Watch Your Language!—Misusage and Neologisms in Clinical Communication

Thank you for bringing our attention to this pervasive and potentially dangerous practice. Crisp, clear communication is vital in clinical medicine, particularly in high-stress situations. Jargon and acronyms mean different things to different people. When I discuss the correct use of language with students and house staff I am often met with bemusement or worse, facial expressions suggesting that I'm a bore or a pedant.

'In-house' jargon may be understood by other members of the medical and allied health team, but when it creeps into external communication it can mislead the reader. A hospital discharge summary is a vital medical handover document: it must be concise, accurate and clear in its meaning.

There's another subtle but important aspect to this discussion. Jargon and secret gestures are often used to create sub-cultures in organisations. Competition between sub-cultures has the potential to undermine the overall organisational culture. This can harm morale and work against the central mission of the organisation. If the mission is first-class health care, harm can result.

When did endorsing become a medical/psychological term and why?

When did "disposition" become synonymous with "discharge plan"?

I've seen confused looks on patient's and families' faces when we say pseudo-intellectual pretentious sounding colloquialisms like "early on" and "down the road." Once they thought we were saying the patient was going to wind up in the cancer center down the street.
Sometimes they're wise to us when we say cute euphemisms thinking that we're disguising our idea that it's all in their heads.

The article points to what in many cases clearly amounts to undermining of understandable and effective communication to patients and to families, but ignores the basic fact that languages are living entities which evolve inexorably over time.
Learning to be physicians – or virtually any other member of the health care team – requires mastery of the language of medicine, which, as with most professions and their particular argots, is complex; often opaque to non-speakers; and parsimonious in terms, but swollen with referential meaning. Some terms are also clearly linguistically incorrect: e.g., transaminitis does not reflect inflammation of the transaminases, as a lexicographical analysis would suggest; but those who use that term understand the complex pathophysiological processes leading to the clinical condition the term is used to describe. It’s not likely any efforts to curtail this sort of language evolution can be successful, the at times almost hostile efforts of prescriptionist and proscriptionist lexicography scolds notwithstanding. (I subscribe to the descriptionist faction of dictionary devotees: our task is not to police but to describe language as it is used by speakers.)
It might be useful to consider training students in the clinical professions to understand that they shall master a new language which will never be clearly understood by the great majority of their patients, and that this language ought not be utilized where patients are present: it’s not unlike refraining from speaking English where the patient is monolingual in a non-English tongue. This problem may be more complex with English speakers, since the bulk of us have achieved maturity as mono-lingual individuals; citizens of other continents are likely more accustomed to switching between and among languages, according to the understanding of the listener(s).
Before medical lexicography collapsed with the advent of the Internet, there was an effort, centered at this desk, to supplement the lexicon with an appendix of ward parlance terminology, comprising a list of words and terms essentially prohibited from use when patients were present, but with definitions useful to novices in training.
The efforts of the authors provide a cogent approach to this problem, which is clearly crying for a solution.

Thomas W. Filardo, M.D.
Chief Lexicographer and New Terms Editor, Stedman’s Medical Dictionary
Ann Arbor, MI
twfilardo@aol.com

Like weeds in a garden (where DID they blow in from?), bizarre forms of documentation sprout overnight and suddenly become widespread. Here are some of my most recent pet peeves (trust me, there are many others):
1. "The patient was ordered for antibiotics": I know of no evidence that ordering a patient for an antibiotic is of any demonstrable benefit to an antibiotic. Conversely, ordering antibiotics for an infected patient is of indisputable efficacy.
2. "Concern for" rather than "With a diagnosis of" in a patient with textbook classic signs & symptoms of a disease. For example, a woman 30 wks pregnant, actively contracting, 6 cm dilated: "Patient admitted with CONCERN for preterm labor." What more would it possibly take to convince the note-writer that the woman actually was in preterm labor?
3. Abbreviations that nobody outside of a given hospital understands. Examples are TNTC.
4. "Patient endorses..." is another of my many peeves, but that's already been endorsed above.

This is an interesting perspective and thank you for bringing this important topic to the surface. I surely agree that when communicating with patients the most careful language should be chosen to ascertain that we are conveying the right information and accurately delivering clear medical advice and message. Nevertheless, many of the examples mentioned in the article, we, the providers, use them to communicate among each other, rather than with patients. I’m not sure if they create confusion in this setting. For example, when a resident tells me that a patient “denies illicit drug use” we both understand that the resident is not necessarily expecting a positive history of illicit drug use and the patient “denied” it. What comes to mind is what the author suggested to use - “patient reports no use of illicit drug” - without explicitly phrasing it that way. The same happens when we use “big-gun antibiotics” to imply “broad-spectrum antibiotics.” In my mind this could just be a different way of describing a term that does not necessarily have a “violent” connotation to it. Actually, it could be seen as a way of breaking boredom and changing the rhythm of rounds. Another example that I noticed residents use quite often is “blood pressure is soft” to imply a borderline low blood pressure.

Some terms and definitions, like "acidemia" and "acidosis" for example, are important to use in the appropriate way since they imply different pathophysiology, but I'm wondering if the use of a phrase between colleagues becomes a routine in such a way that it does not create confusion then what is the harm of using it?

It would be interesting to study what physicians and patients think about this, especially the young physicians-in-training.

I agree completely with prior comments about "endorsing." But while "endorsed" is problematic, it does at least tell us that the patient only reported the problem when it was solicited, rather than having actively reported it. Either we need a better term, or we need to report that "solicited symptoms include blood in the stool, urinary frequency". For me, a pet peeve is "the patient failed conservative therapy" - no, conservative therapy failed the patient!

I was expecting a list of vulgar, demeaning, sexist or dehumanizing words from this article. With a few exceptions, I believe the author's list of verbotten phrases are very standard phrases that are well understood by all who communicate clinically relevant information.

I agree in general with the authors' comments, with their examples of inaccurate, imprecise, and insensitive observations and documentations, but a few of the comparisons may be a little picky. Of course it is easier to be more precise in general medicine than my field of psychiatry, where I allow the patient to express him-herself in a quote which then can be "editorialized" by me. In the future,  some physicians, including those with English language challenges, may not be adequately trained in prpperly "concretizing" words and phrases, so that "neologisms" (though I love them in psychiatry) do not misconstrue medical communication for good care. Also, I think some of these problems have been magnified by the widespread use of the EHR. For example, in my consultation on cases I have learned to talk to the patient first (if communicable) before reading the "robot-ized" keystroke document, in order to figure out what the "real facts" are. (Basically in some systems, if information is not enterable as "ordained" by the computer it doesn't exist unless placed in a "freehand" text. Just another EHR drop down or prompt choices with verbiage insufficient to describe a patient would not seem to be the answer, though it could be more feasible with multiple "structurally-correct" medical terms, as in a specialty.) One interim solution might be possible, though with a little more cost, to use trained scribes who have backgrounds in English grammar and syntax.

Thanks for this, it cannot be repeated often enough. But I gave up on pointing out that it's not the patient who is transplanted, but the organ...

I read with interest the excellent article by Luks and Goldberger. The misuse of jargon is not unique to medicine, and misuse of contronyms such as 'awful' can have very different meaning to the speaker and listener. A key problem for medical journals is use of the term 'reduced mortality' when extolling the benefits of medical intervention; I know of none. Rather a more exact term like 'prolonging life' would codify the benefit, and clarify expectation.

Some of these responses  made me want to ask : do you talk to your patients and their families like that? If so, that is part of the problem. These situations always remind me of an attending professor during internship who sometimes used to deflate pompous pretentious case presenters or other speakers like this: if someone said the word ubiquitous, he would say "and not only that, it was everywhere."

Andrew Luks and Zachary Goldberger give us wise advice when they say, "Watch Your Language!"

As part of the induction to my firm, I lay the foundation stone of "Economy of Language" on the first day of a new fellow's attachment. The principle of 'economy of language' is designed to enhance communication, reduce confusion and, most importantly, reduce medical error and clinical harm.

Avoidance of neologisms is an important component of the guidance I give regarding optimal use of language. The discipline required to use language in an economical and precise way is central to developing as a clinician - and I suggest that the acquisition of these skills should start from the first day at medical school.

A culture of safety is founded on the use of precise, economical language.

In the spirit of using language that is descriptive and objective, we should also use generic names for the medications we prescribe. This might help to avoid being unduly influenced by pharmaceutical firms who promote their products without regard to being evenhanded. Might this have had a positive influence in the epidemic of opioid misuse by helping us examine what we were prescribing?

Like Ambrose Bierce's Devils Dictionary, it will be useful to create a Patients' Dictionary that presents the etymology of the word, the practitioner definition, and then, the patient's definition.
If this dictionary could be updated by all easily, and accessible to all, it would be an excellent teaching tool.
As a proband with an autosomal dominant mutation, I'm looking forward to submitting the patient translation of the genetics jargon.

Please think about creating this dictionary.

When I was in Physical Therapist Assistant training I said once to my patient, "Don't bend forward past 90 degrees of hip flexion or you will break hip precautions" when training a patient who recently had a THA. Well, she started crying in a panic thinking she will break her hip again! I think I was sticking to the script from my books and was trying to impress my clinical Instructor -- not realizing how it came across to my patient. We all have to be careful not to try to sound "smart" but use our smarts to help our patients in the ways that work for them.