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October 3rd, 2013

Choosing Words Wisely

Paul Bergl, M.D.

“What do you think, Doctor?”

For a novice physician, these worlds can quickly jolt a relatively straightforward conversation into a jumble of partially formed thoughts, suppositions, jargon, and (sometimes) incoherent ramblings. Even for simpler questions, the fumbling trainee does not have a convenient script that has been refined through years of recitation. Thus, many conversations that residents have with patients are truly occurring for the first time. And unfortunately, this novelty can result in poorly chosen words that can have lasting effects. An inauspicious slip of the tongue could significantly alter the patient’s perceptions and decisions.

A recent study in JAMA Internal Medicine highlighted the connection between the words we choose and the actions our patients take. As Dr. Andrew Kaunitz reported in a summary of this article for NEJM Journal Watch, avoiding the word “cancer” in describing hypothetical cases of DCIS resulted in women choosing less aggressive measures and avoiding procedures like surgical resection. Dr. Kaunitz notes that the National Cancer Institute has also recommended against labeling DCIS as “cancer.”

I believe this recent study raises a major question at every level of medical education, particularly during residency. How do we counsel our physicians to counsel patients and communicate effectively? How do we choose words that appropriately convey the urgency of a diagnosis without scaring our patients into unnecessarily risky treatments?

I was fortunate to have gone to a medical school where our course directors were forward-thinking. Our preclinical curriculum included mentored sessions with practicing physicians and patient-actors. We were taught how to use motivational interviewing to facilitate smoking cessation, how to ask about a patient’s sexual orientation and gender identification, and even how to use the SPIKES mnemonic for breaking bad news.

Yet all of these simulations can never really prepare a trainee for the first time he or she is on the spot in the role of a real physician with a real patient. Counseling patients requires subtleties; no medical school curriculum could possibly address every situation. But as the above-referenced study by Omer at al. confirms, subtleties and shades of meaning matter.

Of course, not every situation that requires measured words will be so dramatic. The words we choose for more benign situations matter, too. How do I define a patient’s systolic blood pressure that always runs in the 130-139 mm Hg range? Do I tell him that he has “prehypertension,” or do I give him a pass in saying, “Your blood pressure runs a little higher than normal”? Would this patient exercise more if I choose “prehypertension”?

What do I say to my patient with a positive HPV on reflex testing of an abnormal Pap smear? “Your Pap smear shows an abnormality” or “an infection with a very common virus…” or “suspicious cells” or “an infection that might lead to cancer someday…” What effect will it have on how she approaches future abnormal results? How might she change her sexual habits? How might she view her partner or partners?

These days, med schools and residency programs are being increasingly taxed by the competing priorities in educating the 21st-century physician. As technology rapidly threatens to usurp our expertise in many domains of practice, communication will remain a cornerstone of our job. Communicating with patients will never be passe; no patient wants to be counseled by a computer. We must master these vital communication skills.

Unfortunately, studies like Omer et al. only touch the tip of the iceberg. How do we empower patients with information while not scaring them? When should we scare them with harsher language? How and where do we learn to choose the right words? And who decides?

Even a perfectly designed training system could not tackle all these questions. But perhaps we ought to be exposing our trainees to simulated conversations in which subtle word choices matter. Let’s face it: We could all do better at choosing our words wisely.

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Priya Umapathi, M.D.

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