UNFORGETTABLE: PATIENTS’ PERSPECTIVES ON THE UNINTENDED (AND THE UNEXPECTED) IMPACTS OF PHYSICIANS’ SPEECH

Shakespeare famously sought immortality through his words (“When in eternal lines to time thou grow’st”). A review of the (mostly non-medical) literature suggests that similarly ambitious physicians should be careful what we wish for, at least when it comes to the words we use in the presence of patients. Show me an illness narrative and I’ll bet it contains negative attitudes towards a doctor’s unwittingly insensitive speech.

In her poetic memoir, Two Kinds of Decay, Sarah Manguso writes, “When I told my hematologist I was worried about dying, he smiled and said, ‘Look, here is the smallest violinist in the world playing you a Dvorak violin concerto,’ as he rubbed his index finger against his thumb.”

Describing her own critical illness in In Shock, ICU physician Rana Awdish recalls overhearing a disturbing exchange between her physician and her husband while she was still intubated. Dr. Awdish had developed massive hemorrhaging towards the end of her pregnancy, and the two men were coolly strategizing about the best way to break the news that her baby had died.

“They don’t think I can hear them,” Awdish reflected, describing an asymmetry familiar to most anyone who’s donned a hospital gown and submitted to the practices and parlance of medicine.

In What Patients Say, What Doctors Hear, the internist Danielle Ofri explores the barriers to communication that prevent physicians from fully apprehending their patients’ concerns. The gulf between what doctors say and what patients hear is equally wide and fraught with opportunities for awkwardness and misinterpretation, which explains why most physicians who wound with words do so unknowingly.

A group of palliative care clinicians writing in the Journal of Patient Experience¹ tells the story of a nurse who underwent spinal surgery in the setting of metastatic cancer with the hope of becoming eligible for additional cancer treatments. The surgery went well and there were no post-operative complications apart from unexplained tachycardia, the cause of which was finally discovered by the palliative care consultants on post-op day five.

When the patient heard her care team refer to her “morbid obesity,” she had been mortified and became preoccupied with the fear of dying of respiratory arrest in her sleep. When she overheard them refer to her “terminal cancer,” she was devastated and confused, believing that her prognosis had suddenly changed and that she had been kept in the dark. As the patient suffered in silence, those caring for her remained unaware of the pain their words had inflicted.

Raymond Carver’s poem, “What the Doctor Said” renders this irony most poignantly. As the title suggests, the doctor does most of the talking, opening with “it doesn’t look good” in reference to a scan that revealed innumerable tumors, then launching into soliloquy on the role of spirituality in hard times. The awestruck patient says little before the visit concludes with the following:

I jumped up and shook hands with this man who’d just given me

Something no one else on earth had ever given me

I may have even thanked him habit being so strong

That possible thank you haunts me. How many patients have thanked me for levelling them with language, and how often have I mistaken their words for praise?

If physicians can be forgiven for lacking insight or for problematic phrasing never intended for patients’ ears, it’s harder to understand the persistence of so many bizarre and, in many cases, patently offensive terms in our hospital rooms and clinics. In a recent Atlantic article,² “Please Don’t Call My Cervix Incompetent,” Rachel E. Gross notes that while medicine has done well in recent years to retire such labels as “sickler” and “drug abuser,” the habit of objectifying and blaming patients has been harder to kick when referencing pregnant peoples’ bodies. She cites incompetent cervix, hostile uterus, and habitual aborter among other examples of this tendency.

This reminds me of the time that my wife’s obstetrician warned against excessive weight gain during pregnancy by employing the metaphor of a “ship in a bottle,” a phrase he repeated several more times as I scanned the room, making sure that any potential weapons were beyond the petit patient’s reach.

I would describe that visit as unforgettable. My wife still thinks I’m being too kind.

Speaking of metaphors, the linguist and physician Britt Trogen has written² about their utility in helping physicians to better communicate complex ideas. Trogen notes that although physicians who routinely employ metaphors are rated as better communicators, not all metaphors have the intended effects. For instance, patients who embraced the “chemical imbalance” model for depression were found to be more pessimistic about their prognoses, to have lower expectations for treatment, and to be more likely to rely on pharmacology than psychotherapy.

If one oncologist were to describe cancer treatment as a battle while another was to frame the experience as a journey, would a patient’s attitude, experiences, and even clinical outcomes differ? It’s a hard question to study; it’s also safe to assume they might.

If evidence to guide optimal phrasing is lacking, physicians are becoming increasingly aware of how not to speak and write. All manner of labels invites framing biases that distort clinical reasoning and judgement. And it’s clear that the use of stigmatizing language, regardless of intent and however subtle, leads clinicians to develop negative attitudes towards patients and can even influence prescribing behavior.⁴

Dr. Julia Raney and colleagues have published a toolkit for cultivating mindful language to limit the transmission of bias in clinical settings. If physicians made a habit of reviewing their five key questions⁵ (Does [this language] cast blame? Does it reinforce a stereotype? Does it include extraneous information? Does it include a pejorative? How would my patient feel if they [heard] this?), we might also improve the patient experience.

That physicians’ words have such power is a function of our status compounded by the vulnerable position in which we encounter our patients. And our words can do more than wound, demoralize, or bias.

When I was 21, I developed seizures caused by a symptomatic arteriovenous malformation in my right temporal lobe. My parents and I sought the best surgeon in our area and connected with a pioneer of endovascular neurosurgery who had a reputation as both a magician with a catheter and a butcher of bedside manner. After multiple procedures and months of recovery, I visited him in his office for follow-up. He burst into the room, muttered a few pleasantries, and performed a brief neurologic exam. Then, he shook my hand and said, “Well, you never have to see me again,” hurrying away as hot tears stung my cheeks.

That sentence is more than 20 years old, but I’ll never forget it.