Let's Change the Language of Medicine and Get Rid of the Blame-Shame Lexicon
Contemporary medicine is obsessed with failure. Look anywhere, or everywhere and the word “fail” keeps cropping up. The word is almost always associated with personal blame and thus with personal shame. Physicians, for example, worry that they will “fail” to correctly diagnose an illness and be punished for this failure. Pediatric residents worry that they will “fail” to insert an IV into a baby with tiny veins and thus have to call on surgeons (who will, behind their backs snigger at their “failure” to insert the IV and their need to ask surgery for help) to help. Think of some mistake that physicians – who do not escape the human condition when they graduate medical school — could make and you can bet that the word failure is attached to it. Amazingly (given the fact that there is no reported example of a human being making it out of this life alive) physicians are socialized to consider that they have personally “failed” if a patient dies (not only from a medical mistake but from the inevitable fact that some diseases can’t be cured, or even well managed and that death always gets us in the end.
Personal failure is always a very real possibility in the fix /it, fight/ it model of medical treatment. When physicians are conceptualized as the generals and officers leading the war against disease and death, there can only be two possible outcomes – you either win or you lose. If you win, you are a success, if you lose you are a failure.
The personal failure model of healthcare takes a huge toll on physicians and other medical personnel who have been taught that when something goes wrong, it’s all their fault. The verdict? They have not only done something bad, they are bad. That they are participants in, or sometimes even victims of, bad systems is rarely considered. As the patient safety movement has showed us, system thinking is not big in medicine or much of anything else in our culture).
The toll the fix-it-fight-it-fail- at -it culture takes on patients is even worse. If physicians are the officer class in the war against disease, patients are the conscripts, volunteer foot soldiers or civilians who bare the brunt of the action and suffer the collateral damage. The narrative and language of fix-it-fight-it medicine frames their choices, rigs their options, and then blames them for many bad outcomes.
Consider, for example, how treatment decisions are made, particularly when patients have difficult or impossible to treat illnesses, like cancer. As a society, we have for years, been waging a war against diseases that are anthropomorphized into almost human enemies gathering together to intelligently and intentionally plot our downfall. Like coaches of professional sports teams, we as patients are urged to “fight” when we are presented with our treatment options. (Please check out this Geri-Pal rant against terminology) Patients are lauded for how long and hard they “fought” or “struggled” with their illness – as in, obituaries which inform you that died after a long fight struggle against, failure. Indeed, it is now a commonplace that physicians are reluctant to stop what is clearly futile treatment at the end of life because they consider the patient’s death to be their failure.
The preoccupation and terror of failure that is socialized into almost every physician during his or her training, leads to a lot of collateral damage, which in this particular modern war inevitably involves civilian casualties – notably the patient, whose body is the modern battleground on which physicians wage their war against disease. New research is showing us that this terminology is terrible for patients who feel guilty because they have not waged a successful war against disease. Patients often end up dying horrible deaths because they are urged to soldier on. They endure what I have come to think of as the George Washington syndrome, which I have named after our poor first president who, in a short period of time, was tortured to death by physicians, who with the best of intentions, were determined to fend off their old enemy, the grim reaper, even though nothing they did helped and everything made poor George Washington positively beg for mercy and be allowed to just get the hell out. The pernicious effects of these metaphors are now backed up by research. Patients often feel guilty and depressed because they are said to have “failed” in their “fight” against disease.
There has been a lot of talk about how to get physicians to stop torturing their patients at the end of life, and about how to transform the shame and blame culture of medicine. One way to begin to deal with this is to take on the language, which physicians and nurses and other health professionals use to talk about their patients and their mission. Three of the words that need to be deleted from the medical lexicon are “fail”, fight and war. These words are consistently used to construct and reinforce a medical paradigm that blames someone for the inevitable. If we want to fight something, let’s think about how we can starting fighting this kind of language. If we want to be truly patient-centered and help physicians and other healthcare professionals we need to start doing this now. In one of my next blog posts, I will talk about other pernicious language, like the use of the term fail, when it pertains to treatments that don’t work. I will also post a column a colleague wrote about this kind of language. Keep on the look-out.