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Health

Opinion: Doctors Privately Use Cruel Words to Describe Their Patients

The field's "professional language" can be pejorative, paternalistic, and aggressive.

by Michael Zirulnik and Jonathan Cartsonis
May 28 2019, 3:38pm

Image: Martin Vorel/Libreshot

In 1973, an understated article in the New England Journal of Medicine catalyzed a movement. Doctor Budd N. Shenkin and researcher David C. Warner called for a patient's right to access their medical records. They said it would improve the doctor-patient relationship and avoid “excessive bureaucracy.”

Today, 33 million patients have access not only to their medical records but also their healthcare providers’ notes, largely thanks to OpenNotes, an international campaign. But the transparency comes with risks: Medical practitioners often use professional language that is pejorative, paternalistic, accusatory, and aggressive—revealing a power dynamic between doctor and patient that can disrupt therapeutic relationships and affect how patients are cared for.

The language of medicine is rife with troubling terms. For instance, a medical note may read, “The patient denied skipping doses of the prescribed antibiotic though non-compliance is suspected…”. Both “denied” and “non-compliance” are medical-ese, and while their accusatory implications aren’t always intended, they nonetheless color patients, and their accounts, as unreliable and untrustworthy.

The solution would mean using empathetic, human-centered language. An alternative note might read, “Patient states they took all of their doses. I suspect that doses of medication have been missed, as clinical findings do not correlate with outcomes.” And this humane language could translate to better health outcomes: The medical provider might discover dementia, or personal or financial stressors impeding the patient’s ability to purchase or consume the recommended treatment.

They nonetheless color patients, and their accounts, as unreliable and untrustworthy.

Meanwhile, medical rhetoric is even harsher when it concerns women. A woman who miscarries may have medical records referring to her “incompetent cervix.” If she miscarried three or more times due to the condition, the note may read “habitual aborter.” If the pregnancy had carried to term, her due date would be referred to as the “estimated date of confinement.” And a pregnant patient’s decision to skip a recommended epidural anesthesia is often labelled a “refusal,” which paints the drug as a default rather than an independent choice.

If formal medical language is compromising, its colloquialisms are equally, if not more, repugnant. Take for instance the “4Fs rule” used to guide physicians in diagnosing gallstones: Fat, Forty, Fertile, Female. A fifth F, Feo—meaning ugly in Spanish—is sometimes taught surreptitiously to remind physicians that the typical patient presenting with gallstones tends to be Latinx.

This language, and its connotations, has been chronicled over the years by wary health providers. In 1978, a satirical book that explored the pitfalls of medical language, The House of God, was considered revolutionary for exposing this kind of pejorative language in practice. The author, Samuel Shem (the pen name of psychiatrist Stephen Bergman), looked at commonly used terms such as GOMER, for Get Out of My Emergency Room. “GOMERs don’t die” is a phrase referring to the most difficult patients who repeatedly return to the ER. Often they are the elderly or indigent—the most vulnerable people in our society.

A fifth F, Feo—meaning ugly in Spanish—is sometimes taught surreptitiously.

But the use of Shem’s book in medical schools, book clubs, and departments of medical humanism and ethics is largely inward-looking. The conversation favors positive change for physicians while neglecting to look outward at how the use of language affects patients. A 2018 experiment in the Journal of General Internal Medicine, for example, identified how stigmatized language—pejorative terms—used in a patient’s medical records, negatively impacts how subsequent providers care for that patient, including less management of the patient’s pain.

Midwives and nurses have been outspoken advocates for better, humanistic language. A 2006 journal article examined how clinical language choices “affect childbirth, culture, and the care of childbearing women and their families.” The author, nurse and researcher Lauren Hunter, advocated for a healthy mix of holistic approaches, instead of the dominant biomedical Western model that can subjugate patients.

If patients want better care, and providers want healthier, happier patients, we’ll have to reconsider what language we teach in medical schools, and what colloquialisms we’ll support in the practice of medicine. Just as lexicographers formalize this behavior every day by adding and deleting words from dictionaries, medical professionals simply need to do this work with analytical judgment, not for but alongside patients.

Hippocrates held this idea of helping over harming central to his core values in a time before the microscope, when cellular structures were an unknown. Similarly, while the significance of language on health and healing is not yet fully visible, its impacts are nonetheless consequential.


Michael Zirulnik
Ph.D., is a communication scholar and consultant at The Varsity Project, where he designs strategies to mitigate loss in high-stakes, high-risk industries such as healthcare and aviation.

Jonathan Cartsonis, MD is an Associate Professor in the Department of Family and Community Medicine and Director of rural health programs at University of Arizona College of Medicine-Phoenix. He cares for patients in a women’s jail health clinic.