What you say matters

Drs Cox and Fritz have written an article about language in medicine (here is a link). The two authors’ points are well made, medics would be wise to heed them. However, what I want to suggest is that as much as the article is welcome, it is also part of the problem.

The article’s title is:

Presenting complaint: use of language that disempowers patients

and it is a good example of what I want to write about. The title hides who the authors write about. Let me put it differently: it’s not the language use that disempowers patients, it’s people who speak in a particular way. People, not language!

The same patterns you will see in the headings:

  • Language that belittles patients
  • Language that emphasises the patient as passive or childlike
  • Language that blames patients

The authors keep avoiding reference to medics/clinicians. The pattern is then repeated in the text of the article. Consider the following sentences from the three first paragraphs:

  • Indeed, specific word choices and phrases affect how patients view their health and illness,
  • Yet some language used either to communicate directly with patients, or when discussing patient care with other healthcare professionals, might inadvertently disempower patients.
  • language that is belittling, doubting, or blaming continues to be commonly used in everyday clinical practice, both verbally and in written notes
  • we describe how such language, while often taken for granted, can insidiously affect the therapeutic relationship and suggest how it could be changed to foster a relationship focused on shared understanding and collective goals.

And so, phrases affect, language is used to communicate with patients, language is belittling or blaming and so on, and so forth. And the first three paragraphs of the text do not refer even once to who exactly the authors talk about. Who speaks, for pity’s sake? Who speaks?! The article keeps referring to words, to language used, keeps avoiding saying that, oh, the blasphemy of it, doctors do it. The authors pussyfoot around the bush and the non-committal way of their writing reaches the acrobatics such as

  • Some language….might inadvertently disempower.

Is it really better if you inadvertently disempower, rather than just disempower? Is it better when you don’t even think about it, just do it unthinkingly?

Here  I can’t resist my usual gripe about  disempowering. It keeps astounding me that medics keep using this notion that empowering me is somehow good for me. Not, it’s bloody not, stop wanting to empower me. Every time you do, you assume that I am powerless and by your decision to empower me I will recover. Please, take you empowering and shove it….

OK, you might ask: but do the authors actually write about clinicians at all? As a matter of fact, they do. Here are all 4 instances, all referring to acts of communication, more or less directly:

  • Clinicians record their (somewhat subjective) perception of the presence or absence of signs on examination
  • There is also evidence that specific words used by clinicians can affect how patients feel about their doctors, thus directly influencing the therapeutic relationship
  • In obstetrics, clinicians refer to “failure to progress” and “poor maternal effort
  • Much of the language highlighted here is deeply ingrained in medical practice and is used unthinkingly by clinicians.

They also write about doctors. There are 10 such instances, but only two refer to doctors saying (or writing) something (i.e., using language). Here they are:

  • In medical documentation, doctors sometimes use language that questions the authenticity of a patient’s symptoms.
  • Here doctors assign patients responsibility for something over which they have no control: “the patient failed immunotherapy” rather than “immunotherapy failed the patient.

And it’s surprisingly benign, isn’t it? Where have all the belittling, blaming, constructing patients as children gone? All those things are hardly worth writing home about. Clinicians only record and refer. Then there are words/language used, obviously unthinkingly. All this banging on about reflection on your practice and you get away with ‘unthinkingly’. Congratulations!

Doctors on the other hand ‘sometimes use language’ (obviously, it can only be ‘sometimes’) and ‘assign patients responsibility’. Are these the linguistic crimes that the authors are writing about? Hardly.

And then you get to the key messages:

  • Some commonly used language in healthcare confers petulance on patients, renders them passive, or blames them for poor outcomes
  • Such language negatively affects patient-provider relationships and is outdated
  • Research is needed to explore the impact that such language could have on patient outcomes
  • Clinicians should consider how their language affects attitudes and change as necessary

Have you noticed that doctors disappear again? All of a sudden, we’re back to the abstract language used, with no one responsible for it. And clinicians? Oh, they only should consider. Should consider! And have you noticed that the language is….outdated! For pity’s sake, the language is outdated!! That seems to be mean that 20 years ago it was quite OK to blame or belittle patients. It’s just no longer in vogue.

These references to language rather than to doctors are then repeated beyond the article. One of my favourites is this tweet:

Again, it’s the language use that is “belittling, invalidating, disempowering or patient blaming”.  No, it’s not! People do this, medics do this. Needless to say, this was one of many such tweets in which it’s only language which is the problem. People who use the language are not at all. They all walk on water.

The two authors start the article with:

  • Language is important

and it’s kind of  true. But this sentence hides more than reveals. For it’s not language that is important, what YOU SAY is important. And I wish the article didn’t provide one big screen behind which all those speaking doctors could hide. And by providing such a screen, the article becomes part of the problem. And the problem is to get clinicians to talk differently, and not only to point at a number of phrases.

Moreover, in addition to WHAT you say, HOW you say it is also  important, and WHEN and WHY and WHAT FOR. Yes, ‘taking history’ is not a particularly felicitous term, but it’s more important how you do it. And while some medics simply type things on their keyboard as you talk to their side, some turn to you and listen. I somehow doubt that the former will change much when you change ‘taking history’ into, say, ‘engaging in dialogue’.

So, the next article on doctors’ language could start not with a cliched statement on how language is important but with: ‘What you say matters!’. Yes, you. And you. And you in the back, too.

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