Communication Matters
Bad Language in Medicine
As a father of five, there are incidences where one of my children says something that is in-appropriate, for which there is a rather sharp “Watch your language young man (young lady). We don’t speak that way in this house.” I am guilty of this same parental tone at times with medical residents when certain medical words are spoken inappropriately. The medi-cal students, while not addressed as harshly, are guilty by association like the younger child who has gone along with the bad idea of their older sibling. And I must admit that at times, I have resorted to a kind of forced sarcastic smile along the lines of the SNL church lady and respond to residents in snarky love tones I would not dare to speak in to my colleagues. I have grouped this correction of “bad medical language” into two catagories: 1) those words which are used wrongly and 2) those diagnoses that are over-reaching.
“We Don’t Speak That Way”
The following terms are either figmentary, oxymoronic, inaccurate, or inappropriately ap-plied. They are words used wrongly.
“Substernal chest pain”
The resident says, “The patient presents with substernal chest pain.” To which I ask, “Can you point to me where the anatomical area is on the chest that is substernal? Are you meaning that the patient presents with xiphoid tenderness or epigastric pain? in which case you are no longer really talking about the chest. Oh, you mean retrosternal chest discomfort!
“Kidney stone pain”
The resident says, “The patient comes in with kidney stone pain.” To which I ask, looking dramatically confused, “If we did a CT and found a stone only in his kidney, what would you likely conclude about the patient’s pain? Kidney stones don’t cause pain.“Kidney stone pain” is an oxymoron. You mean a ureteral stone.”
“IUP”
The resident says, “The patient has an IUP consistent with dates.” To which I ask, “How old were you when you were a “pregnancy? At less than 8 weeks, you were an embryo. At greater than 8 weeks, you were a fetus. But you were never a “pregnancy” because that is the condi-tion of the mother. There is no such thing as an IUP. It is an IUE or an IUF.”
“Running a temp”
The resident says, “The kid is still running a temp here.” To which I ask, “Do you know under what conditions a child does not run a temp? It is in the morgue!! Do not confuse a tempera-ture with a fever, that is the mistake for which you must educate more than half the parents you see who bring their children in.”
“Hypertensive with a blood pressure…”
The resident says, “And the patient is hypertensive with a blood pressure of 180/100.” To which I ask, “How do you know who much of their blood pressure is due to the disease hyper-tension? If you slap me in the face and take my blood pressure, do I have hypertension? Or am I just in pain, angry, or scared? Do not assume that elevated blood pressures are the patho-physiological state of hypertension.”
“Watch Your Language…”
The next set of terms are “bad language” which is not as much inaccurate as it is presump-tive. The resident physician over-reaches for diagnosis instead of remaining more humble, and legally safer, in their statements of ambiguity.
“GERD or gastritis”
The resident says, “And the patient has a past history of GERD (or gastritis).” To which I ask “Has the patient ever had endoscopy?” (They “forgot to ask”). GERD or gastritis are often trash bucket diagnoses made because the patient needed a diagnosis or they responded to a GI cocktail or an antacid in the past which is a poor predictor of either. The wiser term is “uninvestigated dyspepsia” which leaves the differential diagnosis open to other diagnoses like non-ulcer dyspepsia, peptic ulcer disease, esophagitis, biliary colic, pancreatitis, etc.
“TIA”
The resident says of the 22 year old patient, “And they just got out of the hospital with a TIA ;and had similar symptoms today so we should probably re-admit them.” To which I ask, “How do we know they were hospitalized with a “TIA”? Wouldn’t illicit drugs, seizures, and somatization also have a “normal MRI”? The better term under most conditions is “acute fo-cal neurological deficit - resolved”. The proclamation of an absent disease by a specialist does not necessarily make it more accurate.
“Unstable angina or vasospasm”
Same argument as TIA. Except that when the probability of ACS is very low, your cardiac coordinators want you to use “non-cardiac chest pain.” so they don’t “fall-out” on “chest pain” work-ups. I would avoid the temptation to go either direction in the “chest pain that went away.” In the patient without a heart cath or even in the patient with a heart cath that had “spasm” when the catheter poked the vessel wall, better to diagnosis for accuracy and integrity with “undifferentiated chest discomfort - resolved”. Let the coders worry about the diagnostic
Undifferentiated Abdominal pain instead or “irritable bowel”
The resident says, “All the labs are normal, urine is normal, and the CT of the abdomen with contrast is normal, so I gave them some Bentyl for “irritable bowel”. To which I ask, “Accord-ing to the AGA, how does one make the diagnoses of “irritable bowel”? (and this same argu-ment can be made with the American College of Rheumatology and fibromyalgia). “There are other necessary tests to be done outside the ED before you can use “a diagnosis of ex-clusion”. We underuse the word “undifferentiated” in the ED to include “undifferentiated vomiting and diarrhea” instead of “viral gastroenteritis” and “undifferentiated URI” instead of “sinusitis”, and “undifferentiated headache” instead of “migraine”.
“We are all our children, and our residents.”
The great irony of “bad language” and parenting your children “to use their words” in ways that are more accurate and healthier is they often heard the bad language at home. And in this sense, we are all really parenting and teaching ourselves. It is too easy, especially when you are tired and irritable, to resort to “bad language” in medicine with the lame adolescent excuse, that “everyone else speaks that way and they don’t get in trouble.” Whether medical student, resident, fellow, physician assistant, nurse practitioner, attending, or senior ten-ured professor, we must continue to not speak in certain ways in this house. We should bathe our words in accuracy and humility before they get out of the tub of our frontal lobe. As Will Rogers says, “It isn’t what we don’t know that gives us trouble, it’s what we know that ain’t so.”