Words, Words, Words

Polonius: What do you read, my lord?

Hamlet: Words, words, words.

—William Shakespeare, Hamlet, Act II, Scene II: 191-194

Because Hamlet wishes to feign madness or simply to disguise what he is reading from Polonius, he implies that whatever the words, they don’t matter. Of all people, however, Shakespeare used words for their explicit and multiple meanings, knowing that specific connotations could determine courses of action. In medical practice, our choice of words can be most critical. They can convey hope or despair, progress or inertia, life or death. In this column, I am concerned with the language that we, as physicians, speak to each other and to, or not to, our patients.

Several hundred years ago, physicians spoke in Latin to each other to discuss a case secretly and in order to have patients admire them for their wisdom. Doctors also found it convenient to obfuscate diagnoses by naming afflictions in Latin. Thus, a reddish rash of unknown origin was not called “a reddish rash” but designated as roseola; chest pain was angina pectoris. Certain words for incurable afflictions of the time were spoken only to close relatives or persons of authority, but hidden from the patient. In the last century, and in some circles, even today, the diagnosis of cancer is kept from the patient. In my youth, polio was a word often only whispered, as in prior centuries was the verdict of syphilis.

But what about the words we use today in common conversation with other health care professionals and with our patients: words with double entendres, words with subtle interpretations, words of subterfuge, words with lethal connotations, words of expectations good and bad, words of joy, and words of sorrow.

For certain of the thoughts expressed in this column, I am indebted to my colleague of many years, Mary E. Knatterud, PhD, who has written extensively on the impact of language in medical practice. A word Dr. Knatterud and I greatly dislike is “elderly.” “Elder” means a person advanced in age, and has, in the past, been a sign of respect. The specific starting age for this designation is not defined. “Elderly” has become almost the opposite of “elder,” implying infirmity of body and/or mind. Other dictionary synonyms for elderly are venerable, aged, declining, hoary, long in tooth, no spring chicken, over the hill. In general, these synonyms are neither favorable nor laudatory; they imply that the elderly are no longer in the vigorous fullness of life and that somehow this is a transgression warranting a loss of respect. In another column with the title “Live Fast, Die Young” [GSN, May 2017, page 1], I emphasized that ageism is the formative basis for age discrimination. I reminded the young among us that if they are lucky, they, too, will one day be old.

I do not wish to imply that age is irrelevant in medical and surgical practice. A person’s age may be a critical factor in determining a diagnosis or therapy. For example, a person with significant changes in motor function at age 65 is unlikely to be exhibiting the onset of cerebral palsy and is more likely to be developing Parkinson’s disease. Women with the onset of breast cancer at age 25 versus ages 55 on to 85 require a different constellation of therapeutic considerations. However, a woman at age 85 should not be denied the appropriate range of therapy because of her age.

In my career, I have seen being designated as elderly used as justification for passive euthanasia. I have witnessed care conference decisions for withdrawal of active therapy and maintenance of comfort care only until death, based on the patient’s being called “elderly.” I have seen surgeons I respected deny therapy based on the patient being elderly or old. I once did a Whipple procedure for a carcinoma of the head of the pancreas on a 90-year-old and was severely criticized; however, happily, the patient lived an active life into her late 90s.

Another term Dr. Knatterud and I find alien in taking care of patients is “manage.” Dr. Knatterud in the AMWA Journal (2020;35[3]:129-130) wrote, “I find it imprecise and disrespectful to posit patients as inanimate things or unruly kids or hapless subordinates to be managed by the powers-that-be.” Patients are to be cared for as fellow sentient humans, with dignity and compassion, with respect, courtesy and regard, with the empathy they are entitled to by their offer of faith in us, their physicians.

Two of the darkest words in the medical lexicon are “terminal” and “incurable.” A physician, a person of knowledge, who speaks those words to a patient is pronouncing a death sentence. Though we must at times make that pronouncement, we must do so with the greatest compassion, recognizing that life per se is terminal and that someday all of us will face the pronouncement of terminality. We must emphasize the time remaining and help the patient live the best life possible with the knowledge that we, as their doctor, will be there for them.

Incurable is less an expression of knowledge, than an apology for helplessness. Syphilis was incurable; diabetes was incurable; certain cancers were incurable. There was no surgery for congenital heart disease, obesity and its attributes. These afflictions are now curable, yet today, the list of incurable diseases is just as long and just as dramatic. We can’t cure the multitude of neurocognitive functional impairments; or Crohn’s disease, ulcerative colitis, or irritable bowel syndrome; and the many causes of deafness and blindness; or the huge spectrum of autoimmune diseases; and so on.

If we must tell a patient that his illness is incurable, we need to add the word “today.” We can recite to the patient diseases that were once incurable but that today are not. We can offer visions of cure as more effective therapy in their lifetime is developed, possibly fairly imminently. We need to portray hope not defeat; providing patients with the best palliative therapy available and the belief that better is to come.

Recently, a 17-year-old I know was introduced to living with type 1 diabetes after a frightening episode of hypokalemic ketoacidosis that required emergency hospitalization. Her excellent diabetologists talked to her about lifelong glucose monitoring, insulin administration, and avoidance of diabetic complications. I talked to her about the future: islet cell transplantation free of the disadvantages of immunosuppression therapy by treated xenografts, organic polymer encapsulation, and islet cell transformation of her own polypotential embryonic cells. I told her that these “cures” will likely be available in her future.

Within the realm of medical research, the word “incurable” should be followed by the word “yet.” It should represent not a barrier, but a challenge. A plethora of incurable infections, from strep throat to leprosy are now curable. Once polio and today malaria were incurable, but the polio vaccine now prevents the former and, recently, the first malaria vaccine has been produced and is about to be introduced.

Finally, I want to call attention to the term “idiopathic,” derived from Greek roots. Idios means “one’s own,” and pathos is a “disease.” So, idiopathic is, “a disease of its own,” or a disease with no identifiable cause. We certainly have many of those! In using this term in a discussion with a patient, most physicians hide behind the word and pronounce it as if it portrayed some universal knowledge rather than universal ignorance. Would it not be more honest to say, “I don’t know why you have atrial fibrillation,” rather than “you have idiopathic atrial fibrillation”? The same is true for pulmonary fibrosis without determinable cause, and so many other diseases currently labeled idiopathic.

Comparable terms that hide ignorance and attempt to portray wisdom are “essential” and “primary.” What is the purpose, other than obfuscation, of diagnosing “essential hypertension” or “primary immunodeficiency disease?” These terms are themselves nearly as harmful to the mental perspective of physicians as are terminal or incurable. They convey complacency and acceptance of the status quo rather than dissatisfaction with the lack of knowledge professed. We require the inquisitiveness to learn, explore, research, to abolish words of concealment and replace them with words of knowledge.

The most important words spoken to patients take place in the examining room in an atmosphere that should be imbued with courtesy toward the patient. A smile, a post-COVID handshake or a touch of the shoulder, and certainly greeting a patient by name, should start an interaction with a patient. Talking to the patient is ever so preferable to talking about the patient to associates in the room. Personally eliciting a patient’s history and performing a physical examination establish rapport. Above all, concentrating one’s communication on the computer in the room rather than the patient is a poor substitute for care, for doing the job of a physician. The doctor–patient relationship is a unique bond whose tone and boundaries the doctor establishes.

Words are among our best tools in establishing empathy between doctor and patient. In a health care world under the control of administrators, a world of robots and frustrating receptionists, designated hours, prescribed patient management, loss of physician independence, the doctor (not employee) is left in control only of the few moments allowed for patient interaction. In this minimal timespan, the patient should not be treated as a client to be managed. These are the few moments for words to tell the patient that his/her problem, though serious, does not preclude a rewarding lifetime remaining, whatever its length. These are the few moments to explain that though the etiology of the problem is as yet unknown, you, as their doctor, will do your best to ascertain and overcome their affliction. These are the few moments for empathy. Only by empathy for the patient does the physician warrant the patient’s trust in return, and the designation of being—a healer. The right words matter.

---

Dr. Buchwald is a professor of surgery and biomedical engineering, and the Owen H. and Sarah Davidson Wangensteen Chair in Experimental Surgery (emeritus), at the University of Minnesota, in Minneapolis. His articles appear every other month.

Editor’s note: Opinions in General Surgery News belong to the author(s) and do not necessarily reflect those of the publication.

This article is from the December 2021 print issue.