The way physicians talk and write can be unclear and confusing for patients.
“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)?” asked a Perspective article published last November by JAMA Internal Medicine. “Is there a reason we frequently refer to the culinary arts and acts of violence in our discussions of patient care?”
Coauthors Andrew M. Luks, MD, professor of medicine in the division of pulmonary, critical care, and sleep medicine at Harborview Medical Center and the University of Washington in Seattle, and Zachary D. Goldberger, MD, FACP, associate professor of medicine in the division of cardiovascular medicine at the University of Wisconsin School of Medicine and Public Health in Madison, recently spoke with ACP Hospitalist about problems with clinical language and potential solutions.
Q: What led you to write this piece?
A: Dr. Luks: I kind of had a bug in my head about a lot of this terminology since the time I was probably even a fellow, and then certainly in the early stages of my career as an attending. When [Dr. Goldberger] came back from his fellowship at University of Michigan and was on faculty here at Harborview, he and I would talk a lot and kept sharing our own personal growing lists of these terms that either just drove us a little bit crazy or we thought were inappropriate in the context of patient care, and we never really acted on it. Between some nudging from friends and colleagues and more discussions by email with [Dr. Goldberger] after he left for the University of Wisconsin, I realized it was finally time to get these thoughts down in a more formal way.
Dr. Goldberger: I developed a similar list when I joined the faculty at the University of Washington, with terms that were mostly centered upon cardiology. The list seemed to keep growing, and I made a slide that I would show at the end of didactic talks, just to see how fellows and residents would react. Like [Dr. Luks] said, we often shared our lists of collective terms. . . . We would joke around about it, but it became clear as our lists continued to grow larger, based on what we were hearing among trainees, especially younger ones, that these breaches of language, these medical misusages and neologisms, are more than musings on what we don't like to hear on rounds. I began to think about how some of the things we say inadvertently impair or sometimes frankly subvert our efforts to convey information and deliver empathetic care.
Q: Your article discusses several types of inappropriate language, from jargon to neologisms. Why do these terms pose issues for patient care?
A: Dr. Luks: The ones I really struggle with are the ones that I consider not very patient- and family- centered. It's a lot of these terminologies that patients and families just won't understand. It'll confuse them or make them think, “What are these people talking about?” An analogy I always use is, if I go to the mechanic to have my car repaired, I don't know anything about repairing a car engine. So when the mechanic says, “Well, this is broken, this valve is bad, and it's going to cost you $1,800,” . . . you hope that everything's right and you're not being taken for a ride. And I think patients and families quite often go through the same thing in the hospital, except the difference now is it's their personal health, and maybe even their lives are on the line. . . . I think we make it worse when we communicate in ways that make it very hard for them to understand what the heck is going on.
Dr. Goldberger: Oftentimes we say things in the ICU or on the wards just because we think they sound cool. “The patient is throwing PVCs,” or “We're going to hit him with big-gun antibiotics and sprinkle on a little Lasix.” Trainees who are just learning this language of medicine . . . [are] going to adopt these phrases very easily and immediately. And it's hard to impart to them that what makes sense in the new vernacular they are adopting often leads to patients hearing terms they may not understand.
Q: What are your favorite examples of commonly misused medical terms in the hospital, and why do they concern you?
A: Dr. Goldberger: The one which I think is the most alarming is saying that “The patient is trying to die.” Or “This patient is a train wreck.” If the patient or the family ever heard that . . . that's horrible. Even if it's said out of earshot, the implications to students and trainees are significant.
Many terms and phrases are much less harmful but are simply terms we should not use. We mention several in the article. For example, I would discourage any trainee and physician from using the term “troponinemia.” Just adding the suffix “-emia” or “-ize” at the end of words—like syncopize, surgerize, troponinemia, etc.—doesn't make the word more scientific. I hear these all the time, and those terms all the time in progress notes. Those words are not in any medical dictionary; they're just neologisms, and they don't actually have anything to do with what the true pathophysiology or disease process is. Say that the patient had a syncopal event, and consider what may have caused it. Or say that troponin levels are elevated, and offer a suggestion about why that is.
Dr. Luks: There's a very common phrase that's used when patients are ready to get out of the intensive care unit and go to the regular hospital ward. Teams will always say, “We're going to transfer them to the floor,” or “We're going to put them on the floor.” And I know what my team means, but a patient or a family member may be sitting there thinking, “My bed is just fine. Why do they want me to be on the floor?” . . . I really prefer the team to be more precise: “We're going to transfer you out of the intensive care unit to a regular hospital ward today.”
The other terms that I really get worked up about are references to patients and their medical conditions. There's a lot of, “So Mr. Smith, our 55-year-old COPD-er, came in with difficulty breathing,” or “We got this GI bleeder down in the ED,” or “We're admitting this total vasculopath.” These are just inappropriate ways to refer to patients. They're individuals, they're people, they have meaningful lives, and we should refer to them as, “This is our 57-year-old gentleman who's coming in with a GI bleed,” or “This is our 56-year-old woman who has a history of peripheral vascular disease.” . . . The worst phrase I've ever heard in reference to a patient that, fortunately, I've not heard in a while: Many people with chronic kidney disease can be quite complicated . . . and I've heard some people refer to them in the past as “renal bombs.” It's terrible. And it may not be used in front of a patient, but you can imagine that term gets used in the hallway . . . and the fellow and residents are standing by or there are students that are watching this. They see us using the terms, and they're going to think, “This is how I should be communicating with my team members,” and they pick up use of that language.
Q: What are some potential solutions?
A: Dr. Luks: I think the first thing we can all do is we can model appropriate use of language in our communications, both verbally and in our written notes. . . . You have to stop that process of acculturation, and the way you do that is by modeling appropriate behavior. I think we also need to try to work some feedback in about this. I will periodically break into a presentation on rounds or after a presentation's done and make a comment to an individual team member or the whole team. . . . I try to pick one or two points of emphasis for the week that I'm going to try to work on, but it is amazing how difficult it is. I might, on the first day of a weeklong block, call out someone for the use of the term “transfer to the floor,” and I will make a point about it, explain the rationale for why I don't think it's an appropriate term, provide some examples of other phrases they should use instead, and it is amazing how many more times during the week that phrase will still come up. Some trainees will catch themselves and others will just kind of keep going on as if nothing ever happened.
Dr. Goldberger: Feedback is incredibly important—iterative and active. I think that hopefully, as trainees have learned that these phrases are problematic, they'll also be able to give some feedback to their own students, fellow trainees, and even, daringly so, their attendings.
Dr. Luks: I actually think the most powerful feedback sometimes that the trainees get is when the family member or the patient turns around and asks, “I'm sorry, what do you mean by this?” That often gets them to stop. . . . I'll often say, “Look, when you do your presentation at the bedside, don't talk in a language that you think I'm going to understand; talk in the language that the patient's going to understand. Because I'll know what you're talking about, but so will they.” . . . COVID has actually been a bit of a setback for some of our efforts to try to work on this, because at my institution, we used to do bedside rounding. We would go in the room of all the patients, and if family was there, they would sit and listen as we were discussing the case, and if the patient was awake, they would participate too. But because of COVID, we're not going into all the rooms as a team anymore; we're rounding outside the rooms. And I think it's made it easier to lapse back into a lot of these habits, because you don't directly see that facial reaction from the patient or their family member when some of these terms come out.
Q: Do you have any advice for hospitalists, particularly those who teach, on implementing this?
A: Dr. Goldberger: I think it takes a commitment among teaching attendings to focus on this aspect of communication. It's hard, and there's simply just not a lot of time spend on rounds to correct these misuses, but . . . now, it's even more important given it's not just what we say, it's what we write. . . . “Open notes” [a term for the information-blocking rule included in the 21st Century Cures Act] allows patients access to everything that doctors write.
Dr. Luks: The note thing brings in a whole other realm of problems related to terminology. The use of these nonstandard acronyms and abbreviations for things just seems to be getting worse over time. For example, a common one would be STH (said to have) or BIB (brought in by), and there's a whole range of these acronyms that are getting thrown into notes these days.
Dr. Goldberger: We always joke about how are notes are “alphabet soup,” and there seems to be an acronym for everything in medicine. That can be helpful because a lot of these that we use, like EGD instead of esophagogastroduodenoscopy, which can be a tongue-twister to say, so EGD is fine. But a lot of these acronyms that we just make up—NOE (no overnight events)—it's just a lot of letters. Or even worse: F/U SOB (follow-up for shortness of breath).