Word to the Wise: Misuse of Language in Clinical Communication Causes Harm

Commentators

• Andrew Luks, MD, MS
• Zachary Goldberger, MD, MS

Transcript

Careless use of language is not just an annoyance to English teachers and fussy book editors. In medicine, the misuse of language can have serious clinical consequences. It can also leave patients and families with a bad impression or misunderstandings.

A 2015 study of 7,000 medical professional liability cases across specialties nationwide found that more than a third involved communication failure. Fifty-seven percent of those malpractice cases featured communication problems among clinicians, and 55 percent involved provider-to-patient miscommunications.

Two physician colleagues recently penned a cautionary Perspective commentary in JAMA Internal Medicine, titled “Watch Your Language, Misusage and Neologisms in Clinical Communication.” Dr. Andrew Luks, professor of medicine at the University of Washington School of Medicine, and Dr. Zachary Goldberger, associate professor at the University of Wisconsin Madison, argue that slang and jargon among peers might seem harmless: using the term “room air” instead of the more relevant term “ambient air,” for example, or “troponemia,” instead of elevated troponin. But a lack of precision in some instances can mislead a colleague or adversely influence clinical decisions by a team.

We invited Drs. Luks and Goldberger to join our podcast and talk about what worries them and what doesn’t, when it comes to the misuse of words in medicine.

Q. Gentlemen thank you for joining us.
[Dr. Luks] Pleasure to be here.
[Dr. Goldberger] Thanks for having us.

Q.) Maybe I’ll ask my first question of Dr. Luks: Why is this a serious concern for patient care?
[Dr. Luks] The way I look at it is in terms of me being able to communicate with a colleague and get them to understand what we need to do or what the situation is with the patient, a lot of these terms don’t have a huge effect. If I use the term ‘room air’ and ‘ambient air,’ it’s a meaningless distinction in a conversation with a colleague. But when I look at the patients and families, I actually think it’s a really big issue. Patients and families have to make decisions about are they going to agree to a procedure or they need to understand what lays ahead for them. Are they getting better? Are they getting worse? What are the risks that they face? And if they don’t understand what we’re talking about in our communications at the bedside or our communications with them, how are they supposed to process this information? How are they supposed to relate to other family members about how their loved one is doing? How are they supposed to make decisions about whether or not to give consent for various aspects of the care?

[Dr. Goldberger] Also how can they trust us if they’re not really understanding what we’re saying? That’s also the issue there.

Q.) You say in the article that jargon and this sort of misuse of language can affect the medical team’s perspective in ways that become problematic for patient care. Can you say more about that?
[Dr. Luks] I think there are definitely situations in which you can change the perspective about patients. The term vasculopath, for example, often applied to patients who have bad peripheral arterial disease. And when you hear that term vasculopath, it often implies that they have severe peripheral arterial disease and then all of a sudden it might convey in the back of someone’s mind that this person’s long-term prognosis is actually pretty poor, when in fact people with good medical care can live for pretty long periods of time despite having severe underlying medical problems. And I think the same thing applies when the term COPD’er is used. A lot of times it implies that someone is at the later stages of their disease, prognosis is not very good when in fact, again, people with good medical care, immunizations and other things, can actually live quite a long time despite having very severe COPD.

So some of this terminology that gets used and applied as descriptors of patients has an ability I think to sometimes affect the way we think in the back of our minds, sometimes subconsciously, about how that patient is doing and what their long-term prognosis is. And that might then cloud the way you have discussions about how aggressive to begin their care and things like that.

[Dr. Goldberger] One of the things that we didn’t actually get a chance to allude to too much in our piece that was resonating in my mind since, is we also have a lot of semantic bias in the terms we use. Just take for example the term antiarrhythmic. That’s a drug that we would use to treat patients who have heart rhythm disturbances, try to keep them out of a rhythm such as atrial fibrillation, but the problem with a word like that, antiarrhythmic for instance, it creates an expectation that those drugs actually have the effect of treating this component, when in fact oftentimes those drugs are proarrhythmic. So even the words that are innocuous, words that are the subject of book chapters, for instance, that you will see in textbooks, often are problematic as well. When you give someone an antiarrhythmic, there is an expectation that patients are going to be doing better. Again, those terms, I wouldn’t say we should avoid them, just have an expectation that the patient’s family and the patient themselves may actually have little understanding of what you’re trying to do with the medical therapy or any kind of intervention.

Q.) What are some examples of real misuse of language that can actually cause real problems?
[Dr. Goldberger] When you have a situation of a family listening to a patient presentation at the bedside, when you start talking about things that actually really are just jargon, you know, the example of someone “flying off the ventilator,” or talking about “big gun” antibiotics, that has a very negative pejorative, almost evokes an idea of violence that you’re doing to someone under your care. That’s really the issue here. As far as medical-ese, it seems that patients and families expect to hear, and that can be forgiven, but I think the real issue is that when you’re using jargon that almost sounds unprofessional and is a misuse of language and it disrespects the language of medicine that we’re supposed to learn, that’s when the real problems come.

[Dr. Luks] I think often about the example of, I do a lot of work in the trauma surgical ICU at my institution. And occasionally, we have patients who are admitted following gunshot wounds. And you can imagine if you were a patient or a family member listening to a presentation and the resident or the fellow or someone else on the team makes a proposal, ‘hey, I think we should really pull the trigger here and start some diuretics.’ I’m pretty sure that someone who was shot or who had a family member that was shot probably doesn’t want to hear that term pull the trigger in that moment. It is going to have a negative connotation for them in that situation. I also think there’s a lot of other terms and we reference this in the piece. Quite often, patients are referred to COPD’ers, CHF’ers, vasculopaths. The worst one we hear in residency, but I don’t hear much anymore fortunately, patients who are very complicated patients of chronic kidney disease are sometimes referred to as renal bombs. I think that those are terrible terms. And I think what happens is you overlook the fact that your patient is actually a person who has a medical problem, and they should be referred to as such and not just defined in terms of that medical problem. It is amazing how often, when you talk to patients and their families, and then you actually just inquire a little bit more about them beyond the medical reason why they’re in the hospital with you, how much the patients and, in particular, their families really appreciate it when you take time to learn about them as an individual and look at them more that someone who is having respiratory failure due to their COPD.

[Dr. Goldberger] I remember very vividly when I was on rounds in medical school or maybe residency or fellowship where you would say ‘oh, we got the gallbladder over in room 4,’ or in the ICU say, ‘oh this patient is trying to die; we should keep an eye on him tonight.’ It really was disheartening to hear that and I suspect that maybe it’s not as prevalent as saying those things as much anymore and I can’t say for sure how it differs from institution to institution, but it is still very prevalent and that could be challenge that we are trying to allude to that at what point do we actually try to instill in our learners the right way to say things and what not to say.

Q.) Do you think that this is getting worse? Is it getting better? I don’t know if there is any way to measure that.
[Dr. Luks] I don’t actually have a good sense of it getting worse or getting better. I mean, everyone always refers back to the book, The House of God, and frequent use of similar terminology back then. I know certainly when I was a resident and even a fellow, I used quite a bit of this terminology and I’ve tried to do a better job over time of eliminating it from my communications and then modeling better communications.

[Dr. Goldberger] I am not sure if it has actually got worse or better, but I will say that what I’ve enjoyed about response to the piece is that people actually are commenting online about some of the things that they actually find to be dangerous misuses of words or their own pet peeves. And again, these are the things that actually I wasn’t even aware of until I though ‘oh yeah, that actually is problematic.’ And so I think it is persistent. I try to do the best I can when I had my own service with the team where I had a resident and fellow in clinic just by sort of dissuading. And I think the more you actually are going to make trainees aware of these terms, the more they are going to start to think about a little more carefully as well.

[Dr. Luks] I think the challenge is how do you effectively kind of intervene to change this practice? Certainly from a personal standpoint, I think we can model better communications, and I know Zack, like myself, we’re very careful about the use of these terms on rounds and try to be very precise in how we’re communicating about the patient’s clinical situation or what we want to do. The challenge becomes how you correct the members of your team, the students, the residents, the fellows, and even harder, how do you correct colleagues who may be at or above your level in the faculty hierarchy. I certainly found on rounds you cannot interject every single time when one of these terms come up, you’ll never get through rounds. And what you’ll probably end up doing is just engendering a lot of frustration because people say ‘look, this lingo, it’s part of the profession, you understand what I’m talking about.’ So I try to pick some spots and one or two terms that I’m going to try to bring up a point about or find some lighthearted moment to interject something about something else. But not try to do it every single patient discussion, every word that comes out of their mouths because it won’t engender the change in behavior that you want.

[Dr. Goldberger] Especially with this new movement that now legislation calls ‘Open Notes,’ patients are not only going to be listening to us as well as their families, but they are actually going to be reading what we write. So if you start using words that don’t exist such as troponinemia or surgerize, anyone with a standard medical dictionary you can take a look at this, they are not going to find these words anywhere and they are going to be more confused.

[Dr. Luks] The thing that I would add too is some people push back and say this is really harmless when it’s amongst physicians that this terminology is being used, but I think in the end what we have to remember that the ultimate object of our work are the patients and their families. And to the extent that we leave them confused or use terminology that is difficult for them to hear, then we’re doing them a disservice in our care, and I think that’s where we really need to keep our focus.

Thank you both. Dr. Andrew Luks is Professor of Medicine at the Division of Pulmonary Critical Care & Sleep Medicine at the University of Washington School of Medicine. Dr. Zachary Goldberger is Associate Professor of Medicine in the Division of Cardiovascular Medicine & Electrophysiology at the University of Wisconsin Madison.
I’m Tom Augello.