The Secret Language of Doctors

by Brian Goldman

  * * *

  Poetic or crude, the slang doctors use in hospital to talk about each other serves an important yet largely unspoken purpose: it reinforces a kind of tribalism.

  We enter medical school as equals. We take the same courses and pass the same exams. But then we enter the various residencies. And by the time we’re finished with that part of our training, we belong to a tribe of “Us” separated from all other tribes, to be regarded forever as “Them.”

  For example, ER physicians like me see internists and surgeons not as colleagues but as people we have to persuade to accept the patients we refer to them. When they give us a hard time by asking too many questions, we get our backs up. We get defensive. Often, we feel humiliated. In the same way, we see radiologists as people who have the power to say yes or no to that CT scan of the abdomen we need to diagnose appendicitis or at the very least to cover our butts by proving to an anxious and possibly litigious patient that she has nothing serious going on inside her belly. In our worst moments, we see radiologists as doctors who don’t practise real medicine because they sit in a dark room all day looking at pictures.

  At the same time, internists, surgeons and radiologists don’t see ER physicians and other specialists as their equals in medical knowledge and in the ability to make diagnoses that they find easy but people like me find difficult. Sometimes, different specialists see each other as competitors for patients and sometimes even as adversaries.

  Cardiologists may feel superior to internists just as neurosurgeons think they’re a cut above their less-trained “colleagues” who take out your appendix. They believe they’re a much higher form of primate in the hospital zoo. Family doctors and ER physicians feel insecure and inferior next to their specialist colleagues. And residents often feel abused and persecuted by their attending physicians. The slang doctors use to describe each other only symbolizes the differences among us. Money, power and influence are the envy factors that reinforce those differences.

  In his 2008 book Us and Them: The Science of Identity, author David Berreby says humans are hard-wired to form connections with one another based on trivial commonalities; Berreby calls that ability “kind sight.” What’s astonishing is that the seeds of the vast differences between groups of physicians can be found in those tiny commonalities. Kind sight is in our human nature because it was once necessary for our very survival. It’s difficult to argue that sort of motivation should exist between surgeons and internists in the twenty-first-century hospital. But it does.

  It comes out in the way doctors talk—especially the slang we use to describe each other. This sort of talk goes on everywhere doctors and other health professionals ply their trade, from the lowly clinic in rural Arkansas to the most sophisticated of tertiary-care facilities.

  In addition to serving up some of the most well-respected health care in the U.S., one hospital I visited serves up something else: a healthy dose of medical slang—some of it used to describe colleagues in less than flattering terms.

  The anesthesia residents’ lounge there doesn’t look like much; a three-by-five-metre room with a desk, a couple of desktop computers, a printer, two sofas and some chairs. Still, it’s a refuge where residents in anesthesia can relax between cases in the OR—and grouse about their surgical colleagues on the other side of the surgical drape.

  “Portraying the surgeons as butchers or carpenters or mechanics is probably not unfair,” says a third-year resident in anesthesiology.

  I’m seldom shocked to hear that sort of rush to judgment from residents like the two anesthesiologists I spoke to at this particular hospital. But I was more than a bit surprised to hear something similar from an experienced attending physician.

  It’s 8 a.m., and I’m attending rounds in one of the hospital’s intensive care units. There are sixteen rooms—each containing a very sick patient decked out with a ventilator, a urinary catheter, one or two central venous lines, an arterial line and some plain old intravenous drips as well. A veteran attending specialist in critical-care medicine is leading a large and unwieldy pack of seventeen health professionals, including residents, nurses, speech therapists, a registered dietitian and a respiratory therapist. Rounds are a daily ritual in which the team discusses extraordinarily complex care plans that keep the patients alive.

  “The patient’s vitals are stable and so is his urine output,” says a senior ICU resident who acts as second-in-command. “He still has a nasogastric tube in. He’s got so much suction coming back I think we can kill the Lasix.”

  Translation: The patient is doing well except for the fact that he has a poorly functioning bowel that is causing his intestines and his bloodstream to fill up with fluids—so much so that he was given the powerful diuretic Lasix to keep his lungs from filling up with water. Now he’s becoming dehydrated and the resident wants to discontinue the Lasix.

  Up to that point, the resident has spoken about the technical patois of critical care. Suddenly, he adds an observation that pricks up my ears. “The vascular surgeon decided to put the patient on some chicken heparin,” he says. Members of the group smile.

  I’m quite sure no doctor anywhere—much less the highly respected ones who practise at this top-flight centre—administer any medicines to patients that are derived from poultry. It sure sounds like slang to me. I pull aside the attending physician for a translation.

  Chicken heparin is a term used “when the surgeons are too chicken to fully anticoagulate the patient,” says the ICU attending physician.

  To anticoagulate means to give the patient a medication like heparin to make the blood less likely to clot. The meds are called blood thinners and they’re used to prevent patients who have had surgery from forming blood clots in the legs that can travel to the lungs and cause a potentially fatal complication called pulmonary embolus.

  The ICU attending physician was accusing the surgeon of ordering a dose of heparin too low to actually prevent clots. “They want the patient’s blood not to clot but they’re afraid to go all the way.”

  Spying the chicken surgeon in a corridor of the ICU, the attending doctor steps away from the team to confront him about the order for chicken heparin. After five minutes, she comes back with a wide grin on her face.

  “I told him I’d like to see the data supporting the use of low-dose heparin,” she triumphantly tells the assembled team. “He replied, ‘There is no data.’ Asking people for data is the polite way to ask what the heck they’re doing,” she adds with a smile.

  As a sincere inquiry, asking for data is part of sharing the latest medical knowledge. But asking for data when you already know that there is none is code for “You don’t know what you’re talking about.”

  The message was not lost on the ICU team. The attending looked smart and prudent; the vascular surgeon looked foolish. That sort of petty rivalry is not unique to this particular hospital. And if that sort of talk happens there, believe me, it happens everywhere.

  * * *

  In their 1961 article, Hukill and James were among the first to hint at the emerging rivalry between internists and surgeons. The authors noted that a specialist in internal medicine was known back then as a pill pusher, in sharp contrast to a surgeon. Clearly, the term pill pusher was used by surgeons to dismiss the work done by their colleagues in internal medicine. And, just as clearly, non-surgeons got in a little dig at their surgical colleagues. The phrase knife-happy made it onto the list compiled in the 1961 article. Analogous to trigger-happy, knife-happy refers to a surgeon who is overeager to take a patient to the operating room.

  “The rivalry between surgeons and non-surgeons goes back,” says Dr. Grumpy. “I mean it’s even mentioned in the Hippocratic Oath. It’s old.”

  You can’t talk about the rivalries between various kinds of physicians without talking about the money they make. According to a 2012 survey by Medscape/Web M.D., the top U.S. medical money earners
on average were radiologists and orthopedic surgeons at $315,000 a year each; cardiologists earned $314,000 a year, with anesthesiologists and urologists rounding out the list of high rollers at $309,000 a year.

  At the other end of the scale, psychiatrists earned $170,000, diabetes specialists $168,000 and internists $165,000, followed by family doctors at $158,000 and pediatricians at $156,000.

  There is no doubt that the higher the pay, the greater the respect—often grudging—among colleagues. And let’s not forget the envy that doctors feel toward other physicians who make a lot more money than we do. Income is the lightning rod for medical argot about competence and work habits of physicians.

  You’ve heard of the road to success? Dr. Ryan Madanick, a gastroenterologist at the University of North Carolina School of Medicine in Chapel Hill, says the acronym ROAD has become a telling slang word in medicine. It stands for “radiology, ophthalmology and orthopedic surgery, anesthesiology and dermatology.”

  “Those five fields are the road to financial success,” says Madanick. They are also targets of professional envy. “This is especially true among internists, family practitioners, pediatricians, psychiatrists [and] OBGYNs: that you go into a field like dermatology, and the same with radiology, because it’s easy work and it’s lots of money. I’m not going to say that other groups don’t work, but they get less financial remuneration for their mental work or for the time that they put in. I would certainly love to make the money that they do for the amount of time that they put in per patient per procedure or what have you, but it’s not the field I chose.”

  Peter Kussin says he refers to rheumatologists as ruminologists, because they ruminate, and dermatologists as derma holidays. “I think a lot of it has to do with workload. The lighter the perceived workload of a specialty, the more ribbing they’ll take and the more slang that will be directed at them.”

  I think Kussin is right. When I did rotations in rheumatology and dermatology, I was rarely on call and always got a good night’s sleep. We called those slack rotations.

  The rivalry between groups of physicians is a natural reflection of our competitive personalities. In med school, it’s all about who gets the top marks. Then we graduate.

  “All of sudden, you’re in a job or a specialty or a practice,” Kathy Grichnik says. “How do you continue to achieve? How can I make myself better? Unfortunately, the historical culture has based this on ‘getting better marks’ than another physician.”

  Getting marks ends with medical school; the drive to establish superiority over colleagues can last a lifetime. Income, a stock portfolio, a Ferrari in driveway or a yacht parked at the marina is the attending doctor’s equivalent for top of the class.

  But there may be more to the sniping than envy and competitiveness. Sometimes it reflects genuine concerns about another physicians’ competence.

  One doctor I know refers to that sort of criticism as a “back- channel M and M.” M and M is slang for the morbidity and mortality conferences held regularly in hospitals to discuss cases in which concerns have been raised that a poor patient outcome (death or injury) was caused by suboptimal medical care. The conferences originated in the early twentieth century at the Massachusetts General Hospital in Boston. At M and Ms, the case is discussed anonymously and without blaming or punishing the people involved. The objective is to discover mistakes and correct them so as to prevent them from happening again.

  “It’s an ongoing M and M where we comment on their foibles and they comment on our foibles,” says my colleague. “This is a way of us maintaining sort of back-channel quality control.”

  Unspoken or not, reputations matter in all walks of life—including medicine. Every clinical ward has a jungle telegraph that tells us what we think about the reliability, bedside manner and—last but not least—the clinical acumen and competence of our colleagues and everyone else we rely on when we’re taking care of you.

  A 1993 article in the journal Social Science & Medicine by Robert Coombs and colleagues referred to Gomer Doc and Fossil Doc as physicians who haven’t kept up with recent medical developments. An HST refers to an uptight attending physician with “high sphincter tone”—a tight-ass. A private physician with a bad reputation for killing patients is known as Double O Private—a riff on the Ian Fleming character James Bond, code name 007, who famously has a licence to kill.

  To appreciate that part of hospital culture, a good way to begin is to pick up on the slang.

  * * *

  One of the most enduring bits of medical argot doctors use in less-than-flattering ways is calling each other “cowboy.” The quintessential cowboy used to be a general surgeon. Today, surgeons of all kinds can earn the label.

  “A cowboy is someone who rides by the seat of his pants,” says Dr. Grumpy. “It’s someone who kind of does things quickly. You’re trying hurriedly to do everything in a somewhat haphazard fashion, hoping like hell it all comes together correctly at the end. Cowboy is also used to refer to a surgeon who perhaps doesn’t have the best judgment—someone who operates first and asks questions later.”

  Unlike romantic notions of the Wild West cowboy, when the term is used in medicine, it’s an insult.

  “To me, a cowboy is the worst thing you can be called,” says Dr. Erin Sullivan, a newly graduated physician from Ireland’s University of Limerick who returned to her native Canada in July 2013 to do a residency in rural family medicine in Saskatchewan.

  One ER nurse knows all about medical cowboys. She remembers working with a doctor who she called a cowboy because he did invasive procedures—usually without local anesthetic and definitely without warning. “We had a kid who came in with an abscess on his neck,” the nurse recalls. “The kid was sitting on the mom’s lap and the doctor had a scalpel in his hand. And he just said, ‘Look, at your mom.’ The kid turned and he literally plunged the scalpel right in the neck. The kid obviously flipped out.”

  When the nurse reproached the doctor later that day, he said the alternative was to restrain the child by wrapping him in a blanket and pinning him to the stretcher. The possibility of giving pain relievers and sedation by intravenous drip or at least injecting the skin over the abscess with local anesthetic had obviously not occurred to the doctor. “Those people I find are the most frightening to work with,” she says.

  Surgical resident Dr. Christopher Kinsella has a reflective take on cowboys. He defines a cowboy as a surgeon undertaking a risky operation for marginal benefit in which the patient bears the consequences. “In one sense, it’s my risk. But if I fail, the person who suffers is you,” says Kinsella. “If you’re making those types of decisions on behalf of your patients, it’s almost always inappropriate. And that’s what makes you a cowboy.”

  I find Kinsella’s take startling; for a young surgeon to accuse colleagues of operating with reckless abandon is unusual.

  * * *

  The common slang term for orthopedic surgeons is orthopods. It doesn’t sound like an insult to me, but it does to them.

  The term “doesn’t go over well with orthopedic surgeons,” says Peter Kussin. What makes it an insult is its similarity to the word anthropoid—animals in a category that includes apes and gorillas. It suggests that orthopedic surgeons are a step behind in evolutionary terms. In hospital corridors, Kussin says, orthopedic surgeons are often referred to by unflatteringly as knuckle scrapers and knuckle draggers.

  Back inside the anesthesia residents’ lounge at one of the top hospitals in America, a first-year resident told me about a cartoon skit on YouTube called “Orthopedia vs. Anesthesia” in which an orthopedic surgeon proposes to fix a broken bone on a dead patient. The message is clear: orthopedic surgeons like to operate so much it clouds their judgment.

  “I feel bad for picking on the orthopedic surgeons, but oftentimes you’ll get these 90- or 100-year-old patients who need a hip pinning,” says a third-year anesthesiology
resident. “And they’ve got 100 co-morbidities and [take] 1,000 medications. These patients couldn’t tell you their own name, much less the date or the time.”

  More and more, the job of caring for the non-orthopedic medical needs of such frail elderly patients goes to specialists in internal medicine, says a resident in internal medicine. Once when he was on call, he was asked to see an elderly woman just back from the operating room, where an orthopedic surgeon had fixed her broken hip. That night, she was agitated and so the orthopedic surgeon ordered an injection of five milligrams of haloperidol, an antipsychotic drug used frequently in hospitals to sedate disruptive and violent patients.

  “You come to see the patient in the morning and they’re completely snowed and the tone in their muscles is completely stiff because of the medications,” says the resident. “You try and find the surgeon [for an explanation] but they’re in the operating room, so you can’t talk to them.”

  FOOBA, which stands for “found on ortho barely alive,” describes this situation. Some doctors call it FDOOBA for “found down on ortho barely alive.”

  “There’s this basic perception that orthopedic surgeons are very good technicians at fixing bones and doing the procedures that they do,” says Dr. Zubin Damania. “But other than that, they know not a lick of medicine.” Damania’s duties as a hospitalist include handling the medical stuff (as he calls it) that his orthopedic colleagues fail to do. “A lot of times you’ll get a call and the patient is barely alive [on the orthopedic ward] because they’ve already screwed things up so much that by the time you stumble onto the case, you’re basically trying to undo all these horrible things done by neglect.”

  An experienced internist I know says he’s seen many patients in orthopedic wards who have been put into heart failure because their surgeons gave them too much IV fluids, causing shortness of breath. Then they call on my colleague to save the patient. “It’s always the same thing,” says the internist. “They don’t even know that they caused it.”