Medical words can hurt!
Could the relationship between patients and health care staff be improved with some simple rephrasing?
I was pondering this recently after listening to a Radio 4 interview with Dr Caitríona Cox and Dr Zoë Fritz, who have recently published their analysis on the subject, titled ‘Presenting complaint: use of language that disempowers patients’. In the interview, Caitríona and Zoë stated that ‘language that is belittling, doubting, or blaming continues to be commonly used in everyday clinical practice, both verbally and in written notes’ (1). Their analysis found that 'specific words used by clinicians can, indeed, affect how patients feel about their doctors, thus directly influencing the therapeutic relationship’, and urge doctors to use language that ‘facilitates trust and supports shared decision-making’.
Examples they describe include:
‘Patient denies chest pain’ instead of ‘patient reports no chest pain’
‘Patient claims pain is 10/10’ instead of ‘patient experiencing 10/10 pain’
‘Patient failed pain management course’ rather than ‘pain management course failed the patient’
‘Patient “insists” her injury occurred with no prior trauma’ instead of ‘patient reports her injury occurred without any prior trauma’.
Each implies a degree of disbelief or blame.
Another example is the unhelpful term ‘non-compliant’, sometimes used in relation to therapy or taking medication. Without any expanded explanation, the term does not explain what may be perfectly valid reasons for a patient’s actions – e.g. the patient being unable to cope with unpleasant side-affects, or may struggle with anxiety that prevents them attending group therapy (2). Instead, it has negative connotations, implying the patient is being knowingly belligerent or unwilling to stick to ‘the rules’.
In another paper looking at language used with diabetic patients, Holt and Speight describe how ‘using the right [doctor-patient] language is not a matter of political correctness; it affects the core of our interactions’ (6).
I can relate to the comments in Caitríona and Zoë’s analysis. I remember leaving a physiotherapy appointment, for which I’d held so much hope, and Googling the word kinesiophobia, after seeing 'Patient non-compliant during examination - kinesiophobia' on my notes. It was written in relation to me letting out a yelp after a physio moved my knee-cap during an examination, without having warned me first, and my asking her to stop because I felt it may dislocate. At the time, the notes made me feel bewildered and totally misunderstood, firstly by the words ‘non-compliant’ and then by the definition of kinesiophobia, which is 'an irrational, excessive and debilitating fear of physical movement and activity'. I had felt that our interaction had been completely non-confrontational and I had been very willing to sign up to the exercise plan that was prescribed. Having experienced many debilitating joint symptoms in the past, I definitely didn’t feel that my reaction during the examination was irrational! I felt this language broke my trust in the physiotherapist, and I remember being particularly concerned by the thought that these words would be read by future health professionals who would think I was a difficult patient.
I am not alone in this concern. A 2018 randomised controlled study examined how language used in the medical record of a patient would influence physicians who read the note afterwards (3,4,5). They found that biased terms can be perpetuated through patient medical records and can influence subsequent clinician attitudes and decision-making. ‘Stigmatized patients may encounter clinicians in sequence, with each subsequent clinician treating them in accordance with the impressions expressed by the previous clinician’. Perhaps even more concerning, the researchers found that ‘Readers of stigmatizing (vs neutral) language had more negative attitudes toward the patient and opted to administer less analgesia, even though all clinically relevant information was the same’.
With hindsight, I can see that the kind of wording described above is widespread in medicine. As Caitríona and Zoë explain in their analysis, ‘It is taught in medical textbooks and handed down through the generations’. When you consider the potential such words have for undermining patient-doctor relationships, I very much agree that it’s time for a change.
Have you been affected by negative language in a healthcare setting? Dr Caitríona Cox and Dr Zoë Fritz would love to hear your perspective. Get in touch at: firstname.lastname@example.org. Their analysis can be found HERE.
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Cox C. & Fritz Z. 2022 - Presenting complaint: use of language that disempowers patients. BMJ 2022; 377 doi: https://doi.org/10.1136/bmj-2021-066720 (Published 27 April 2022)
Kleinsinger F. 2003 - Understanding Noncompliant Behavior: Definitions and Causes Perm J. 2003 Fall; 7(4): 18–21. PMCID: PMC5571787
Park J, Saha S, Chee B, Taylor J, Beach MC. Physician Use of Stigmatizing Language in Patient Medical Records. JAMA Netw Open. 2021;4(7):e2117052. doi:10.1001/jamanetworkopen.2021.17052
P Goddu A, O’Conor KJ, Lanzkron S, et al. Do words matter? stigmatizing language and the transmission of bias in the medical record. J Gen Intern Med. 2018;33(5):685-691. doi:10.1007/s11606-017-4289-2
Chen M, Bargh JA. Nonconscious behavioral confirmation processes: the self-fulfilling consequences of automatic stereotype activation. J Exp Soc Psychol. 1997;33(5):541-560. doi:10.1006/jesp.1997.1329
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