--but I wondered now if I should bring it up just to reassure the girl's parents it was not what she had.

It wasn't a proposal without risk: efforts to reassure parents sometimes have the opposite effect of what's intended. It has happened that in trying to explain to parents that their children didn't have something terrible, I've planted seeds for worry about something they hadn't even thought to be concerned about. Especially in conversations about cancer, people sometimes hear only "cancer," without the reassuring words around it. I didn't want to plant any seeds.

I took a deep breath.

Sometimes, I said, people who've known other people with cancer worry that a fever in their family member can represent cancer.

The mother said nothing.

I just want you to know, I said, that your girl's blood tests are very reassuring for her not having leukemia.

Here, she burst into tears.

Her white cell count is very normal, I said, and the kinds of cells she has are in very normal proportions.

She continued to cry, and her husband put his arms around her, and they both thanked me several times. I nearly cried with them, but instead went to collect myself and print out their discharge papers.

I don't know why this mother didn't ask her biggest question. Maybe she was worried about seeming uncool, or that saying the word would make it true. Or maybe she didn't even realize she had the question until I answered it.

With the standardized patients we learned to take histories from in medical school, there was often a "money question" that quickly revealed the scripted subtext underlying the patient's complaint. Finding that subtext in real practice is one of the great challenges of outpatient medicine, especially to doctors in training. Most of us have the goal of creating an environment where patients feel safe revealing their deepest concerns, but I think we can all identify that there are times when we have to hunt down and find those concerns ourselves. I don't know what to call that skill, or how to develop it. I guess a large part of it is experience.

Somewhere between saying too much and saying too little are the right words for each patient. If only it were easier to find them.