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If there’s one thing medical sociologist Fred Hafferty wishes, it is to hear first-hand what doctors and other health professionals say when they let their guard down. “I want to be in a room where the conversation is about the hidden curriculum,” says Hafferty, “where nobody knows me.”
For the past thirty years, I’ve been in that room. George Rutherford introduced me to medical slang when I was a resident. As a career ER physician who has treated more than 60,000 patients, I’ve heard the coded words spoken by residents and students and trusted colleagues—and I have experienced the attitudes from which those words were uttered. And now I reveal what I have learned about the culture of medicine to you.
The Secret Language of Doctors is not an urban dictionary of medical slang. Many such informal collections of terms can be found on the Internet. To present such a glossary is to imply that all doctors speak slang all the time. I have met many colleagues who never use such terms. More important, in my view, slang is not the problem but the symbolic language that reveals much about what ails medical culture and what needs to be fixed.
I have selected argot that is either typical of many hospitals or particularly revealing about critical aspects of medical culture. My mission is to take you inside the Bunker so that you understand more about our innermost thoughts, attitudes and feelings about modern health care.
Each chapter takes you to a different part of the hospital—from the Emergency Room to the Labor and Delivery floor and from the psychiatry ward to the intensive care unit. I even visited jails and prisons to learn about medical culture in places like those.
In researching the book, I interviewed hundreds of attending physicians, residents, nurses, paramedics and students. In some cases, I have protected their identities. I am grateful to all of them for allowing me to tell their stories in this book.
I have interviewed noted experts in internal medicine, critical care, surgery, obstetrics and gynecology, anesthesiology, nursing and paramedicine. I also interviewed some of the leading thinkers in medical ethics and medical professionalism to find out what they think of medical slang and how they propose to eradicate it. And I tapped into the expertise of some of the world’s best and brightest medical sociologists—especially those who have unpacked the hidden curriculum.
Some of the source material for the book comes from interviews that I did for White Coat, Black Art. Quotes that are taken from interviews that aired on the show are acknowledged as such. Portions of interviews used in the book that did not air on the program are not acknowledged. In some cases, I conducted interviews intended originally as source material for the book and subsequently used excerpts of these interviews on the show. Again, in such instances, White Coat, Black Art is not acknowledged as the original source for the interview.
To protect patient confidentiality, identifying details have been limited or altered. In some cases, patient stories are composites. My first book—The Night Shift: Real Life in the Heart of the ER—depicted a typical night shift in the emergency department at Toronto’s Mount Sinai Hospital—where I have worked for over twenty-five years. The Secret Language of Doctors is not about what goes on at Mount Sinai Hospital but rather about what goes on in hospitals across North America.
As a reader of this book, you may come to know what your doctor really thinks about what’s wrong with you, your personality, even your chances of making it out of the hospital alive.The Secret Language of Doctors is also a book filled with extraordinary stories of doctors who battle personal and professional obstacles and demons while working to save patients beset by illness and injury. Many of the stories will make you laugh. Some will make you cry. Others will make you angry. However you feel, the next time you find yourself in a hospital elevator with a group of doctors, you’ll keep your ears pricked.
But first, let me take you to meet the Harvard-trained physician whose megahit novel introduced generations of young MDs to the world of medical slang and made it cool to speak it.
2. Slangmeister
When it comes to modern medical slang, there’s Before Shem and After Shem. Shem refers to Samuel Shem, the pen name of Dr. Stephen Bergman, psychiatrist and author of the blockbuster novel The House of God, which introduced millions of readers—and generations of doctors—to the argot that is the lingua franca of residents and interns then and now. I call Bergman the Slangmeister because until he arrived on the scene in 1978 with his satirical novel, little had been published about medical slang.
The House of God gave the public the first insider’s look at the underbelly of hospital life, revealing the hazing, abuse and psychological damage inflicted on medical interns back then and introducing the public and generations of doctors—especially young ones—to a jarringly new kind of medical slang. In doing so, Bergman shook the culture of modern medicine to its very foundation.
By far the most important argot to come from The House of God is the term GOMER—an acronym for “get out of my emergency room.” In his book, Bergman describes a GOMER as a patient who is frequently admitted to hospital with “complicated but uninspiring and incurable conditions.” It’s unlikely there’s a doctor who has graduated since The House of God was published who hasn’t heard GOMER used in that context.
And there are lots more where that came from. Turf is a verb that appears frequently in the novel; it refers to finding any excuse to refer a patient to a different department or team. Buffing a patient means sorting out medical problems like dehydration before trying to turf. Bounced is slang for when a patient who has been turfed is returned to the department or team that turfed her in the first place. Turf and bounce are used everyday in hospitals across North America; I hear residents at the hospital where I work use them all the time.
Bergman not only introduced those terms, he also acted as a purveyor and catalyst of modern medical slang. Generations of doctors have been influenced and instructed—some might say infected—by Bergman’s work. Many of the terms invented since his book was published have their roots in his original slang.
My visit with Bergman in October 2012 at his home in Newton, Massachusetts, a picturesque patchwork of thirteen villages eleven kilometres west of Boston, was like going on an archeological dig through slang history. Bergman and his partner, Janet Surrey, live in a rambling brick building bordered by an old stone fence and with an even older gnarly tree in front. I entered through a back door into a massive white kitchen, where I found Bergman standing beside a large rectangular table, peeling and eating a grapefruit with gusto.
Bergman shook my hand with a strong grip. He looked a bit older than his publicity photos—as if he’s gotten leaner as he approaches the end of his seventh decade of life. He appeared comfortable in jeans and a charcoal grey, round-necked T-shirt. He has lost almost all of his hair on top. He had longish hair on the sides and a neatly trimmed beard—both of which were nearly white. Bergman’s expression was kind and peaceful. He seemed at ease inside his own skin.
“Have you got a good agent!” Bergman exclaimed almost as soon as we shook hands. He said he’d had lousy agents over the years. As proof, he said that numerous publishers rejected The House of God before Richard Marek/Putnam published it. Despite an uncertain beginning, the book has been in print continuously ever since.
I first heard about The House of God during my final year of medical school in 1979, just a year after it was published. When my senior resident, George Rutherford III, asked how many patients I’d “boxed” on my first night on call on the cardiology floor at the Hospital for Sick Children, the year was 1980, just two years after The House of God was published. Rutherford mentioned the book by name, which made me want to read it. Meanwhile, more and more fellow residents read the book and were starting to quote from it.
After finishing his grapefruit, Bergman—born Jewish but now a practising Buddhist—led me out the back door into the garden and along a path that led
to an old two-storey carriage house at the back. He took me up a narrow wooden staircase to a large attic, where he has his office. He sat at a large rectangular desk; behind him, shelf after shelf was crammed with books.
I felt as if I were meeting the proverbial man behind the curtain. I was in the presence of the Wizard: the Great and Powerful Doctor of Medical Words. I asked him many things, but what I wanted to know most of all was where he got the vivid slang he used in The House of God. How many of the words were taught to him in medical school and internship? After all, if generations of interns and residents read The House of God and learned slang like turfing and bouncing from Bergman, then Bergman must have borrowed argot he heard on the hospital wards in much the same way. Bergman’s answer was startling.
“Well, I don’t think actually any of them were taught to me when I was a medical student,” he said. But when he started his internship at Beth Israel Hospital in Boston in 1973–74, “GOMER was in use. I didn’t invent that. I did invent GOMERE (pronounced “go-mare”), which is the female. Either I invented most of the others in the novel when I was writing it or I did so joking around with some guys. I can’t remember now which is which, but buff and turf, I think that was sort of a group thing that evolved. I’m sure I thought of the bounce. The thing is, it’s one thing to have this language. I codified it. I took it further.”
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Bergman took a nascent secret language and made it deeper and broader than ever before. Until The House of God, almost nothing had been published on medical slang or on the culture of medicine from which it came.
One of the closest I found was an article published in 1973 in the journal American Speech by Philip C. Kolin, an American author, poet and currently a University Distinguished Professor in the College of Arts and Letters and professor of English at the University of Southern Mississippi in Hattiesburg. In an article titled “The Language of Nursing,” Kolin noted the growing number of medical dramas on television—such as Medical Center, Marcus Welby, M.D. and M*A*S*H—that were being “eagerly received by the viewing public.” Kolin—an outsider to the world of medicine—was the first to observe there was something more to the language than efficient communication of highly specialized information. He noted that nurses used dignified language when speaking to patients but exercised less caution in collegial conversation. Kolin wrote that a hospital gown is sometimes referred to as a “monkey jacket,” and that “chandelier syndrome” refers to the tendency of a patient startled by the coldness of a stethoscope on the skin to jump toward the ceiling.
I can remember hearing a variation of that phrase during my training. We called it “the chandelier sign.” More than one attending or resident gynecologist taught me that a doctor could diagnose a woman with pelvic inflammatory disease (PID) by demonstrating that her cervix was tender to touch and therefore inflamed. As he explained it, the way to determine if a cervix is tender is to don a lubricated glove and wiggle the woman’s cervix from side to side. The official name of this finding is cervical motion tenderness. The slang phrase made me cringe then, and still does.
In Kolin’s article, patients with alcohol dependence were called alkies. Those with drug addiction were labelled ads. Nurses called patients with manic depression (now called bipolar affective disorder) manics, and referred to those with schizophrenia as schizzes. Commonly, they described patients agitated by psychiatric disorders as bouncing off the walls; such patients were placed in a quiet room, or QR, until their agitation settled. Such slang terms tell me that non-psychiatric health professionals back then were as mystified and threatened by emotionally disturbed patients as we are today. The only thing that has changed is that it’s no longer considered politically correct to use such terms.
Kolin also discovered a nickname for what was then called electric shock treatment (EST). He wrote: “When, as frequently occurs, their doctors order an EST ‘electric shock treatment,’ the nursing staff say they are going to zap a patient.” Today, EST is known as electroconvulsive therapy (ECT). It is a psychiatric treatment that induces a seizure in an anesthetized patient for therapeutic benefit. Although considered controversial by some, ECT is recognized as a valid treatment for severe depression that hasn’t responded to antidepressants and other therapies, as well as for mania and catatonia.
What surprises me about the use of the slang verb to zap a patient is its wider cultural context. Ken Kesey’s novel One Flew Over the Cuckoo’s Nest—set in an Oregon psychiatric hospital and featuring graphically disturbing descriptions of patients receiving ECT—had been around for eleven years by then and even adapted into a Broadway play. Just two years following the publication of Kolin’s article, an Academy Award-winning film version of the novel was released.
The early twentieth century brought the first references to modern medical slang. A 1927 article, “Hospital Talk,” by Dorothy Barkley, published in the journal American Speech, introduced phrases such as scrub nurse and scrub room to the public. But Barkley also captured some pointedly unflattering terms. “A woman physician invading a profession dominated by men,” wrote Barkley, “is a hen-medic, and, in many minds, is schizy to do such a thing. [Schizy], culled from the term schizophrenia, means much the same as the colloquial crazy.”
Dorothy House, in her 1938 article “Hospital Lingo,” also published in American Speech, was one of the first to identify a hierarchy of medical trainees. She wrote that although they were both medical school graduates studying at a hospital, residents outranked interns by reason of experience. Often, interns were known as house men. She wrote that the newest intern “may be assigned to routine laboratory tests and called a pup or junior.” Today, we call them scut dogs—scut work referring to the endless paperwork and other tasks that residents consider beneath them.
House wrote that patients who were critically ill and near death were on something called the DL, or danger list. I’ve heard of DL signifying keeping things on the down low or referring to a baseball team’s disabled list, but I’ve never heard that use of DL in medical circles.
In a 1961 article, Peter Hukill and James Jackson wrote about “an extensive, informal language” they referred to as argot, slang or cant. Much of it was technical. An electrocardiogram was shortened into an ECG or EKG, an intravenous into an IV and morphine sulfate into MS. A lunger was a patient with a chronic lung disease such as emphysema or tuberculosis, and a stroker a patient with a stroke. Hukill and James wrote that the word terminal was used to describe a patient approaching death, but it is passé these days because laypeople know what it means. But the jargon term pre-terminal—as in pre-terminal cancer—is still used widely.
Hukill and James cited two examples of pejorative argot. Out in left field was slang for a patient who is disoriented or out of touch with reality, a phrase still used by health professionals. The most astonishing piece of slang on the list is crock, which the authors defined as “a patient who complains continually of multiple symptoms, many of which are either imaginary or of psychic origin; one whose complaints are out of proportion to his illness.” I’ve been hearing patients described as crocks since I was a medical student.
But those were sporadic examples. For medical slang as reflected in the novel by Bergman and in the academic writings of Kolin to take off, some wholesale changes in the culture of modern medicine had to occur.
The era after the Second World War brought incredible transformations to health care. Surgeons carried out the first successful heart, lung and liver transplants. Vaccines for measles and rubella were developed. Birth control pills and the intrauterine device ushered in an era of sexual freedom. In 1964, the U.S. Surgeon General first linked cigarette smoking to lung cancer, emphysema and heart disease.
But amidst the awe and wonder of new medical discoveries, a growing cynicism was bubbling just under the surface of medical culture. Thalidomide, an anti-nausea and sedative drug, was introduced as a sleeping pill in the late 19
50s; doctors began to prescribe it to pregnant women for morning sickness. The drug was withdrawn after numerous reports of catastrophic birth defects. Advocates for victims of thalidomide say the drug affected more than 10,000 babies worldwide. Canada has the dubious distinction of being the last country in the world to pull thalidomide from pharmacy shelves.
The drug was never approved for use in the United States. However, there are twenty-six known American thalidomide victims. Although the Food and Drug Administration was lauded for keeping thalidomide off American pharmacy shelves, the experience in other countries led to tougher regulatory standards. The lasting legacy of this episode was that it underscored the capability of pharmaceutical drugs and other “wonders of modern medicine” to do great harm—a lesson that would be repeated again and again in the decades to follow.
The 1960s and ’70s also brought tumultuous changes to the health system. Canada introduced universal health care in 1966, and health care became the fastest growing industry in the United States in the ’60s. Doctors went from seeing themselves mainly as healers and maintainers of their patients’ health to running their practices like businesses. As you’ll see, these developments put in place some of the conditions that made medical slang flourish in the 1980s.
During the ’60s the United States experienced a violent political era that included the civil rights movement, the Vietnam War, the assassinations of President John F. Kennedy, his brother Robert F. Kennedy and civil rights leader Dr. Martin Luther King, and the Watergate scandal that led to the resignation of President Richard Nixon in 1974. Bergman was a member of the generation of students that came of age during that time. They believed in the power of protest as a force to correct injustice. Their protests helped end the Vietnam War and helped create civil rights laws.
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