Increasingly, though, patients like these are in the minority. Today’s typical patient makes many of my colleagues flinch.
Why don’t we like them? Different patients illustrate different aspects of the problem. Cockroaches—patients who come back again and again to the ER and other parts of the hospital—represent failure to doctors. After all, if we’d helped them the first time, why would they need to come back? Swallowers, likewise, represent the failure of the repeat customer—plus the added frustration that comes from being unable to know what makes them tick, much less help them.
We invent the slang terms status dramaticus for anxious patients because they test our ability to quell their anxiety and C-section consent form to vent our frustration with patients who want a say in how things go during labour and delivery.
We dislike bariatric or morbidly obese patients for complex reasons. Most health professionals receive little education to counteract society’s overt prejudice against overweight people. Doctors are no better than the rest of society about seeing obesity as a condition that is entirely self-inflicted. And although bariatric-rated lifts, stretchers and other equipment for heavy patients are on the market, many hospitals fail to purchase them.
Likewise, we don’t like GOMERs or FTDs for complex reasons. Dementia means they can’t answer our questions thoughtfully, if at all. In a health-care system that prizes speed and productivity, old patients slow us down. Most doctors have little if any substantive training in how to recognize many of the unique health challenges facing frail older patients. I suspect we also dislike seniors because they’re manifestations of a future few of us look forward to. And some of us wish they would just die because we believe their continued existence wastes precious health-care dollars and offends the notion of a dignified end to life.
The reasons we invent slang such as cowboy and flea that disparages colleagues are somewhat different. Insecurity over income and status are among the factors that motivate doctors lower down on the food chain to disparage colleagues who are seen as being higher up. A slang term such as hypervaginosis is used to reinforce cohesion within a group and isolation of outliers, as well as dominance by the group’s leadership.
These musings are my opinions on the subject gleaned from more than twenty years as a keen observer of the culture of modern medicine. I doubt many of my colleagues would agree—at least publicly. Let me go one step further. I’d say the vast majority of doctors have given scarce thought to what I’m talking about. That slang exists in such abundance is proof that it’s easier for front-line doctors to express frustration with patients and with each other than it is to talk about what makes them frustrated in the first place.
To be sure, lots of articles have been published in medical journals about what medicine calls the “difficult patient.” Typically, it’s someone who argues constantly with doctors about treatment choices or who never follows the doctor’s advice. But those articles almost always focus on the patient as a difficult person. Almost never do they focus on doctors who dislike their patients.
One doctor who has written openly about dislike for patients is Don Dizon, a cancer specialist and director of medical oncology at the Program in Women’s Oncology at Women & Infants’ Hospital of Rhode Island. In a March 2013 blog published in ASCO Connection, the professional networking site for the American Society of Clinical Oncologists, Dizon wrote at length about a woman in her forties with a newly diagnosed breast cancer who at her first meeting with Dizon got angry that the cancer doctor wasn’t already up to speed on her clinical history.
In his blog post, Dizon says he tried to empathize with the woman. “It must be really shocking to be here,” he told her. “No one our age expects something like this to happen.”
The patient responded with more anger. “Just concentrate on the facts, please,” she replied. “I don’t need your pity. What I want is your expertise.”
Dizon says the relationship went downhill from there. The doctor began to dread his patient’s appointments. He sought the support of his colleagues. “I don’t like this woman,” he told his partners. But they weren’t with him at all.
“You should not say that,” one of them told Dizon. “It’s not her fault she has cancer, and people cope in very different ways.”
Despite the difficulties, Dizon didn’t end the doctor-patient relationship, as often happens. Instead, he forged a more realistic relationship with his patient by acknowledging and processing his dislike.
“Medicine requires us to do what’s in the best interest of our patients, to ‘do no harm.’ It does not compel us, however, to ‘like’ everyone we treat.”
It’s both brave and unusual of Dizon to admit he didn’t like the woman. Far more common is the reaction of knee-jerk admonishment from the colleague who articulated to Dizon an unwritten rule in medicine: You never hate your patients, because you are better than they are, and admitting those feelings says you aren’t. Maybe it’s me, but I sensed something more than disapproval from the colleague—something closer to rejection, a sort of punishment for being honest.
There are strong parallels between the reaction of Dizon’s colleague and the response of organized medicine to medical argot and the pejorative attitudes the slang words represent.
* * *
Twenty years ago, a new force bubbled up in hospital and medical school corridors that threatened to eradicate slang from the known medical universe. It was an earnest movement with the Orwellian name of “medical professionalism.” According to an article published in 2000 in the journal Academic Medicine by early acolyte Dr. Herbert Swick, then the executive director of the Institute of Medicine and Humanities, a joint program of the University of Montana and St. Patrick Hospital and Health Sciences Center in Missoula, Montana, “Medical professionalism consists of those behaviors by which we—as physicians—demonstrate that we are worthy of the trust bestowed upon us by our patients and the public, because we are working for the patients’ and the public’s good.”
Swick listed nine attributes of medical professionalism, including this one: “Physicians evince core humanistic values, including honesty and integrity, caring and compassion, altruism and empathy, respect for others, and trustworthiness.”
Dr. Richard Cruess and his wife and professional partner, Dr. Sylvia Cruess, have become internationally recognized leaders in this burgeoning field. In 1995, both left stellar careers in academic medicine to do research on professionalism. “What we try and do in medical school and during residency training is inculcate the values of the physician so they come to think, act and feel like doctors,” says Richard Cruess.
In sociological terms, what the Cruesses are talking about is helping medical students and residents forge what’s known as a professional identity.
“So what they do is they play the role,” says Richard Cruess. “They analyze what the role is supposed to be.”
“And they analyze it by what they see around them in their role models,” says Sylvia Cruess.
“This is not bright people consciously doing this,” says Richard Cruess. “Most of the time, it’s intuitive. You’re in a culture where there are certain norms and you adhere to those norms.”
And where does this professional identity come from? The Cruesses say some of it goes back to Hippocrates himself. The Hippocratic Oath is filled with ethical standards such as promising not to harm patients and keeping what the patient tells the doctor secret.
When I went to medical school in the 1970s, there were no courses on medical professionalism. It was the same for Richard and Sylvia Cruess, who trained before me. Even the word professionalism was seldom used. I wanted to find out why it became such a priority in the late 1980s and early ’90s.
Richard Cruess says at the time there was a general feeling that several forces were threatening medicine’s traditional concept of professionalism. Sylvia Cruess says one factor was the
explosion in medical technology. “We had many more technical things in our armamentarium,” she says. “The more technical you become, the less you remember that it’s a human being you’re working with.”
Richard Cruess says another factor that underscored the need to spell out the principles of medical professionalism was the growing heterogeneity of doctors. “Life was much simpler in those days,” he says. “You have to remember that most of our society was much more homogeneous. The values were Judeo-Christian. Those values corresponded much more to the values of the professional. There were very few minorities in medical school. Our professors were more homogeneous.”
Since everyone came from pretty much the same religious and cultural background—and shared the same values—it was assumed that everyone adhered to the same notions of professionalism. That’s certainly not true anymore.
Another factor is economic. In Swick’s article in Academic Medicine, he wrote that medical professionalism is “a way to respond to the corporate transformation of the U.S. health-care system.”
The corporate transformation of medicine in the 1970s and ’80s took America from GPs in solo practice to large managed-care institutions, and forced doctors see a lot more patients more quickly. That produces stress, which in turn gives rise to unprofessional behaviour.
“They’re under a lot of stress,” says Sylvia Cruess. “They take it out by using a form of humour and funny language which is often derogatory.”
In response to factors such as these, organizational heavyweights including the Association of American Medical Colleges and the American Medical Association in the United States as well as the Association of Faculties of Medicine of Canada and the Canadian Medical Association threw their weight behind the principles of professionalism.
The leaders of three powerful groups representing internists from the United States and the European Union started the Medical Professionalism Project, which, in turn, introduced the 2002 Charter on Medical Professionalism. Among its three principles (patient welfare, patient autonomy and social justice) and ten commitments—one of which deals with professional responsibilities—came the admonition to “be respectful of one another.”
In the past few years, one medical organization after another has tried to turn the principles of professionalism into policies designed to rid the practice of medicine of unprofessional behaviour. This excerpt from the 2010 Code of Conduct at the University of Illinois at Chicago College of Medicine is typical: “The manner in which we treat each other contributes to effective communication and maintenance of a professional, safe and effective work environment. Our interactions can directly impact patient perceptions of the institution, engagement in their care and willingness to choose us as their preferred care provider.
“Inappropriate communication can create situations where errors are more likely to occur. All individuals have the right to be treated with respect, courtesy and dignity. All practitioners and employees are expected to refrain from disruptive, abusive or otherwise inappropriate behavior towards patients, employees, visitors and other practitioners.”
In addition to policies, most medical schools give seminars to incoming students and residents.
“We spend a huge amount of time on inappropriate, unprofessional behaviour,” says Richard Cruess. “We talk a lot about the importance of maintaining patient confidentiality and not talking in elevators and hallways in ways that will identify a patient.” They also talk a lot about doctors having respect for their patients—and for each other. “Respect is a central tenet of professionalism,” he adds.
To the Cruesses, respect means not using slang, or what they call derogatory language. “One of the concerns is the so-called derogatory language that is used, especially during training,” says Sylvia Cruess. “Calling a patient a cockroach isn’t respectful.”
Notice that when it comes to professionalism, the emphasis is on what the doctor says—not what he or she thinks. Sylvia Cruess says the distinction is important.
“What you think is what you think, but what you say in public reflects on the whole profession,” she says. “So we try and give them a reason for not using this sort of language in public. It may damage the trust that people have in the health-care system and in physicians in particular.”
It’s unclear to me how thinking something pejorative but not saying it in public is any less damaging than saying it aloud.
In addition to admonishing students and residents, Richard Cruess says there’s a new emphasis on rooting out bad role models.
“I’m aware of an institution where a surgeon actually lost his operating privileges because of persistent bad behaviour,” he says. “I won’t name the institution but the chair of a major department in a major northeast American medical school lost his job because of bad behaviour which didn’t appear to be remediable. I’m absolutely positive that would not have happened fifty years ago. Probably not twenty-five, either.”
* * *
I’m all for rooting out abusive attending doctors. Putting good medical role models into positions of influence seems like a no-brainer as well. But admonishing young ones not to speak disparagingly about patients and each other seems both counterproductive and strangely out of touch.
Do parking tickets get you not to park illegally? How about a tongue-lashing from a parking control officer? Didn’t think so. So, then, how do you expect young doctors to respond when the slang police issue them a summons for dishing argot on an elevator? Frankly, anyone who thinks that’s going to work doesn’t understand the culture of modern medicine.
One woman who does is Dr. Vineet Arora, associate program director for the Internal Medicine Residency at the University of Chicago. Arora is an academic hospitalist who supervises internal medicine residents and medical students, and serves as a career mentor to both. Her research focuses on medical professionalism, resident duty hours, patient handoffs and the quality of medical care. Her blog FutureDocs is must reading if you want to understand the culture of medicine that fosters medical slang.
“Professionalism Is a Dirty Word . . . And Why Are Medicine Docs Called Fleas?” That’s the headline on a 2010 blog post. Arora wrote that while attending a meeting put on by the Association of American Medical Colleges on how to put quality into teaching hospitals, she heard speaker after speaker asking “how to address the fact that doctors in teaching hospitals don’t get along.”
Wrote Arora: “Unfortunately, all the specialty bashing that takes place prevents the adoption of a team-based culture necessary to advance quality and safety. As one speaker highlighted, how can we really start to address this topic when specialty services are busy blocking the consult . . . or disparaging the internal medicine doctor by calling them a ‘flea’? I hadn’t heard the term ‘flea’ in a while, but many onlookers were nodding in agreement, possibly thinking about the last time they heard someone disparaging the ER for an incomplete workup or a specialist blocking the consult as ‘inappropriate.’ The discussion about quality and safety morphed into every medical educator’s favourite topic, ‘professionalism.’”
I can understand that doctors in practice who are long past their medical formative years might reject medical professionalism and embrace medical slang and other forms of patient and colleague disrespect. On the other hand, given the power medical schools wield over students, I’d expect that group to be at the forefront of change. Wrong again, according to Arora.
“Ironically, while medical educators love discussing professionalism, this word has become despised by medical students,” she wrote back in 2010. Far from embracing it, Arora says, senior medical students at the school where she teaches regularly lampoon medical professionalism. Arora thinks she knows why. “As you can guess, any efforts to ‘teach professionalism’ to students seem preachy and insincere.”
One man who understands the pushback from students perfectly is Fred Hafferty, director
of the program in Professionalism and Ethics at the Mayo Clinic in Rochester, Minnesota. Hafferty is a medical sociologist who, more than anyone, has explored the hidden curriculum of medicine—the stuff that’s passed from doctor to doctor yet is seldom, if ever, set down in textbooks.
Hafferty suggested I check out Absolutely American: Four Years at West Point, a 2003 book by David Lipsky that follows cadets from raw recruits to graduation. Hafferty says the clear message he got from the book is that breaking the many rules at West Point is what recruits do for fun.
To Hafferty, if medical professionalism is all about the rules, then slang represents breaking them.
“You’re not supposed to talk about certain things in elevators,” says Hafferty. “I mean, we have signs all over [the Mayo Clinic]. I wouldn’t be surprised at all that within environments focused so much on saying the right thing, that saying wrong things in ways that nobody recognizes would be great fun. And I mean that sociologically. If I was a student, it would be great fun to figure out how to dance around this without having faculty realize that they’re dancing around.”
Duke University respirologist Dr. Peter Kussin has championed the use of slang throughout his career. He worries that professionalism’s focus on slang as derogatory ignores its therapeutic value to those on the front lines of medicine. “In the ICU, my greatest fear is that when I crack a joke in front of the [patient] room and everyone laughs—even if the joke has nothing to do with the patient—they’re going to assume I’m laughing at their loved one,” he told me.
“The inability to laugh on rounds in an environment like our ICU, where there’s very little to laugh about, is going be tragic and injurious to safety and to the quality of care. You need to have those moments where you take a little break and reset, and the humour does that and the slang is the quickest way to get to the humour.”
More than that, calling in the slang police is like outlawing basements because some get flooded. Telling students and residents to keep slang to themselves may sanitize the public hospital discourse, but it doesn’t get at the root causes of slang.
The Secret Language of Doctors Page 32