Last year, Professor Andy Luks launched our BMMS UCLan Mountain Medicine Winter Webinar Series with a brilliant talk about skiing in the Pacific North West. His talk can be found here. Recently, Andy published a fascinating article on medical language in JAMA. Here’s an excerpt...
Despite our best efforts to ensure appropriate care for patients, we often find ourselves distracted on rounds by the sometimes bewildering array of jargon during bedside presentations. Why does our team want to “sprinkle” or “hit” the patient with diuretics? Do our patients have the capacity to “fly” off the ventilator or “throw” PVCs (premature ventricular contractions)? Is there a reason we frequently refer to the culinary arts and acts of violence in our discussions of patient care?
“The patient is trying to die...” - patients rarely come into hospital with the intention of dying. Try, “The patient is very ill and is at a high risk of dying”
Faculty in preclinical courses spend considerable time teaching not only principles of physiology and pathophysiology, but also the language students must master to communicate effectively in their clinical work. We serve in this role and are fairly certain that this instruction does not include the terms and phrases mentioned in the prior paragraph. Yet somehow when students transition to the clinical setting, use of such terms is common. Why does this occur? If we are honest, we will admit to a simple fact: it comes from us. As with learning any new language, attaining fluency stems from cultural immersion and modelling the vernacular used by those who are well versed. As clinical preceptors,we are the role models. By listening to us and to more senior trainees, our students become immersed in the unofficial language of medicine.
Problems With Jargon
Like other professions, medicine has its own jargon. While it can be fun to needle trainees in a lighthearted way about some of these terms, many of them have little effect on patients. The captions in this post provide examples of improper terminology and more appropriate language. However, there are a host of commonly used terms that are problematic because of their potential to affect on patient care. Practitioners commonly conflate terms such as hypoxia and hypoxemia, acidosis and acidemia, and atrial fibrillation and atrial flutter. This usage may inaccurately describe the patient’s clinical issues and risk overlooking distinctions that impact disease management. For example, respiratory acidosis may not require intervention when the pH is normal but does warrant action in the setting of acidemia. Atrial fibrillation and atrial flutter often warrant different management strategies in the acute and chronic setting.
“The patient denies drug use” - denying something connotes that it is there, but the patient refuses to admit it. Try, “The patient reports no use of illicit drugs”
Another challenging set of terms are neologisms, newly coinedwords or old words used in a new way. Examples related to technology include terms such as malware and webinar. Medical neologisms, including syncopize, satting, and surgerize, can be confusing to those who have not heard them before and can lead to misinterpretation and error. Other jargon is problematic because of its ability to shape the medical team’s perspective in ways that ultimately affect care delivery. Referring to patients as COPDers or CHFers, or placing the term end-stage before the name of a disease, may result in anchoring bias or unintentionally conveying an unavoidable risk of clinical worsening, leading to less aggressive treatment than warranted. For instance, patients with chronic obstructive pulmonary disease (COPD) who develops respiratory failure for reasons other than COPD exacerbations, and those with heart failure may warrant aggressive fluid repletion when they present with sepsis. Patients with various types of so-called end-stage disease can live for many years with appropriate medical care.
“Big-gun antibiotics” - terms related to guns or violence should not be used. Try, “broad spectrum antibiotics”
Perhaps the biggest challenges arise when we consider how our words sound to patients and their families. Many of ourword choices run the risk of confusing them rather than clarifying the patient’s condition, diagnosis, or treatment. They may nod, but do they clearly understand what we have said? Even worse, are they offended by what they hear? Patients and family members may be familiar with the terms we use in presentations but not with their use outside of the traditional context. They might wonder why we want to “blast” them with medications, “move them to the floor”when a bed suits them just fine, or refer to them as a “vasculopath” rather than a person with a particular disease.They likely do not want to hear about indwelling vascular catheters that are “dying” as this could easily be misconstrued that the patient is the one who is about to expire. Frequent puzzled looks from patients and their families are an important signal that our use of the unofficial language of medical communication — one which we inappropriately try to excuse by saying “we’re going to talk shop and will fill you in when we’re done” — needs our attention.
Achieving Better Communication
So how do we temper the endurance of common yet problematic phrases and build a culture of clear and accurate patient - and family - centered communication? The solution likely lies in a combination of modeling and feedback. Given that those seeking to join the medical community are likely to adopt the language they see and hear every day while in training, it falls on us to choose our words deliberately and with purpose. We need to recalibrate our language. Conscious efforts on our part can redefine the standard learners seek to achieve.
“The patient is a poor historian” - a historian gathers and interprets information. That is the role of the clinician not the patient. Try, “I had difficulty obtaining a full history”
Feedback also has a role. Those who use inappropriate terms and phrases yet never receive feedback may not understand that their communication is problematic. Admittedly, it makes no sense to stop presentations every time neologisms such as troponinemia or transaminitis are uttered, for it would lead to overly long rounds and likely just engender frustration. However, feedback that is well timed, directed toward the most problematic language, and delivered in a safe spacemay chisel away at the problem. Incorporating feedback about communication in end of rotation evaluations would likely be welcomed by most learners. Furthermore, such feedback might carry more weight if learners saw it delivered among members of the community rather than only in a top-down manner toward those in training.
On the surface, it may seem daunting to try to reframe all of our communication, given the ubiquity of inaccurate and arguably inappropriate terminology. But if we reflect on what we do each day, it becomes obvious that we have abundant opportunities to model better communication skills and speak the official language that is a privilege to learn.
"You won't understand our medical talk..." Take a look at this hilarious clip from the 1954 film comedy "Doctor in the House" - pay special attention to the words of Sir Lancelot Spratt!
Is there such a thing as an accident? Read this to find out!
In Part 2 we’ll take a closer look at the language we use in clinical practise and find out how to make improvements!
If you would like to find out more about mountain medicine why not join the British Mountain Medicine Society? See this link for details.