No matter how skilled a physician is with patient care, using the wrong language when speaking with patients or families can derail the whole process. Studies have shown that patient parameters such as blood pressure, for example, are affected by doctor-patient communication,[1] as is overall patient health.[2] In fact, a clinician's specific choice of words can influence a patient's medical decisions.[3] And patients are becoming more vocal about which terms they prefer to describe the conditions they have. The following terms have already been scrubbed from the lexicons of many healthcare professionals. After you review each one, answer the poll to share whether you think the language shift is justified, then click on "comments" to add any other changes that you want to propose for the medical lexicon. 1. Heart Failure (noun): inability of the heart to function properly Due to the imprecise nature of the word "failure" and its inability to describe the full spectrum of cardiac complications, Dr Lynne Warner Stevenson, professor of medicine at Harvard Medical School and Brigham and Women's Hospital, advocates using alternative terms such as "heart dysfunction" or "cardiac insufficiency." Stevenson suggests that the label "heart failure" is hindering effective care. "This stigma has consequences not only for self-image and personal goals but also for families, employment, and insurance," she said. "Clinics labeled as 'heart failure clinics' and the linked attachment of heart failure diagnostic codes may discourage entry of those patients who could benefit the most."[4] Dr Richard Lehman, professor at the University of Birmingham (United Kingdom) shares the view that "heart failure" does not adequately represent the variety of heart illnesses that are lumped together under that term. "For doctors, 'heart failure' covers a confusingly wide spectrum of illness, whereas for patients it has a deadly ring of finality," said Lehman. "Failure means the end of hope, and many patients who have been told they have heart failure prefer not to remember the term or let it dominate their lives. This partial denial may have damaging consequences, both psychologically and in terms of adherence to treatment."[5] On the other hand, Dr John McMurray, professor of cardiology, University of Glasgow, said that he believes using the term "heart failure" is fine as long as you explain what this really means to your patients and their specific condition. "When I tell patients that I have diagnosed 'heart failure,' I explain that this is the description that doctors use when referring to the symptoms patients experience when their heart isn't pumping normally—ie, breathlessness and ankle swelling," said McMurray. "I point out that it doesn't mean a 'heart attack' or 'cardiac arrest' or that I expect them to drop dead in the near future." "If they have HFrEF [heart failure with reduced ejection fraction], like most of the patients I see, I go on to say that we have many effective treatments, that I expect to have them feeling better in a few days or weeks at most, and that as I introduce these new treatments slowly over the next weeks and months, I expect that there will probably be some improvement in their heart function." In fact, some physicians are adamant about keeping the term "heart feature" in use. Dr Barry Borlaug, a cardiologist from Mayo Clinic, believes that it would be a huge detriment to remove the term from clinician vocabularies. "To change the term runs the risk of trivializing what is in fact a significant and lifestyle-altering medical condition," Borlaug said. "The job of the heart is to pump blood to the body at rest and during exercise without an untoward increase in heart filling pressures. If the heart fails to do this, and that causes symptoms of effort intolerance or shortness of breath, then we call that 'heart failure.' That is its very definition. To pretend that this is not failure of the heart is dangerous in that it may lead to ignorance in both patients and caregivers about the magnitude and scope of this problem." 2. Intensify (noun): to increase in strength or magnitude When new guidelines were released at the American Diabetes Association's annual meeting in Orlando in 2018, the guideline committee was bombarded with many questions about their recommendations for treating hyperglycemia in type 2 diabetes. The discussion included choosing between various therapeutic options to achieve patients' glycemic targets and the importance of intensifying or escalating therapy. One question seemed to surprise the committee. Dr Alice Cheng, an endocrinologist and associate professor at the University of Toronto, suggested that perhaps the terms "intensify" and "escalate" (with respect to treatment) should be changed to phrases that make patients less fearful. "Language matters when we are interacting with patients but also with each other," Cheng said. "Perhaps the term 'intensification of therapy' should be altered to 'reaching appropriate therapy,' because 'intensification' sounds serious and suggests greater complexity and adverse effects. Maybe this is contributing to some of the hesitancy our colleagues have in increasing therapies appropriately." Committee members said they found the idea intriguing and would take it under advisement. 3. Mid-level Provider (noun): an individual, other than a veterinarian, physician, podiatrist, or dentist, who is licensed to dispense a controlled substance Catherine Bishop, DNP, an oncology nurse practitioner at Johns Hopkins' Sibley Memorial Hospital, recently wrote about her experience of hearing the term "mid-level" for the first time when studying to become a nurse practitioner (NP).[6] "I was puzzled. Was the term 'mid-level' a way of quantifying the amount of care that NPs and physician assistants provided? Was it a way of qualifying the type of care they provided? I felt confused and belittled. I was in the midst of graduate-level (advanced) education and as such would be practicing at an advanced level of nursing." The term "mid-level practitioner" is used by the US Department of Justice's Drug Enforcement Administration to characterize healthcare professionals who monitor controlled substances. This description can include advanced practice nurses (nurse anesthetists, nurse midwives, clinical nurse specialists, and NPs) as well as physician assistants. While Bishop wrote that she does not intend to fight to change this name in legislation, she advocates avoiding the term due to its ambiguity. "The title or term 'mid-level' is certainly not appropriate," she writes. "Virtually all advanced practice nurses have at least a master's degree and many hold doctorates. We are clinicians, educators, and researchers who are highly trained to care for and manage patients with a variety of illnesses." This sentiment is shared by some physicians and other healthcare professionals. In an editorial post, Dr Michael D. Pappas, a pediatrician at Children's Intensive Caring in Toledo, Ohio, writes, "Nurses are the foundation of medical care. They tell us (MDs) when they recognize a problem or a need for an intervention. Then, we act. They are not low-level providers. Therefore, if nurses are not low-level care providers, then nurse practitioners cannot be mid-level providers."[7] 4. Diabetic Cynthia Rissler, the mother of Shane Rissler, says that her son has diabetes, but he is not a diabetic. "When you are a person who has been diagnosed with diabetes, you're still the same person," she told Diabetes Daily.[8] "Just because you have diabetes it does not mean that the disease is allowed to name you. It can never change who you really are." Individuals who are averse to the term "diabetic" suggest using "person with diabetes" as an alternative. Rissler is among a growing movement of patients, parents, and healthcare professionals who promote the use of this alternative term to refer to the person with the condition, and on social media it has become exceedingly popular via the hashtag #PWD. "We don't say paraplegic, we say a person with paraplegia," writes Karen Kemmis in a blog post for the American Association of Diabetes Educators. "Similarly, we don't say quadriplegic for a person with quadriplegia; stroke victim for a person who had a stroke; Parkinson's patient for a person with Parkinson's disease; or diabetic for a person with diabetes. This was long before the notion of being politically correct and long before the terminology of person-first language. It was just the right thing to do. It shows empathy. It shows that we see a person first, ahead of the disease or disorder."[9] The term "diabetic" is still appropriately used as an adjective (eg, diabetic retinopathy), just not as a noun to refer to the patient. 5. Noncompliant (adjective): refusing to comply with something In an article for the New York Times,[10] Dr Danielle Ofri, associate professor of medicine at New York University School of Medicine, discusses the dilemma over calling patients "noncompliant": As soon as a patient is described as noncompliant, it's as though a black mark is branded on the chart. "This one's trouble" flashes into most doctors' minds, even ones who don't want to think that way about their patients. And like the child in school who is tagged early on as a troublemaker, the label can stick around forever. Ofri sheds light on the fact that compliance is not black and white; there could be a dozen reasons why patients aren't following their doctors' instructions. Ofri cites an article by Dr John Steiner in Annals of Internal Medicine,[11] in which Steiner created a chart for one of his patients with diabetes and found that if the patient followed all of his instructions by the book, he would have to complete more than 3000 behaviors annually. Ofri also cites her grandmother's experience with heart disease to show the many different of adherence: Had she taken her medicines at the appropriate doses, she might have survived the heart attack. But then maybe she would have died a slower and more painful death from some other ailment. Her biggest fear had always been ending up dependent in a nursing home, and by luck or design, she was able to avoid that. Perhaps there was some wisdom in her "noncompliance.." Breaking Habits Dr Jennifer Fong Ha and colleagues at Sir Charles Gairdner Hospital in Australia elaborate on the importance of the physician-patient relationship in their paper "Doctor-Patient Communication: A Review"[12]: Good doctor-patient communication has the potential to help regulate patients' emotions, facilitate comprehension of medical information, and allow for better identification of patients' needs, perceptions and expectations. Patients reporting good communication with their doctor are more likely to be satisfied with their care, and especially to share pertinent information for accurate diagnosis of their problems, follow advice, and adhere to the prescribed treatment. Patients' agreement with their doctors about the nature of the treatment and need for follow-up is strongly associated with their recovery. Dr Susan Guzman, co-director of the Behavioral Diabetes Institute, explained why language and word choice is critical in patient care. "If you feel like you're to blame for having a disease and your doctor scolds you for not meeting goals, what about that says, 'I'm going to take a class and become more engaged'? These are all very good-intentioned physicians, but the way they talk to patients pushes patients away. Instead of calling patients noncompliant, they should try to find a way to work around the obstacles." In response to people who claim that emphasis on language and word choice is a reflection of a movement to become "politically correct," Dr Guzman replied, "The whole 'politically correct' thing doesn't make sense to me. So, caring about people and what they think doesn't matter? [To] someone [who] says, 'I don't buy into any of this,' if all of your patients are at goal and are perfectly engaged, then completely ignore what I am saying. But if you have patients who are struggling, then you might want to consider it." It is evident that there are several benefits to assessing your communicative skills with patients. While it may be difficult to stop using words that are already part of your vocabulary, being conscious of certain terms and how they make patients and coworkers feel is a small step toward ensuring the best quality of life for everyone involved. References Kaplan SH, Greenfield S, Ware JE. Assessing the effects of physician-patient interactions on the outcomes of chronic disease. Med Care. 1989;27:S110-S127. Abstract Boynton PM. People should participate in, not be subjects of, research. BMJ. 1998;317:1521. Abstract Barnato AE, Arnold RM. The effect of emotion and physician communication behaviors on surrogates' life-sustaining treatment decisions: a randomized simulation experiment. Crit Care Med. 2013;41:1686-1691. Abstract Stevenson LW. Who would be branded with failure? Circulation. 2017;136:1359-1361. Abstract Lehman R. Cardiac impairment or heart failure? BMJ. 2005;331:415-416. Abstract Bishop CS. Advanced practitioners are not mid-level providers. J Adv Pract Oncol. 2012;3:287-288. Abstract Pappas MD, Pelzman FN, Lamberts R, et al. Stop calling nurse practitioners mid-level providers. KevinMD.com. Source January 10, 2015. Accessed July 5, 2018. Griswold B. The word "diabetic"...Does it offend you? Diabetes Daily. Source April 20, 2017. Accessed July 5, 2018. Kemmis K. Is it a person with diabetes or a diabetic? American Association of Diabetes Educators. Source March 12, 2013. Accessed July 10, 2018. Ofri MD. When the patient is 'noncompliant'. The New York Times. November 15, 2012. Source Accessed July 5, 2018. Steiner JF. Rethinking adherence. Ann Inten Med. 2012;157:580-585. Abstract Ha JF, Anat DS, Longnecker N. Doctor-patient communication: a review. Ochsner J. 2010;10:38-43. Source Accessed July 5, 2018. Source
