by Carolyn Thomas ♥ @HeartSisters
A recent editorial in the medical journal The Lancet (coincidentally, celebrating its 200th anniversary milestone this year) revisited a subject that’s been niggling at me and many others for years: what the authors called blame-ridden language – which they describe as being “pervasive throughout medicine.”(1)
Unintentionally hurtful words tripping lightly from the lips of physicians seem to be a routine part of medical life. For example, when doctors say harmless-sounding things like “Patient claims her pain is 10/10” , it implies that the patient is lying. In the real world, we would say “She is experiencing 10/10 pain”.
Or consider the word deny: “Patient denies having fever or chills.” In the real world, that word also hints at this patient being untrustworthy. As one patient clearly explained to researchers in 2021: (2) “I did not DENY these things. I said I didn’t feel them. Completely different! Language matters.” .
The Lancet editors acknowledge that hurtful words in medicine don’t come from a place of malice, but more from a lack of empathy or awareness:
“They’re not reflective of an intentional effort to offend. These phrases are typically used as shorthand in an effort to aid communication.”
One of my Heart Sisters readers, who worked in maternal/child health for many years, mentioned to me in response to a recent post that her OB-GYN colleagues routinely used hurtful words like incompetent cervix, failure to thrive or elderly primigravida. (I’d add angry cervix and hostile uterus to her list, too). By the way, her third example (elderly primigravida was first used in 1958 by the International Council of Obstetricians and Gynecologists referring to women aged 35 years or older who were pregnant for the first time. I’m guessing that most OB-GYNs don’t actually believe that any 35-year old woman is “elderly”, but they kept saying it anyway because that’s just the way it was done since 1958. (Last August, however, the American College of Obstetricians and Gynecologists announced its new preferred terminology: “pregnancy at age 35 years or older”).
The Lancet authors add:
“The medical literature regularly uses blame-ridden language, stating for example that patients failed treatment, failed to reach a treatment endpoint, failed screening, or were unsuccessful.”
And every day, many North American heart patients must endure hearing cardiologists say out loud: “Your heart is FAILING!” – despite the need to then immediately reassure these horrified patients that the cruel name of heart FAILURE doesn’t actually mean that death is imminent. But if physicians truly believe that FAILURE does not mean failure, then stop saying it – and come up with a more appropriate name. (See also: Is It Finally Time to Change the Name ‘Heart FAILURE’? )
Here’s another area where words matter: many people still tend to describe patients using disease-first language e.g. with names like diabetics or epileptics or rheumatoids – instead of a person with diabetes, or a person with epilepsy, or a person with rheumatoid disease (all examples of person-first language). The Lancet editors remind us that the former is “a common practice that can dehumanize the patient, equating them with their disease rather than as individuals.”
Dr. Tessa Richards is not only the associate editor of the British Medical Journal (BMJ) but she is also living with a number of serious chronic conditions. In her BMJ opinion piece called “Words That Annoy, Phrases That Grate” (3), she too weighed in with her thoughts on the dehumanizing practice of disease-first language:
“Doctors who use these words think it’s fine and seem oblivious to how insulting and rude they sound to people who are patients. While it’s convenient to categorize people by their disease or its severity, few people look in the mirror and see ‘a poorly controlled diabetic’. And who would introduce themselves as a ‘co-morbid patient with multiple complaints’?
“Medical paternalism may be on the wane, but the medical lexicon is littered with words and phrases that can feel top-down and demeaning.”
When Diabetes Australia wanted to improve its communication with and about people with diabetes, the organization issued a revised Position Statement covering what they called “a new language”. Here’s how they described the importance of this language:(4)
“Language has the power to persuade, change or reinforce beliefs and stereotypes – for better or worse. Words do more than reflect people’s reality: words create reality and affect how patients view the world and their diagnosis. Language needs to support people in their self-care efforts.
“Importantly, language that de-motivates or induces fear, guilt or distress needs to be avoided and countered.“
(Perhaps somebody over at Diabetes Australia could have a wee chat with the heart FAILURE docs who have had lots of experience inducing “fear, guilt or distress” in patients and their family members simply by delivering their needlessly cruel diagnoses). See also: A Patient, a Caregiver and a Cardiologist Walk into a Bar…
Physicians use hurtful words because they were taught as trainees in medical school by professors who had learned the same words from their own profs for generations back. An insightful 2015 paper published in the Journal of Graduate Medical Education suggests that this medical language is deeply rooted in tradition, as old as the profession itself. In fact, physicians’ routine use of words like complain, deny and fail when describing their patients dates back more than 300 years. (5)
Yet the lesson starts anew the very next time any young medical student is asked about an assigned patient’s chief complaint (instead of being asked about the patient’s chief concern like the real world does). The required response then goes something like this:
“Ms. Smith is a 74-year-old hypertensive diabetic complaining of chest pain. She denies shortness of breath. She has a history significant for metastatic colon cancer, and recently failed chemotherapy.”
Good job, young med student! You’ve learned to include as many blame-ridden words as possible, which will be heard and then adopted by your current classmates, too.
Meanwhile, The Lancet editors specifically cautioned general practitioners (GPs) to be wary of “dismissive attitudes towards young people with cancer symptoms who do not fit the typical profile of a patient with cancer, so are often seen as just another ‘case’ “:
“The lack of time available to GPs for each consultation does not help to foster human connection and thorough reflection, but such flippant profiling of patients is a dehumanizing behavioural trait similar to using dehumanizing language – especially considering that the number of people younger than 50 diagnosed with cancer has increased by nearly 80% over the past 20 years.”(6)
1. Editorial, “Patient First, Person First”. The Lancet. Volume 24, ISSUE 10, P1053, October 2023.
2. Fernández et al.“Words matter: what do patients find judgmental or offensive in outpatient notes?”Journal of General Internal Medicine, 2021;36:2571–8.
3. Tessa Richards, “Words That Annoy, Phrases That Grate”. BMJ Opinion, April 7, 2017.
4. J. Speight, “Our language matters: Improving communication with and about people with diabetes. A position statement by Diabetes Australia.” Diabetes Research and Clinical Practice, January 7, 2021.
5. Sykes DB, Nichols DN. “There Is No Denying It, Our Medical Language Needs an Update.” Journal of Graduate Medical Education. 2015 Mar 7(1):137-8.
et al. “Global trends in incidence, death, burden and risk factors of early-onset cancer from 1990 to 2019″.
Image: Gerd Altmann, Pixabay
NOTE FROM CAROLYN: I wrote much more about doctor-patient communication in my book, A Woman’s Guide to Living with Heart Disease. You can ask for it at your local bookshop (please support your favourite independent booksellers!) or order it online (paperback, hardcover or e-book) at Amazon, or order it directly from my publisher, Johns Hopkins University Press (use their code HTWN to save 30% off the list price).
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Q: Have you or someone you care about experienced this “language of blame or disrespect” in a healthcare encounter?
♥
Heart Sisters 
Note from Carolyn:
This email arrived today from C. Parkes in response to this post, FYI:
“Many years ago I was being treated for recurrent breast cancer. While waiting one day for the oncologist, I slipped my patient folder out of the pocket on the outside of the door. I understood it was put there for the doctor, but since it was my history, I felt entitled to look at it.
“I remember very little of what was in the record, but I certainly remember reading that I apparently had undergone a ‘toilet mastectomy’. That ugly phrase describing surgery done on my body has stayed with me for over 30 years. I often wished I hadn’t seen it. . .”
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Oh, CP – that name is absolutely disgusting. I just looked up “toilet mastectomy” and here’s what I learned: “a complete mastectomy, removal of all the skin overlying the breast tissue, with debridement of any devitalized tissue. . . “
It sounds absolutely brutal, and then to give this traumatic procedure such a revolting NAME like this?!?! What kind of person could have possibly thought this was even remotely acceptable at the time!?!?!
Thank you for sharing what is, so far, the most appalling example yet of a procedural name that needs to be changed – YESTERDAY!
What’s truly awful about it all, especially for any clinicians reading this who are tempted to minimize the effect disrespectful words like these can actually have on patients, is the fact that the words are just as hurtful today, over 30 YEARS LATER, as the day they were accidentally discovered in that chart.
Take care. . .❤️
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Parsing the language of blame and disrespect used by healthcare providers has been a subject near and dear to my heart since 2009, after I read though physician notes in my medical records.
I finally knew why it took 9 1/2 years for a correct diagnosis of A-fib and A-flutter. Carolyn, you may remember this part of the tale of woe involving my heart, but for others, here is the very abbreviated version.
In May 2002, a primary care physician entered this statement into my chart:
“She has a bit of a mysterious and mythical approach to her health care.”
By that point, I’d been having classic and not infrequent cardiac arrhythmia symptoms for 3 1/2 years. That doctor’s erroneous statement impacted my subsequent care and I was not correctly diagnosed for six more years.
By the way, that PCP was female.
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Hi Genevieve – I do remember your story! I’m pretty sure that “a bit of a mysterious and mythical approach to her health care” is NOT mentioned as a valid cardiac risk factor in the 12th edition of the leading ‘gold standard’ cardiology textbook (Braunwald’s Heart Disease: A Textbook of Cardiovascular Medicine (Elsevier, 2022)
What on earth could that doctor have meant by her comment? That you were lying about years of cardiac symptoms? And putting those words into your chart notes!? Part of your medical record!? It is dismissive and appalling.
Although a growing number of studies are indeed reporting that patient outcomes ARE generally improved when patients are treated by female physicians, missed diagnoses and critical thinking errors can still happen – in male OR female doctors.
Yet it somehow feels so much more disappointing when I hear stories of female docs missing serious conditions like yours – maybe I still harbour deep hopes that these errors might stop with female physicians! Researchers suggest this is likely more true than not – just not 100% of the time.
Take care – I hope you are doing much better these days. . .♥
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This is an interesting article. I thought that I was merely being overly sensitive and now I don’t feel that way.
I had a short hospitalization in September, and a couple of terms surprised me. Firstly, the diagnosis of “asymptomatic menopausal state” threw me into a tizzy. What does that even mean? My period ended in 2012, so am I to be considered in this “state” for the rest of my life, or can they allow me to move on?
Secondly, the term “morbid obesity due to excess calories” almost flipped me on my head! I lost over 40 pounds in 12 months. Besides, my slow weight gain was due to inactivity after having bilateral joint stiffness and pain in 2015. I am currently much more active since my slow-onset “widow maker” in May 2023.
I saw a doctor last week and when I viewed his “Notes” in my portal, I was offended. “She denies having hallucinations” – while he never asked me if I had hallucinations! I don’t, but he didn’t ask me, so how could I deny it? Also, “she denies any suicidal ideation.” Again, I wasn’t asked. No, I don’t have “SI.”
In the future, I’m going to question the words that doctors use to “define” me because I’m frankly fed up with the negativity, and these words follow me around no matter which doctor I see.
Thank you so much for your enlightening blog!
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Hello Mary – reading those doctor notes must have been alarming to you – particularly since you weren’t asked about hallucinations or suicidal ideation.
I also wonder (because symptoms like “hallucinations”, for example, are unusual enough that you’d likely remember if you’d discussed those with the doctor) if the doctor was dictating notes off a check list – in which anything you did not report would be recorded with “she denies”?
You have a legal right to amend or correct errors in your medical records.
If you’re in the USA, see more info here.
If you’re in Canada, see more info here.
I hope you will consider doing this – otherwise, you’re right: those words will follow you around.
Good luck to you . . .❤️
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When I was working as an ICU nurse, I often had physicians ask me “Are you taking care of the liver transplant in bed 4?” or “How is the Mitral valve in bed 6 doing?”
I would always answer with the patients name “Do you mean Mrs Smith?”
In ICU, where patients are often unconscious or sedated, it is downright dangerous not to identify patients by their names. Another caveat I had to remind physicians of was to always assume a patient can hear no matter how unconscious they may seem.
On that note, of patients hearing: Nicknames made of medical abbreviations can be heard and mis-construed by patients or families. Such as a Coronary Artery Bypass Graft (CABG) being referred to as a “cabbage”.
As in “Mr Smith is a 75 year old cabbage.”
I remember in one of the hospitals I worked at, the nurses had Computers On Wheels which they referred to as COWs. A patient who was rather large heard her nurse say “I am going to go get the COW” and thought the nurse was referring to her and became quite distressed, reporting the nurse and asking for a different caregiver.
I sort of digressed but the underlying theme remains the same: Words are Powerful, especially when uttered by a person of trust.
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Hi Jill – those examples of ICU physicians questions about patients-as-body-parts reminded me of overhearing the Emergency Department nurses who were arranging my transfer upstairs to the cath lab during my heart attack: they referred to me only as “the MI in bed 8”. I knew I was in Bed 8 (because there was a big #8 sign overhead) but I had no clue what MI meant (myocardial infarction, as I was to later learn).
Bless you for always interjecting your patients’ names into those questions from your medical colleagues to confirm which patient they’re talking about! That’s a bare-minimum common sense patient safety solution right there.
It’s understandable to expect overwhelmed hospital employees to say “CABG” out loud rather than saying “Coronary Artery Bypass Graft” repeatedly when speaking to their colleagues. I get it! But I’ve heard hospital staff use abbreviations like that to overwhelmed PATIENTS – as if they think we’ve been to med school.
I laughed out loud at your “COW” story – but then immediately felt bad about laughing. That poor patient! The Computers on Wheels were a great example of an abbreviation desperately in search of a brand new name!!
❤️
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I also laughed when I recalled the incident… It is quite a bizarre happening.
I remember that administration immediately banned the term COW and came up with new terminology, though I don’t remember what it was.
I often wonder why the bad, sad, hurtful and painful aspects of life seem so much more vivid in our memory than the good, the true and the beautiful?
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Yep – For example, I’m never going to forget that COW story of yours, Jill!
Although I must say, I do try every day to also notice and remember all those good, true and beautiful moments! They seem even more important these days. . .❤️
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Where to start? This is a very thought-provoking article and I think will be a topic of discussion at one of our departmental meetings.
My specialty, OB-GYN, is full of hurtful language: missed abortion means an early pregnancy where the baby has died, and the body has not miscarried, for example.
The prevailing attitude when I trained is that depersonalization of the patient allows for dispassionate, objective and superior care. (I was actually taken off a case as a resident because I was “too emotionally involved” to give good care.)
Huge food for thought,
thank you.
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Hello Dr. Anne – I’m just imagining a young pregnant woman whose baby has died being told she’s had a “missed abortion”. How horrible and cruel!!
I’m very glad you were “too emotionally involved” in your patients’ care. That’s exactly the kind of doctor I want!
Take care. . . and thanks so much for sharing your perspective here. ❤️
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When given a Blame-Ridden diagnosis, it implies that I made life choice errors that got me into this predicament. It’s all my fault.
I think that’s why some people don’t accept the treatment as they feel embarrassed they got sick. Or that can’t be what’s wrong, because I don’t have those behaviors that usually lead to that type of illness.
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Hi Jennifer – I think so too. It’s quite normal, I think, after a shocking diagnosis to immediately want to know WHY this has happened (and that’s what our family members demand to know for sure!) Even in the CCU, every doctor and nurse I met there asked “Do you have a family history of heart disease? Were you a smoker?” I had been a healthy distance runner for years with few if any other known risk factors, so as you said, my heart attack seemed to make NO SENSE!
Heart disease is a good example of a diagnosis that’s often believed to be self-inflicted (compared to most cancers that seem to attack the innocent out of the blue).
But even if I’d had known cardiac risk factors, it’s hard enough to adjust to any serious diagnosis without being made to feel guilty about it.
Take care. . . ❤️
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Yes, after a colonoscopy procedure, my report stated I was an ASA Assessment III (severe multiple systemic disease).
I am not.
My BMI is 25.3, I don’t have diabetes, don’t have a pacemaker, not an alcoholic, don’t smoke, etc. Yes, I have UC (in remission for 13 years), mild HBP, AFib caused by pneumonia (but gone now), and osteoarthritis.
I protested this report with my Gastroenterologist. I was extremely upset. I became depressed upon reading the report. Yes, I may be a II but not a III.
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Hello Carol – I can imagine what a shock seeing that colonoscopy report must have been for you! I’m not a physician, but my understanding is that an ASA Assessment is basically a tool used mostly by anaesthesiologists to help them anticipate if a patient with more than one serious medical issue will be at higher risk during any upcoming surgery.
Try to think of this as an aid to protect patient safety, not an evaluation of your day-to-day functional life.
The differences between ASA II and III seem quite broad: in level III examples, they list conditions like active hepatitis, alcohol dependence or abuse, morbid obesity, implanted pacemaker, etc.) – as you say, none of which you are experiencing.
But try not to focus on that gastroenterologist’s report. If you were to have surgery in the near or distant future, I’m guessing you would certainly want your surgical team to be MORE cautious and careful, not less. That’s one more positive way to interpret that assessment.
Take care . . .❤️
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To Carol Savage:
The first time I had a colonoscopy about 20 years ago, I had an oxygen sensor on my finger and a BP cuff on my arm with no other monitoring.
I was concerned, I have multiple cardiac risk factors. I asked, “Aren’t you going to put me on an ECG monitor?” They said no, it isn’t necessary for such a low risk procedure.
The last time I had a colonoscopy, I too saw the ASA III notation on my chart and was put on an ECG monitor. I was happy that I had that designation.
I agree with Carolyn, I’d rather have more monitoring and special attention than less while under anesthesia.
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Hi Jill – Lots can happen in the 20 years between your first colonoscopy and your last one!
That ECG monitor during the latter was likely either a reflection on improvements in patient safety protocols, or a reflection on your current ASA III status!
Either way, I’m with you: I want all the “special attention” I can get at the hospital these days!!
Take care. . . ❤️
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