Language matters. The words we choose can have far-reaching impact on those we interact with. This is arguably more true in medicine than in any other field.
Ryan Madanick wrote a recent blog post on the use of descriptor terms used by physicians in patient’s charts. He felt that the use of phrases like “is a very pleasant 52 y/o woman” or “is an unfortunate 16 y/o boy” is inappropriate. I agree. However, in response to this post one reader commented that he felt Dr. Madanick was nit-picking. He isn’t.
When I see such comments in colleagues’ note I wince. I was taught well by attending physicians who appreciated the power of language. I was taught to leave judgements like “pleasant” and “unfortunate” out of my notes. I was even taught not to use the ubiquitous term “complains of “or complaining of” (as in Mrs. Jones is a 43 y/o woman who complains of stomach pain”). When I was a medical student I had a trauma surgery rotation. The attending during that time was a wonderfully dynamic and caring man. One morning he brought his wife to rounds to listen in (this was pre-HIPAA). Afterwards he asked her what she thought of the experience. She was outraged. Outraged by our use of language. The patients who needed us most were “unfortunate”, “demanding” and “complaining”. Those we liked were “pleasant” and “stoic”. Those we did not were “difficult”. She asked how pleasant, fortunate and stoic we would each be if we were stuck in the trauma unit after a car accident left us unable to walk or, a bullet to the chest left us struggling to breathe pain-free? She volunteered that it was likely we would all be pretty darned demanding and complaining.
These words aren’t only judgmental and fault-finding, they are dangerous. Dangerous in their tendency to narrow our thinking. I had an experience early on that made this point loud and clear to me. Before seeing a patient one night I was handed the chart by a nurse who asked if I knew the child. I did not. She went on to tell me how difficult the parents were and how the kid was a “frequent-flier”. I glanced at the chart before seeing the child and read a few notes all with comments about this “unfortunate” child and her demanding parents. Several days later I learned that after seeing me, and returning to another physician she eventually presented to the ED in extremis. I sat down alone and went back over my visit. The only error I could find in my care was one of perspective. I entered her room biased. Biased by descriptive words used by the nurse and found in her chart that should not have been used. Did I miss her diagnosis because she was in my office too early in the disease process? Or did I miss it because I was viewing her as a complaining frequent-flier with difficult parents?
When we enter into care for a patient we need to approach them as if they are a tree of possibilities. The choices of diagnosis and the decisions around care should be narrowed not by our own bias and judgment but by careful medical thought. To speak of our patient’s with critical descriptors is not only rude but it is medically dangerous; doing so hurts them, and leaves us at risk as well.
mdmommusings 
Excellent observations.
Patients get punished unnecessarily for many things: drug histories, complaining of pain, ‘difficult’ personalities – even for simply having difficult-to-treat conditions.
Thank you for pointing out how language contributes to our judgment, thus treatment. Great teaching point.
You are so welcome. This teaching point was well taught to me…even though I perhaps have had to refresh my memory at times!
I couldn’t agree with you more. Very nice post, a must read for trainees…and attendings. Thank you for the compliment of being inspired by a post of mine!
I should note that the commenter who called me “nit-picky” is also a buddy of mine from high school (and currently a vascular surgeon) so I think he felt more comfortable calling me nit-picky since he knows me personally. 🙂
Your post was absolutely inspiring and thought-provoking! I did guess that the nit-picky comment was meant lightly. However, I could see your message being written off by similar thoughts from other people and wanted to contribute to the dialog. Thanks for the ideas!
Jerry Groopman in How Doctors Think describes this as attribution error – error made when patients fit a perceived stereotype. Confirmation bias would fit here too.
While language has the capacity to create texture it can truly be dangerous. Nice post, Kate
Thanks so much Bryan, for the thoughtful input, I appreciate it! I have not read How Doctors Think but after glancing at it just now – it looks like a must read. I have ordered it.
So true. I recall an episode in our inpatient unit where an ‘anxious’ family were ‘demanding’ care for their ‘anxious’ child who ended up in the ICU due to hypoxia (low oxygen). Clearly the adjectives being used to describe the people and the situation led everyone to underappreciate the child’s condition until she was in extremis. Review of the situation revealed a desensitization of the housestaff and others to the reality of the illness. They all thought they were witnessing a ‘difficult’ family and couldn’t see the changes that were occuring right before their eyes.
Exactly! I also have to ask if positive biases can cause error also? Certainly we may see that when we care for fellow physicians – we may afford them “favors” like early discharge or shortened med courses that in the end hurt their care. We should fight against both positive and negative bias and descriptors.
BTW, I glanced at your enjoyable blog; I am originally from beautiful Roanoke!
In reading your post I thought again of a paper I read that cited adults with autism. Reading about their experiences with those ‘off the spectrum,’ I experienced a paradigm shift. I am now hyper-aware that we, as researchers of neurodevelopmental differences, must remember that the participants in our studies are different, not broken, and we should not devalue them by trying to fit them into a ‘neuro typical mold.’ Labels can be a blinding as adjectives in many situations.
This is such an astute observation and one I was thinking about today as well. In this article I failed to mention the ubiquitous habit of physicians to label patients by their diseases. This would be as in “the abdominal pain is in room 12”, “the diabetic has another question” and so forth. It is completely depersonalizing and rude. Thanks for the reminder!