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Jun 9, 2023Liked by Camilla Alderighi

What is the purpose of a medical note? According to JAMA Patient Page (11/2021)

(JAMA. 2021;326(17):1756. doi:10.1001/jama.2021.16493), the purpose of a medical note is to "provide succinct and straightforward documentation and communication between doctors", and in that same article, "to communicate information among health care professionals, not between doctors and patients". The medical note is a documentation of the observed facts as the physician sees them, and as such, is typically devoid of emotion. It should be read in the same manner as well. The words chosen are not meant to offend or insult, and usually are following a format that is typical of a medical note. The issue here is the reader. The health care professional is usually aware of medical terminology and reads the information without further interpretation than what is recorded. A patient or family member would likely read it and interpret the same information differently. And therein is our problem.

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I honestly don't understand how one would make it through a work day in a timely fashion if they must consider the detailed substance of every office note. If you are rethinking and second guessing a multitude of phrases that you have somehow decided might be offensive or defeating for a patient, it must be a slow process. The way we all get through our day is a compilation of the habits we've developed over our professional life. In 30 years, I've never had anyone comment on "denies" or "diabetic". The medical record or office note is not a novel or inspirational essay we are writing for people. This is not a daily "affirmation" or anything that a patient should take that much from! I don't think patients gather their self-worth or identity from an office note! If you are a truly caring physician, interested in people in general, fully invested in your patient - that is what people respond to! writing "a person experiencing diabetes in an uncontrolled fashion" is no more "affirming" than "poorly controlled diabetic". "denies" is not a "charged" term - the office note is not questioning the veracity of a patient's experience - it is simply one person capturing what another is telling them, generally trying to be quite neutral.

I see this trend of doctors focusing on the minutiae of "affirming" language - lets face it: doctors are not that influential in every person's self worth on that level. Yes, a doctor who treats people with disrespect or contempt can be quite harmful. Basic medical language is not in that category.

I would say patients should be more alarmed when they read "dot phrase" templated notes with detailed physical exams that were never done and all the other "garbage" that ends up in an office note these days. Getting to this level is not something to waste time or energy on.

And aren't we on the verge of AI writing our office notes for us? As it should be. The situation we are currently in, where the physician is responsible for "scribing" the interaction between two people - what other professional situation requires that? AI should gather pertinent data in a neutral fashion, form it into exactly what is needed by each stake holder in the process and the note should be done by the time the physician and patient leave the room. THAT will transform medicine. Not doctors overthinking each descriptor and word in the office note.

In the meantime, why not just let the patient write out their part and they phrase it however they want? The speed at which medical care needs to be done these days does not leave anyone time to write out a "medical vignette" for every encounter.

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Dr. H, you make a good point but I don't think the authors' intent was to advocate for scrupulous writing. Rather, to just be as accurate as possible and avoid concealment, distortion and the like.

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Medical language is simple. The more drugs, vaccines, tests, procedures and mRNA substances you use, the quicker your life will end. There is no reason to trust medical journals and standard medical advice. It is all tainted and geared toward promoting the use of more and more drugs. The entire medical establishment does not know squat about curing diseases or helping people live healthier. Otherwise, they would cure you and you would never need to be on endless drugs for life.

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author

Thank you for the comment. The reference to the phrase "patient denies" comes from an article in the British Medical journal (2022), which we cited in our piece: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9273034/.

Quote from the article: "In medical documentation, doctors sometimes use language that questions the authenticity of a patient's symptoms. For example, they often translate the reported absence of symptoms or experiences as the patient 'denying' symptoms - for example, 'patient denies fever, chills, or night sweats.' To deny is to refuse to admit the truth or existence of something, and the term can hint at untrustworthiness. In a study examining reactions to outpatient notes, patients responded negatively to language that questioned the validity of their experiences."

The negative connotation is similar in Italian as well.

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Nobody is "questioning the validity of their experience"! The patient is the only one reporting this, is the only one able to report this. This isn't a courtroom document being reviewed by a tribunal to decide which side is right! To be more succinct and simpler, many doctors just write: Review of systems positive for: (or negative for:) - it just lists out what symptoms the patient is telling the "stenographer". "denies" is a common phrase in a medical note - not a value judgement on a person.

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Thanks for providing the reference.

That BMJ paper is political correctness/wokism run amok, and is not research in any substantive or medical form. It’s little more than an opinion piece with a litany of anecdotes.

I agree that the content of a medical record belongs to the patient, and they have a right to access it. But in so doing, they should expect medical language, and should have no expectation that physicians record interactions in colloquial vernacular. The burden is on them to understand the language as it is used medically. They’re reading a medical record, not their diary.

Hence, for example, “deny”:

https://www.merriam-webster.com/dictionary/deny

Websters does list the colloquial definitions, but entry 5 is the “medical” definition...which, as we all know, is simply “reporting the absence of”. This is how we use the word professionally. And if a patient chooses to read their chart, they should read it in a manner that befits the intent of the entrant in a clinical context.

The next bit is comedy. The “dr” doesn’t simply “claim” “to hear a diastolic murmur”. He/she, as the person entering data into the medical record, heard it. That is not debatable; what is debatable is whether he/she was correct in their auscultation. Or, from another angle, it should be assumed that everything written in a medical record reflects the writer’s opinion. To suggest a need for adding the word “claim” is simply redundant.

Objections to “poorly controlled” or “non-compliant” are examples of projecting by the lay reader. If you didn’t follow instructions, you didn’t follow instructions. There’s no included accusation that you didn’t try your best. If you A1c is 10%, your problem is not one of being judged by your doctor.

The one area where I would concede the point is with “treatment failure”. Framing such events as “the treatment failed the patient” is the one useful takeaway I will have from a paper that belonged in a tabloid rather than an esteemed medical journal.

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"Whether these perceptions or resulting shifts in therapeutic relationships translate into meaningful differences in patient outcomes, however, is not yet known...it is not clear whether using more empowering language will change clinical outcomes". Perhaps there should be evidence of clinical outcomes before (more) low value nit picking of medical staff begins?

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Those who concern themselves with things like “words are violence” and related euphemisms are unlikely to demand evidence at a higher level than anecdote.

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author

"Denies"- I would simply rephrase as "he says he didn't have chest pain" etc..

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I don't think this will mean anything to a patient.

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founding

I have many thoughts, but I will start by addressing the statement that physicians emphasize the advantages over the disadvantages of a given test or treatment. Of course we do. We are offering things to our patients that we believe will benefit them. Has someone ever started a discussion with a patient by saying, "Here is a test or treatment, but I think the costs are greater than the benefits. " ? I would not offer something to a patient unless I think it is to their advantage.

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I rather think the point is that- at the end of the day- it is for the patient to make the cost-benefit analysis and therefore their own decision. A physician who omits to clarify the potential cost, is by default overselling the benefit, and is therefore misleading the patient. Plenty of real world examples, famous cases, current issues that one could cite.

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The strong form of Whorf's hypothesis -- that language determines thought -- is nonsense. OTOH, the weak form that language influences thought is widely accepted. As such, it is quite appropriate that inflected languages, such as Italian, get away from identifiers that assume all attorneys are male or all teachers are female. For English, using "firefighter" instead of "fireman" is reasonable.

Even so, I harbor a concern that wokism will demand, by penalty of law, grammar based on unscientific genderism that require some ridiculous forms such as "nursepersons" Wokism already requires absurdities: For instance, in OB wards using "mothers" or "pregnant women" is hate speech!

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Certainly agree with the point about “framing” in patient discussions. Even though we say patients get to make decisions (as opposed to the overt paternal routines of the past), how we frame those discussions still unavoidably steers them in our preferred direction. It would require the physician to convey complete neutrality, which could be the ideal, but likely unattainable….since we generally would prefer one course of action over the other.

OTOH, I don’t agree with the suggestion of biased language with some of the examples given. If your A1c is 10, I don’t know how else to describe that besides “poorly controlled diabetic”. Just like if your urine tox screen is positive for cocaine, my note will say “cocaine user” and not “person with coke in tox screen”. Part of that is just for sake of brevity. Why say with 6 words what you can say with 2? Same with “pt denies something something” vs “pt said she did not something something”.

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author

Thanks for your comment. If a patient has an HbA1c of 10, in the medical records - which are also read by the patient - I would write "poorly controlled diabetes" instead of "poorly controlled diabetic". As for the phrase "the patient denies", I used this expression in the past, without giving it enough thought. Then, I happened to read my own clinical notes as a patient and I sensed a subtle distancing effect created by the verb "denies" that, even unconsciously, influenced trust. Since then, I have been striving to be more mindful of my language.

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Dr. Alderighi, I wonder if something is getting lost in translation here. Are you speaking of the phrase "the patient denies" in its Italian equivalent, or in English? I don't speak Italian, but I can easily imagine that some phrases in one language may carry a more pejorative connotation than the "equivalent" words in another language, and perhaps that's the case here.

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Thanks for your response.

I cannot imagine any medical professional would infer “poorly controlled diabetic” to mean anything other their diabetic control. The occasional hypersensitive pt might impute some comment on their overall self, which requires a simple re-orientation….and probably a separate note record as to such proclivities.

How would one rephrase “pt denies”?

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Jun 1, 2023·edited Jun 1, 2023

Complete neutrality is a fantasy. The best we can do is "own" what's going on under the hood when we use something like "diabetic" (e.g., what is diabetes and what are things that look like diabetes but aren't? Is A1c the best measurement of diabetes at this point or is it a construct of historical use and there's actually false positives? etc.) and be transparent about it.

Neutrality is a fool's game, but transparency and intellectual honesty can be practiced at any time.

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Jun 1, 2023Liked by Camilla Alderighi, Raffaele Rasoini

Great article, well articulated. Thank you

When we are speaking of the arts, we would praise the authors ability to elicit anger, empathy, brotherly love, patriotism, etc. with words and language (Dostoyevsky, Tolkien, Dickens, to name but a few). But, alas, the job of the scientist is different. I have reviewed a small number of articles for journals in my career, and I felt part of the job was to hold the authors accountable for their biases and use of spin (we all do it). Maybe not all reviewer’s feel this way...

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Desist from engaging in derogatory or patronizing language when referring to patients, yes, sure.

Police "gendered suffixes", no. Clearly, some academics and even physicians have far, far too much time on their hands, that they spend it pontificating about idiotic, postmodernist drivel that patients not only don't care about, but would be legitimately offended if they knew their self-appointed betters were spending their time on.

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and with the "News" the first version of a story has a greater impact on hearers than the subsequent and more accurate report.

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Jun 1, 2023Liked by Camilla Alderighi, Raffaele Rasoini

I love, love, love this article. It is a topic I have long thought about and tried to teach my children. Unless you are reading/writing, nonverbal has just as much power and slant.

I used to tell them, "its not as much what you say as how you say it."

Words by themselves have meaning. Look it up in Webster's. So listening with unbiased, neutral ears allows the meaning of that word to flow in its context.

On the other hand people have verbally taken a word and added on their own meanings, biased the neutral word to mean something they desire.

We need to be astute enough to listen to the chosen words from the person giving them.

Oncologist says: We have tried everything. Chemo and radiation has done its best. I believe it's time to go home and live the rest of your life.

Patient hears: Ok. Let's go home and plan for our future.

Hospice explains: Let's begin making arrangements, gathering the family, and make sure everyone says what they need to. There isn't that much time.

Patient asks: What do you mean, the doctor said to go home and live your life

Hospice responds: There may be a couple of weeks, I am not God, but in my professional opinion...

Patient reacts:

Racial slurs. Gender degraded words and phrases. They are all just words with definitions, people give them meaning.

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Jun 1, 2023Liked by Camilla Alderighi, Raffaele Rasoini

You can add the deceptive practice of emphasizing “relative” benefit over “absolute” benefit.

This is how science becomes distorted and degraded when business takes it over.

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Lots to chew on here.

Hard for me to believe I’ve overlook “benefits and risks”. Astute observations and recommendations all around.

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Jun 1, 2023Liked by Camilla Alderighi, Raffaele Rasoini

Language, words, tone of voice, body language, empathy.

And as they say "user friendly".

Nothing more, nothing less.

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