Medicine’s F Word from BMJ

suzanne_gordon“The patient failed” this or that therapy.

I first heard medicine’s F word almost 30 years ago when I was having a casual conversation with an oncologist in a break room on the hematology/oncology unit. The oncologist—an earnest man devoted to his patients—was talking about a man who was dying of cancer. “Well,” he said with grim resignation, “he failed six rounds of chemotherapy and there’s nothing else we can do.”

The last time I heard the F word was at a morbidity and mortality round. A group of physicians were discussing a case that had gone badly. The patient had contracted Guillain-Barré syndrome. As the resident was presenting the case, he reported that the patient “had failed” several rounds of antibiotics and was now completely paralyzed. People in the room nodded sagely. No one but me—who thinks of herself as a potential patient or sometime patient—seemed to think there was anything wrong with this formulation.

And why would they? The F word is everywhere in medicine. It’s used when professionals are talking about patients who are in trouble or are dying, when they describe a treatment that has not worked, or when a patient has experienced a set back. Consider the following examples:

Oncology attending to resident– “I put the patient on Taxol and Adriamycin and the patient failed Taxol/Adria.”

ER physician to hospitalist, “Mr Y is a morbidly obese patient with a terrible infection on his left leg. He failed oral antibiotics and needs to be admitted for IV antibiotics.”

An attendant in the neonatal intensive-care unit (NICU) talking to a NICU nurse—“The baby has a congenital diaphragmatic hernia and has pulmonary hypoplasia. We started nitric oxide and the baby failed the nitric oxide therapy course.”

With variations, notes in charts use the same language, as do reports in research journals.
Many healthcare professionals with whom I’ve spoken about the F word think it is purely descriptive—almost neutral in its content and connotations. They don’t recognize that the verb to “fail,” used with the noun “patient” as a subject always implies blame.

Here, for example is how, Ask Dictionary.com defines the word fail:

“to be or become deficient or lacking; be insufficient or absent; fall short:
to fall short of success or achievement in something expected, attempted, desired, or approved”:

Failure is always an act that is accomplished by an agent. When you fail at something—particularly in competitive Western cultures—you have done something wrong. You have not studied hard enough so you failed the test. You did not run fast enough, so you failed to win the race. When one says that a patient failed a therapy, the patient is, by definition, not doing something right or efficient. They are lacking, absent, falling short or—to follow the dictionary definition—setting him or herself up for the medical equivalent of bankruptcy. When a patient is said to have failed something, the unavoidable implication is that the patient—not the disease process, the limitations of contemporary treatments, or of the state of current scientific knowledge—is responsible for his or her own suffering, deterioration, or demise. Unless the patient actively compromised their own treatment, using the term “the patient failed,” ascribes agency or action to someone who, in most cases had very little ability to influence the outcome. When clinicians use these terms, they are infecting the patient experience with the same burden of shame and blame that they so often shoulder. Only this time, they are transferring part of that burden to suffering patients. As Mardge Cohen, an internist and HIV-AIDS specialist puts it, “It’s almost as if nothing is patient-centered except the patient’s failures.”

When I’ve talked about this phenomenon to different healthcare providers, many respond that this terminology is only used when physicians or other healthcare professionals communicate with each other—either verbally or in their charting. They insist that they would never, ever tell a patient—to their face, that they had “failed a therapy” and were about to suffer the consequences. They wouldn’t be so callous as to sit down with the patient and inform him that he’s dying because he failed his treatment.

They somehow believe that we, as patients don’t know that they, as providers, consistently refer to our setbacks in language that makes it seem like they think we are responsible for any poor outcomes we experience. “I always tell my residents that if we use the term the patient failed in our case meetings, this language may slip out of our mouths when we are in front of patients,” says Glenn Bubley, chief of Genitourinary Oncology at the Beth Israel Deaconess Medical Center.

Bubley is right. The F word slips out when physicians-in-training fan out around a patient’s bed and inform their attending doctors that Mr X has “failed four rounds of chemo.” Or when a parent sitting next to their desperately ill child on a NICU overhears rounding physicians tell one another about that poor baby who failed the course of nitric oxide.

I myself was told that my bladder failed when it somehow acquired—all on its own—a urinary retention injury after surgery. After having heard these comments over and over again for the past thirty years, it is hardly reassuring to think that the people caring for me will consider that I may have failed in some therapeutic enterprise and blame me for the poor outcome of my medical journey.

If healthcare is to be truly patient centered, then those who care for the sick cannot continue to use language that ascribes blame to suffering human beings—whether in conversation, through notes in the chart, or discussions in the scientific literature. Medicine, nursing, and all other healthcare disciplines have perfectly good options when discussing poor patient or treatment outcomes. Consider some of the following:

  • The bacteria was resistant to multiple antibiotics,
  • The cancer was refractory to treatment.
  • Taxol/Adria failed to put the cancer in remission.

The patient failed is just not one of them.

Suzanne Gordon is a healthcare journalist and co-editor of The Culture and Politics of Healthcare Work Series at Cornell University Press. Her latest book is Collaborative Caring: Stories and Reflections on Teamwork in Healthcare, which she co-edited and she is co-author of Beyond the Checklist: What Else Healthcare Can Learn from Aviation Teamwork and Safety. Most importantly she is a patient.

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One Comment

  1. Suzanne, you bring out so much in this post. Thank you. The language that is used points to so much of our culture, what we value, etc. Stephen Pinker presents this in his book, The Stuff of Thought. Do we value the patient, the human being at the center of “our medical care business” (I chose not to use the word healthcare)? Or do we value proving we as providers as a system are right, not wrong and pointing the finger to the most vulnerable person in the equation, the patient? Very insightful and thought provoking.

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