Yesterday afternoon I sat in a dark room with a couple of doctors and several mental health professionals and participated in a video conference about integration of primary care and behavioral health. Outside, the late summer sun shone brightly just like it did September 11 eight years ago.
The case for integration is obvious; 85% of the time the ten most common symptoms brought to the attention of primary care doctors (chest pain, dizziness, fatigue, back pain and so on) have no known somatic explanation – the cause for the symptom appears to be psychological.
Yet, the words we use to interview patients, to document the history and physical examination findings, and to present our thoughts to our patients and to our behavioral health consultants are often extremely unhelpful and sometimes downright insulting to the patient.
It seems the place to start integrating primary care and behavioral health is with our everyday choices of words we use to describe the patients we see in our offices.
The days are essentially gone when doctors spoke in technical terms to each other and other medical professionals with the purpose of keeping the patient in the dark. For example, very few of the old prescription-related Latin phrases are still being understood and used by doctors and pharmacists, and most preprinted prescription pads no longer feature the optional “label” box, which in a bygone era gave the prescribing physician the option of not revealing the name of the drug to the patient.
We are nowadays cautioned to clear our vocabulary of words which we as physicians have used and understood to mean something perfectly neutral in clinical language, yet can be offensive to patients, who increasingly often end up reading their own medical records.
In my years as a physician I have read many chart entries that read something like this:
“This pathetic 57 year-old woman returns with a litany of complaints, and seems to completely lack insight into the real cause of her misery…”
Those are words that, perhaps, may insulate a doctor from bad feelings about his/her inability to help such a patient, but they aren’t likely to help the patient manage their symptoms or psychological issues, and they ultimately don’t belong in a therapeutic relationship.
This is not Orwellian Newspeak; our words can heal, and they can hurt. These are some examples of conventional doctorspeak and suggested alternatives from the video presentation by Alexander Blount, Ed. D.:
Chief Complaint = Main Concern
Suffers from = Struggles with
Refused to take = Decided against
Was noncompliant with = Didn’t see the value of
Didn’t keep appointment = Wasn’t able to be here
Arrived late = Was determined not to miss
There is a lot of talk these days in the U.S. about the Patient-Centered Medical Home. It begins here; with the way we see our patients as the center of the clinical work we do, indeed the justification for our own existence as doctors in our communities.
A Country Doctor Writes: 
As a first year med student who is thinking of family care, these seem to me to be words worth remembering, certainly more important than knowing which amino acid is mutated at the 6th position for sickle cell anemia.
Ah, yes – which amino acid was that again?
Glutamate to valine. I know you were dying to remember that.
Thank you! All this information I could read all day. all the knowledge overwhelms me. The writings are so caring and written with compassion with some humor mixed in, I like that. I have experienced a frontal lobe brain stroke…an emotional stroke caused by a very abusing husband using psycological and emotional abues as not to leave any cuts or brusing on my skin to be seen by others. I looked up the medically term for my condition. There was a bacteria in my heart that traveled to the keeper of my emotions in my brain and all the emotions broke down ( no matter how hard I tried to fight the abuse) i understand my condition. I am healing and Praise God The best healing I get besides prayer is “Bluegrass Music’ ther I find solace and forget about the bad in the world and get lost in the artist and their music. …Blue Ridge Mtn Girl.
this is a very provocative article.
the critical quote and the interpretation in its entirety is as follows:
” ‘This pathetic 57 year-old woman returns with a litany of complaints, and seems to completely lack insight into the real cause of her misery…”
‘Those are words that, perhaps, may insulate a doctor from bad feelings about his/her inability to help such a patient, but they aren’t likely to help the patient manage their symptoms or psychological issues, and they ultimately don’t belong in a therapeutic relationship.’ ”
i think the interpretation isn’t completely off but i think it misses quite a bit as well.
The fact is, that most physicians, even the most empathic and concerned, will likely agree that the physician writing those words is likely telling the truth. an udder can produce only so much milk of human kindness.
i recall from my house-officer days – when things were a good deal more loosy goosy – competing with other residents for the most ”witty”’ topic sentences for chief complaints…
let me be really candid, how about: ”this is the 65th admission to the XXX medical wards for this 57 yo patient well known to the emergency room who comes in comatose smelling of cheap wine” is that empathic. i don’t think so.
is that also insulation from the inability to really perturb the trajectory of this awful situation ? i think so.
is it a critical means of trying not to feel the tragedy and pain of a situation in which the young physician has no serious hope of ‘making a difference ? i think so too but saying about such a physician “they don’t belong in a therapeutic relationship….” well perhaps that is a bit sanctimonious.
I think of the joke : ” how many psychiatrists does it take to change a light bulb?” the answer being : ” one, but the light bulb really has to want to change”. i think there are situations where it is arrogant indeed to imagine that the physician’s intervention is going to bring about change. we all treasure the times when that effort HAS made a difference and we all need to generally keep trying but i think to honestly own the fact that we can’t accomplish much on behalf of some souls is not unworthy of a physician.