The Point Blog ARCHIVE
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The purpose of this blog is to stimulate thought and discussion about important issues in healthcare. Opinions expressed are those of the author and do not necessarily express the views of CMDA. We encourage you to join the conversation on our website and share your experience, insight and expertise. CMDA has a rigorous and representative process in formulating official positions, which are largely limited to bioethical areas.
A “Bot” Too Far
July 27, 2017
by David Stevens, MD, MA (Ethics)
Words are important. The words I use to describe my patients, even if I am only thinking those words and not speaking them, affect how I feel about them and how I treat them. I’ve known this for a long time, so I work hard to guard both my thinking and my speech as I care for patients. I don’t consider myself prone to making snap judgments about people based on their appearance—that is, I don’t see myself as biased. So last month, as I was listening to a talk on “Addressing Weight Bias in Healthcare” given by Dr. Scott Kahan as part of a conference on treating obesity, I didn’t think I was one of the physicians whose speech reflected a negative attitude. When the speaker stressed how much better it is to say, “This is a woman with obesity,” rather than, “She is obese,” I nodded assent. Surely I always describe my patients as human beings with a disease, rather than equating them with the disease itself. Yet only an hour after that talk, while speaking with a different presenter about a patient, I said, “He is obese.” “He has obesity,” she gently corrected me. “Yes,” I said, flustered. I hadn’t even known I had said it. So much for my smugness. Unfortunately, in our society people with obesity are considered fair game as targets of stigma. That is, it is socially acceptable to be prejudiced against people affected by obesity, treating them with disdain and considering them lazy, weak-willed and unintelligent. Yet the causes for obesity are complex—including environmental and genetic factors—and one glance at people’s outer appearances cannot possibly give anyone enough information about them to justify treating them in a negative manner. Doing so is to be prejudiced. And we who are following in Christ’s footsteps can look to Him as an example on how to treat those who are devalued by the rest of the world. Jesus’ encounter with the woman at the well in John 4 is a case in point. She had three strikes against her: she was a woman in a male-dominant culture, she was a Samaritan whom the Jews considered “half-breeds” and she had a scandalous sexual history. Yet Jesus looked past the surface issues and reached her heart. Sadly, healthcare workers often have negative attitudes toward people with excess weight. This includes physicians, mid-level providers, nurses, dietitians and psychologists. The quality of the care provided suffers, leading to:
- Fewer preventive health services and exams
- Less access to cancer screening tests, such as pelvic exams and mammograms
- More frequent cancellations or delays of appointments
- Less time spent with the healthcare professional
- Less extensive differential diagnosis—that is, a tendency to blame all of a patient’s symptoms on the excess weight, rather than considering other causes or diagnoses
As their BMI increases, patients report that their caregivers have less patience, less of a desire to help them and more scorn. As a Christian, I don’t want this tendency to be true with me. I want to communicate respect for my patients as human beings made in the image of God. And it all starts with the words I use to describe my patients in my thoughts, deep inside my mind. I remember reading House of God by Samuel Shem during the preclinical years of medical school. House of God is celebrating its 40th anniversary this year, but it was a newish book when I read it. Shem was a pseudonym for Stephen Bergman, who had recently completed his internship and decided to fictionalize his experience. He and his fellow physicians-in-training delivered care with little sleep, constant stress and a pervasive feeling of powerlessness. How did they respond? By depersonalizing their patients and becoming cynical. House of God is satire—a negative example, as it were, and that is how I took it. It galvanized me. I determined to fight the tendency to see patients as mere cases, and not people. The book opened my eyes to how the downward spiral into depersonalization could happen, and I didn’t want to fall into that trap. The book is caustic and raunchy, so I generally don’t recommend it, but both my fellow family-physician husband and I thought it would benefit our daughter, Martha Grace, as she entered medical training. She decided to delay reading it until the end of her intern year. “I found it cathartic,” Martha Grace said, “because it validated my experience of internship being very hard. Sadly, some people still talk the way they do in the book—though, system-wide, changes have been made. Residents don’t work 120 hours a week, and we’re not verbally abused. If I’d read it earlier, it would have been off-putting. Some loss of wide-eyed optimism is inevitable in the medical training process, but reading it earlier would have accelerated that for me. I admit, though, that I do sometimes say things like, ‘Room 235 is the cellulitis.’ I try to use person-first language, but when I’m just trying to get through rounds quickly, it’s easy to slip up.” Martha Grace’s family medicine residency hosts Balint groups, which are groups of six to 10 residents with a facilitator, meeting to discuss “difficult patients” and their responses to them. These are not medically-oriented discussions, but rather a forum for discussing the struggles of caring for patients who, as she says, “take 90 percent of our energy and are the least grateful.” Balint groups were first formed in the late 1950s by Michael Balint, a British psychoanalyst to “improve physicians’ abilities to actively process and deliver relationship-centered care through a deeper understanding of how they are touched by the emotional content of caring for certain patients.” Martha Grace’s residency hopes they will help forestall cynicism and prevent burnout. In the medical literature, patient-centered language has increased over the decades, recognizing that patients are unique, complex individuals and participants in the research process: “Whereas medical language previously emphasized treatments and disease processes, the trend during the last 40 years has been to separate patients from their disease and to emphasize the patient rather than characterize patients by their disease.” So you will no longer find in the major medical journals a reference to “the diabetic patient” or “the diabetic,” but rather “the patient with diabetes.” Nowhere is it more important to use patient-centered language than in documenting mental health issues. In the electronic medical record, it is best to use objective words that describe behavior, and replace words with negative connotations with less charged words. How we use language either reinforces biases or promotes strengths. So in our documentation, in our conversations with other healthcare professionals, in our encounters with patients, and—most fundamentally—in our thoughts, it is important to choose our words carefully. Are they reflecting what we know to be true, that God made each and every person in His image, for His glory? Words, I say again, are important. Words can harm, and words can heal.