The terms we're supposed to use in healthcare are changing rapidly, but are they becoming too politically correct? It seems that in our passion to get it right, we may be getting lost in a semantic frenzy.
I was scolded last week by San Francisco surgeon Verna Gibbs for using a two-word phrase. I quoted her as saying providers need to find better ways to assure they don't leave surgical sponges in 'our patients.' That possessive construct should be stricken from the healthcare vernacular, she said.
Why? I asked, unnerved.
"Because we don't own people," the former co-chair of the UCSF Medical Center Patient Safety Committee replied.
Gibbs elaborated in an e-mail:
"Residents and medical students have been taught for generations that they have to think of the patient 'as theirs' and 'own' them. Vestiges of paternalism and slavery anyone? Is it right to even think that we can ever 'own' another human being?" She added that "these possessive constructs" make "it difficult for much needed team-based, multi-specialty complex care to proceed because of communication hurdles, as in 'What do you think you're doing to my patient?!' "
The reprimand was off-putting, but it got me thinking how the Affordable Care Act's penalties and incentives, talk of medical homes and accountability have set the stage for a linguistic battleground. We're starting to argue about individual words, but perhaps forgetting what the fight is about.
In his blog last week, New York Times' columnist Paul Krugman tossed a well-phrased grenade at the misguided trend to call people seeking care 'consumers' instead of what they are, 'patients,' and give them vouchers assuming they know exactly what they'd be buying.
"Medical care is an area in which crucial decisions — life and death decisions — must be made; yet making those decisions intelligently requires a vast amount of specialized knowledge; and often those decisions must also be made under conditions in which the patient is incapacitated, under severe stress, or needs action immediately, with no time for discussion, let alone comparison shopping," he wrote.
"The idea that all this can be reduced to money — that doctors are just people selling services to consumers of health care — is, well, sickening. And the prevalence of this kind of language is a sign that something has gone very wrong not just with this discussion, but with our society’s values."
I understand the motive behind this semantic urgency to empower patients to have more say in their care process and choose where and what kind of care they get. But in my opinion, most patients are the last to know where to go to obtain care or whether high quality services are being delivered.
Let's be honest. How does anyone receiving care know whether the right tests were ordered, the right diagnosis given, the correct drugs prescribed or that the surgery went without a hitch? They don't. There is no "Consumer Reports" for this year's model of care from St. Hospital. People need to rely on medical professionals to guide them to the correct course.
Of course, transparency in value ratings for hospitals and doctors and price lists will help a lot, but they may be out of date, not readily accessible or risk-adjusted and irrelevant when you're gasping in the ambulance.
Yes, providers need to listen a lot better than they have been. And patients need to feel it's okay to ask questions. But still....
I asked Robert Wachter, MD, Associate Chairman of the UCSF Department of Medicine for some perspective, and he articulated some of what I have been thinking.
"I like calling them 'patients,' and I don't like calling them 'consumers,' " he says. "It feels like we're selling cars, and we don't have a fiduciary duty. Like we're a vendor. And if we can trick them into buying a fancier car, we do. That's not the way we or other physicians think about what we do."
This new kerfuffle, he says, represents "the reflection that this healthcare universe, metaphorically, is like a bunch of plates and utensils on the table and someone just pulled the tablecloth out. And they're all flying in the air and it's not clear what will land upright and what will tumble to the ground and break. During stages like that, people essentially juggle for power in the realization that the status quo is not going to be the future."
"No one pays attention to words when attitudes toward the words, or power or politics or money that flow around those words, are unimportant," he says.
Paul Levy, former CEO of Beth Israel Deaconess Medical Center in Boston, weighed in last week on his blog, "Not Running a Hospital," (when he altered his blog profile. Instead of being an advocate for 'patient-centered care,' he now is an advocate for 'patient-driven care.'
He says it's to reflect the idea that "clinicians should do their best to collaborate with patients to understand their needs and desires and to jointly design plans of care that are as consistent as possible with those needs and desires."
Wachter took issue with that. "We have to be so careful we don't go so far in the other direction that in fixing one problem we're creating another. 'Patient-driven' feels like it's too far in the opposite direction, and diminishes and marginalizes the role of healthcare professionals, who spent a lot of time trying to gain a kind of expertise and experience that is there to benefit the patient. It makes it appear that they almost have no role."
Levy replied that he knows things are in flux. "But one thing that is pretty certain is that there will be a greater role for patients than in the past. I differ with Bob when he suggests that the formulation I present in any way diminishes or marginalizes the role of clinicians. Not so at all. It suggests, though, that those clinicians will need to expand their repertoire of skills to learn how to appropriately bring patients into the conversation about planning their care..."
Yes, clinicians do spend a lot of time gaining expertise, "but patients also spend a lot of time -- indeed their whole life -- learning and gaining experience about their own bodies and their own needs. It does not take away from one group to suggest that the other has something important to offer to the process of disease prevention or care."
And the ball is bouncing on many other healthcare terms, as well.
- In his blog awhile back, Levy used the word 'non-compliance' to describe a patient who doesn't take medications as prescribed. He too was corrected by a doctor who commented that the preferred term is 'non-adherence,' "which does not have the same power implications and insinuation of blame as the word 'non-compliance.' "
- Wachter says CPOE, which used to stand for 'Computerized Physician Order Entry,' has been changed to 'Computerized Provider Order Entry,' "because physicians are not the only ones writing these things called orders."
- Even the word "orders" is controversial, he says. It's now accused of summoning an "era where physician gave orders and everyone around them was expected to follow that. Now, the effort is to soften that and build in a term that celebrates collaboration," he says.
- Now some want to call physicians or nurse practitioners both 'providers.' "Some believe calling out professions individually continues to validate silos, when what we need is a continuum of different kinds of providers or caregivers, and there's no bright line between what a nurse practitioner or a physician can do; a legitimate argument if you're trying to create a team in a medical home concept," Wachter says.
- Lately, I've heard that some providers want to phase out terms like 'discharge' and 'handoff.' Instead of a discharge planner, the person receiving care leaving a hospital would instead be the responsibility of "a transition team." Could it come to this: "Good news, Mrs. Smith. I'm your transition planner and I'm here to give you your transition instructions."
- There's even an evolving lingo to describe medical mistakes. Wachter says Ken Kizer, founding president and former CEO of the National Quality Forum, first called them never events, "and the stakes began to grow, because the implication is that these things should never happen in healthcare and therefore everything we can do to promote that view, from not paying for them to requiring that they be reported to authorities or transparently available, all that became legitimized when you call them never events."
In fact, 'never events' "is a misnomer," he says. "Because while some of them for sure should never happen – leaving a sponge in the belly and cutting off the wrong leg are never events – clearly there are things on the list that we don't completely know how to prevent. Yet by packaging them under this name of never events, it becomes a political statement that drives a political process forward," Wachter says.
"Now the pendulum is swinging back. Now, they're called just 'events' or 'adverse events' or 'hospital-acquired conditions,' because calling them medical mistakes was too pejorative," he says. "The risk of all of this is that eventually, no one knows what these words are supposed to mean."
Oh, and on the sponges. In my story, I called them 'retained foreign objects.' Wrong again, Gibbs says. They are "retained surgical items" because they are not foreign, nor are they objects like bullets put there by someone's violence. These are items put inside the consumer by the surgeon, 'er, I mean provider.
This debate over what we call things, "it gets exhausting," Wachter says.