Connotations matter in Medicine
Healthcare Professionals often use a SOAP format to record entries in patient notes. SOAP stands for:
Subjective - the words of the patient to describe the problem e.g ‘It hurts above my right knee’
Objective – the outward signs which are picked up during an examination. e.g ‘Patient grimacing and moaning when describing pain’
Assessment- the use of assessment tools such as blood pressure monitoring, mobility assessment etc to make a diagnosis.
Plan - the recommended course of treatment
The important section of SOAP when talking about the connotation of words is the ‘Objective’ section. Nurses are not only encouraged but are obliged to use objective reporting in patient documentation and during handovers. Doctors are also encouraged to hone their communication skills so that there is an awareness of the importance of using objective phrases when interviewing patients.
An entry by Kate Land in the KevinMD blog starts with ‘Language matters. The words we choose can have far-reaching impact on those we interact with. This is arguably more true in medicine than in any field.’ Kate continues with a comment on a blog posted by Ryan Madanick on ‘the use of descriptor terms used by physicians in patient’s charts.’ This resonated with me as the same descriptors are used by nurses resulting in prejudgement of patients and their families. I have come across the following subjective phrases in many patient records, referral letters and during handovers:
• a pleasant woman
• a delightful, elderly lady
• ‘off with the fairies’
• a difficult patient
• an unfortunate patient
• a demanding patient
• constantly complaining
The result of using these phrases can be to alter the care a patient receives. Patients who are described as ‘uncomplaining’ may be seen as ‘good’ patients. Patients who are ‘difficult’ or ‘demanding’ may have good reason to be this way, for example because of pain or anxiety. Doctors and nurses may not listen carefully enough to patients who they prejudge as complaining or difficult and therefore miss the underlying issue.
Expressions such as ‘patient is complaining of pain in the right shoulder’ and ‘presenting complaint’ have negative connotations and may suggest that the patient should not be bothering medical and nursing staff with their symptoms. Instead of these expressions, factual and objective expressions should be used instead, such as ‘patient reports pain in the right shoulder’ and ‘presenting symptom’.
Guidance for nurses in writing patient notes is outlined in the NMC publication Record Keeping Guidance . Section 15 of the guidance states, ‘You should not use coded expressions of sarcasm or humorous abbreviations to describe the people in your care’. A BBC News article of 26 November, 2008 entitled ‘Stop using ‘dearie’, nurses told’ introduced these new guidelines which came into force to protect dignity in patient care.
‘Nurses are advised against behaviour that could be deemed patronising
Calling older patients "dearie" or "love" is set to be ruled out as offensive by new guidelines from the Nursing and Midwifery Council.
Nurses should speak "courteously and respectfully" and use patients' preferred names, the NMC recommends.
But terms of endearment can be used in some areas if they are part of everyday speech - it may appear unusual if they are omitted, the draft guidance says.’
Many nurses objected to the suggestion that by using terms of endearment they were acting in a patronising way. But the potential is there especially when patients are in a physically vulnerable position e.g bedbound or chair bound and being ‘looked down on’ by a doctor or nurse. Some nursing training schools (including the one I taught at) ask students to play the role of a bedbound or chair bound patient and then describe the feelings they experience when another student playing the role of nurse or doctor approached them in conversation. Most student nurses described feeling out of control, vulnerable and very uncomfortable. If we add terms in the conversation which seem to suggest a further imbalance in the power structure, it becomes more uncomfortable. So, an elderly patient who is addressed as ‘lovie’ or ‘dearie’ loses any sense of equality which may have existed had their name been used. On the other hand, nurses who care for the elderly especially on a long-term basis report feeling as they would with their own grandmother or grandfather and like to reflect this in the use of terms of endearment.
A recent press release from The Samaritans in response to the reporting of the suicide of a well-known film director highlighted the effects of the language used in the media to talk about suicide. The Samaritans recommend the use of phrases such as:
• A suicide.
• Die by suicide.
• Take one’s own life.
• A suicide attempt.
• A completed suicide.
• Person at risk of suicide.
• Help prevent suicide.
Phrases to be avoided are:
• A successful suicide attempt.
• An unsuccessful suicide attempt.
• Commit suicide (Suicide is now decriminalised so it is better not to talk about ‘committing suicide’ but use ‘take one's life’, or ‘die by suicide’ instead)
• Suicide victim.
• Just a cry for help.
• Suicide-prone person.
• Stop the spread/epidemic of suicide.
• Suicide ‘tourist’.
Midwives are also being advised to choose their words carefully. A technique called HypnoBirthing emphasises the importance of using words with positive connotations during birthing (even ‘birthing’ sounds better than ‘labour’). Comments on the RCN Midwives blog included this comment: ‘One thing we liked was the language. No contractions. It’s a surge. No pain, but tightening. Not pushing, but breathing the baby out.’
The inaccurate description of pain can also cause difficulties and potentially incorrect treatment. Patients are often asked to rate their pain on a scale from zero to ten. This is very difficult for many patients for several reasons. Firstly, pain is subjective. As a nurse, I don’t know how much pain a patient is in. Some patients experience what would be considered a slight pain to one person as a moderately severe pain. Secondly, pain sensation includes other factors too, for example cultural input, the additional presence of anxiety and lack of knowledge about hospitals or hospital procedures. I always link the pain level to something which a patient may relate to, for example ‘does the pain stop you moving around in bed?’ or ‘does the pain stop you concentrating on reading your book?’ The McGill Pain Questionnaire provides lists of descriptive words which can be used to pin point the nature of the pain felt. These descriptive words have been used on the Macmillan Cancer Support website (www.macmillan.org.uk/Cancerinformation/Livingwithandaftercancer/Symptomssideeffects/Pain/Describingpain.aspx) as an aid for patients to get their message across and receive the correct painkillers for their particular pain.
‘What is the pain like?
You could use any of the following words to describe your pain: aching, biting, blunt, burning, cold, comes and goes, constant, crushing, cutting, dragging, dull, excruciating, frightful, gnawing, hot, intense, nagging, nauseating, niggling, numb, penetrating, piercing, pins and needles, pricking, radiating, scratchy, sharp, shooting, smarting, sore, spreading, stabbing, stinging, tender, throbbing, tingling, tiring, unbearable.’
Care taken to avoid negative expressions must not move into the use of euphemisms. There is always the danger of this happening when doctors and nurses are attempting to break bad news. Showing empathy to a patient and wishing to avoid causing more pain and distress must not lead into the use of phrases which are unclear or confusing. Despite this, some descriptions are easier for patients to accept e.g ‘a small growth’ rather than ‘a small tumour’ allowing doctors to build on the initial knowledge with further information about treatment or palliation.