a doctor involves learning a new language of medical jargon, technical terms,
and common phrases. In fact, it almost entails learning an entirely new
syntax. Using succinct, clear communication is an important part of
working in a health care team. Often, we use stereotypical phrases which
allow our colleagues to rapidly understand what we are saying.
communication is exemplified by staff in the Emergency Department (ED), a
fast-paced environment where there is no time to mince words. This
article and related podcast by Dr Edwards and Dr
Chalkley give consideration to the particular language used in the ED.
The aim of discussing this language is not to criticise individuals or teams
for its use, but rather to encourage reflection on how we might all communicate
with even greater clarity and respect to both our colleagues and patients, as
well as illuminate how this terminology may be viewed by patients and
ED is a stressful environment which inevitably takes a toll on staff.
Unfortunately, this can be reflected in the language we use. At times,
our language to describe patients may sound almost adversarial, as if we were
trying to distance ourselves from our patients as a protective mechanism.
The language we use can impact upon the way we feel about our patients.
Improving our language is one way of improving the healing and respectful
relationship we aspire to create with our patients.
documentation and verbal presentation sometimes takes a litigious tone. A
commonly used term that demonstrates this is “denies”, for example, “the
patient denied illicit substance use”. This can sound adversarial and
accusatory, and if heard or read by a patient, can give the impression he or
she was not believed or valued.
the term “refuses” can distance us from our patients. This is often in
the context of pain relief, for example, “the patient refused analgesia”.
This could be more accurately phrased as “the patient declined
analgesia”. There is usually a reason for the patient declining an
investigation or intervention. Sometimes this is a communication issue,
or due to preconceived ideas of the patient. For example, some patients are
concerned about masking their symptoms by accepting pain relief (“what if I get
worse and hide it?”). It is our role to enquire with patients about their
reasoning, and to clearly communicate our own reasoning to inform their
decisions. We tend to objectify pain in our patients, and there may be a
perception by staff that if a patient “refuses pain relief”, his pain is not
actually severe enough to come into ED. Pain is a subjective experience,
and different people have different thresholds of tolerance to pain. By
objectifying this profoundly subjective experience, and allowing prejudices or
stereotypes to affect the way we relate to the patient, we are not providing our
is a term which commonly enters our verbal and written communication in the
context of presentations where there will likely be resultant forensic or legal
proceedings. There are clear medicolegal reasons for the use of this term
(e.g. a patient who presents following an “alleged assault”). However, it
is also important to consider that the history is what the patient tells you
has happened. It is acceptable to document, for example, “the patient
states that he was punched in the face”. Our patients will often read the
discharge summary, and if this contains repeated use of the term “allegedly”,
it may once again give the patient the impression that we do not believe him or
her. This may even lead to the belief that the appropriate care was not
provided to the patient at that time. Consequently, this may seriously
damage a core pillar of the patient-doctor relationship, in which each party
should assume truth from the other.
around having patients admitted to hospital from ED can also create barriers
between different hospital teams. An example is “the hard sell”, or
“selling a patient” to an admitting team. The “sell” implies that the
patient’s presentation was not really worthy of an admission, but we couldn’t
think of anything better to do for them. This does not give the patient
due respect for their illness, and it certainly doesn’t give the inpatient
teams the respect they deserve for continuing their specialist care of the
patient. The implication in saying we have “sold” a patient’s story to an
inpatient team is that we have been misleading or dishonest. For the vast
majority of patients, the initial diagnosis made in the ED sticks for the
remainder of their admission, and omitting important information can have a
major effect on the care a patient receives. It is difficult to admit
uncertainties of a diagnosis to a colleague; however, sometimes ED doctors
think this is the only way to ensure the patient receives the best care.
Inpatient teams would often like a patient to be “packaged” (another term which
does not do justice to the complexity of medical care), with all investigations
complete, and management underway. Occasionally inpatient teams may
complain of being “dumped” with a patient (“ED dumped a patient on me”).
This term is disrespectful to the patient, and also implies underhanded
deferment of responsibility. Furthermore, these terms simply do not do
justice to the care provided by Emergency and inpatient staff, and are not how
we would like to hear a family member’s admission being described.
surrounding a patient’s disposition can also be confronting.
Unfortunately, sometimes staff will discuss how to “get rid of” a patient when
they really mean “safely discharge him home.” The more we use phrases
like this, the more we begin to subconsciously internalise the emotional
connotations of these terms, and view our work as an annoyance. Junior
doctors are most influenced by this language. No-one comes to Emergency
because they have “nothing better to do”. People come to Emergency
because they want our help. It is our job to provide whatever the
appropriate help may be, and we should never make people feel unwelcome.
Poor historian or
our documentation may contain controversial phrases such as the disparaging
remark that a patient is a “poor historian”. Our teaching may tell us
that there is no such thing as a poor historian, only poor history-taking,
however many of us have experienced that this is not completely true!
Nevertheless, we must remember that everything we do is guided by the
history. Barriers to communication, such as language or cognition issues,
absolutely must be navigated in order to obtain an adequate history. This
is our responsibility as doctors. Root cause analyses for adverse
outcomes commonly identify poor initial communication as a contributing
negative attitudes which separate us from patients, and hamper our
patient-doctor relationships, are encompassed by the phrase “I don’t know why
he’s here”. To utter this phrase completely misunderstands our role in
our community. We are a public service, whose purpose is to look after people
who are sick, worried, and need our care.
blog does not aim to stigmatise individuals or groups within our hospital
team. Our aim is to encourage reflection on the language we use, so that
our words and documentation mirror the outstanding work that is done in our
Emergency Departments. It is easy to change the terminology we use.
More difficult, however, is to change our culture by gently challenging these
statements when we hear them. There is nothing more important than the
health and safety of a patient’s physical and mental state. When we
consider how we truly care for our patients and how we would like them to feel,
it is abundantly clear that empathetic language is at the core of a respectful
and healing patient-doctor relationship.
This article has been adapted from a podcast by Dr James
Edwards and Dr Dane Chalkley (Emergency Department Staff Specialists at Royal
Prince Alfred Hospital, Sydney), originally published on onthewards on 28 September
2015. For access to the podcast “the language of ED with Dr James Edwards and
Dr Dane Chalkley”, click here.
Avant has partnered with onthewards,
a free open access medical education website, run by junior doctors, and
dedicated to delivering practical, high quality online resources for medical
students and junior doctors.
onthewards was developed to
address the gap in formal education specifically designed for, and aimed at,
What started as podcasts for
junior doctors at Royal Prince Alfred Hospital grew into a website that
improves the availability of online resources for early career doctors. Avant
and onthewards have committed to working closely together to develop risk
management content tailored for junior doctors. For more onthewards articles,
Avant sponsors onthewards as part
of our strategic partnerships program. This article was first
published on June 25, 2017 for onthewards and has been republished with their
permission. The views expressed do not necessarily represent the views of Avant
and Avant is not responsible for the accuracy of any information contained in
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