Medicalese and its Discontents

“Rats are female, people are women,” explained the attending physician. I was a lowly shadowing pre-med at the time, and everything the attending said was deific to me. But why was he wasting precious seconds on semantics? Now, I understand how much words matter in medicine.

How we speak is how we think. In medicine, speaking, thinking, and communication are a life and death enterprise; The learning of which largely begins during the clinical years of medical school in a hierarchical environment. Often, medical students talk to interns, interns to residents, and residents with nurses and attendings. Students rank the lowest. Interns have far more experience, knowledge, and power, but they only rank moderately above students and are subject to the same hierarchical social pressures. Students and interns look up to their superiors for more than just knowledge. Behaviors, attitudes, social cues, and slang are passed from one generation to the next via implicit imitation. In medicine, this is called learning1. And when it comes to Medicalese, this method has been less than satisfactory 1–3.

Many professions have jargon, but modern Medicalese is a pseudo-language unto itself. The problem addressed here—there are many problems these dynamics have caused with Medicalese that are not addressed including dehumanizing and arcane language 4,5—is that some routine phrases used by clinicians are redundant, confusing, ambiguous, nonsensical, or even absurd. When a minor error can lead to a preventable fatality 6, even routine terminology warrants critical examination.

Medicalese rarely gets such scrutiny as it is rarely taught explicitly. Indeed, educational time and resources are often spent on obscure pathophysiology or rare genetic disorders rather than what clinicians confront on a daily basis—health care system costs and Medicalese 7. Instead of teaching Medicalese to student doctors, they learn passively by listening to the conversations of more experienced clinicians and reading their medical notes 1. When patients are assigned to students and interns, the learners take the medical history, do a physical exam, and present their findings to the higher-ups. There is an implied expectation to sound like the rest of the team in these presentations and subsequent medical notes. Pretty soon, medical students are taking care of a ‘45-year-old female with a past medical history of hyperlipidemia and no known allergies.’ Their patient may ‘admit’ to smoking or ‘deny’ alcohol use. They may even have a patient who is ‘positive’ for depression ‘status post’ cesarean section who ‘endorses’ pain and is being managed ‘conservatively.’ And, they may be worried about being ‘pimped’ about this later.

The accurate transfer of information is paramount in medicine. Access to electronic medical records and resident hour restrictions further increases the importance of clear and precise communication, because these developments have increased the opportunities for miscommunication. The 21st Century Cures Act mandates that patients have full access to their medical records 8, and the evidence suggests that this is a beneficial development 9–11. But this expansion of a clinician’s readership to those outside of the medical field inflates the likelihood for confusion and potential for harm caused by ambiguous language. This is also true of patient handoffs. Interns and residents are no longer forced to work more than 80 hours in a week. Because of these rules, the care of a patient is often transferred to a night team and back again to a day team. These ‘sign-outs’ are known to be precarious, and the communication that happens during these handoffs is critical to patient safety 12. These modern dynamics emphasize Medicalese and compel healthcare professionals to reexamine their language 13.

Below, some common Medicalese phraseology is examined, and simple substitutes are suggested to increase clarity in clinical communication. This is done in the context of a medical education system that generally rewards observation and imitation and a hospital culture that struggles to balance hierarchy with critical thinking 1,14,15.

Moreover, the word ‘history’ inherently refers to past events. Thus, the phrases ‘past medical history’ and ‘past surgical history’ are redundant. These phrases can be shortened to ‘medical history’ or ‘surgical history’ with the same meaning. The word ‘past’ is unnecessary. Imagine enrolling in a college course entitled: ‘The Past History of Medicine.’

Likewise, Latin-based phrases and abbreviations are abstruse. Will a patient reading his chart understand ‘status post’ or ‘s/p’ stent placement? Instead, the chart can read that the patient ‘had’ stents placed. This plain language has the same meaning and is far more relatable 13.

The words ‘positive’ and ‘negative’ are also problematic. For example, the phrase ‘positive for cancer’ could be interpreted as a sadistic oxymoron if taken literally. Writing that a biopsy ‘demonstrates the presence of cancer’ or is ‘consistent with cancer’ is less ambiguous. Additionally, medical signs are often referred to as ‘positive’ or ‘negative’ when the intend communication is to state whether the sign was present or absent. That is, ‘positive Babinski’ describes the quality of the Babinski reflex, not its presence or absence. ‘Babinski absent’ or ‘present’ is more coherent. Lab value communication also has this problem. Labs are often referred to as ‘positive’ or ‘negative’ when a value is elevated, decreased, or normal. For example, the phrase ‘positive d-dimer’ is wrong for the same reasons mentioned above. ‘Elevated d-dimer’ conveys the meaning with higher fidelity. This hyperscrupulous use of language promotes specificity in thought while minimizing confusion.

The word ‘conservative’ is best left out of Medicalese altogether. A politically conservative treatment plan may include every available intervention no matter the evidence, invasion, or cost. Politically conservative treatment can also manifest as not seeing a patient at all if he or she cannot afford it. Confused yet? Additionally, the phrase ‘conservative management’ can mean non-surgical management, fluids and rest in place of a pharmacotherapeutic, or topical steroids instead of oral among other uses. The consequences of using this ambiguous word has the potential to cause unnecessary harm as miscommunication is a common cause of medical error 6,16. I suggest removing the word ‘conservative’ from the lexicon and using descriptive language such as ‘non-surgical management’ or ‘fluids and rest’ in its place.

Similarly, the word ‘endorse’ describes an action that is taken when supporting a political candidate or writing a check. It has nothing to do with a patient reporting symptoms and has no useful function in Medicalese.

In addition, medical notes are often filled with hedges. Patients ‘admit’ to alcohol use, or ‘deny’ smoking. These are words of the judicial system, and their use in Medicalese implies patients have been accused of something. Others have noted the problems with such language as it damages the patient-clinician relationship by implying dishonesty and distrust 4. Instead of writing that a patient ‘denies alcohol use’ we can write that a patient ‘does not drink alcohol.’ Using more trusting wording may improve the patient-clinician relationship. Further, some clinicians evade responsibility with phrases such as: ‘no murmurs appreciated.’ The word ‘appreciated’ is added to protect the physician in case there are murmurs that are not appreciated. Again, this language indicates a defensive clinician-patient relationship while encouraging insufficient effort on the physical exam. Writing ‘no murmurs’ is more parsimonious and will likely promote a physical exam in which the clinician earnestly rules out murmurs. The same is true for the phrase ‘no known allergies.’ We can honestly report what the patient tells us and instead write ‘no allergies.’

Lastly, the word ‘pimp’ is often used as an anti-euphemism in clinical training that replaces the word ‘quiz.’ Others have written about this phenomenon, but few have called out its absurdity 17,18. Socrates Was Not a Pimp focuses on methods to make Socratic quizzing on the wards less stressful. The authors define this word as “questioning of a learner with the explicit intent to cause discomfort such as shame or humiliation as a means of maintaining the power hierarchy in medical education.” This is an illustrative example of how hierarchy can generate deficient Medicicalese and is explained elsewhere in detail 17. Here, we propose ‘quiz’ as a replacement for ‘pimp’ and suggest that this simple change may restore many of the issues surrounding Socratic learning in medicine. Afterall, learners are not hos, teachers are not pimps, and neither should be thought of as such.

How one speaks reveals how one thinks. Medical students are learning how to do to both when they enter the clinical years of their training. When they hear superiors speaking in jargon, read ambiguous language in notes, and see incomplete physical exams, these behaviors are adopted and often rewarded even when they contradict classroom content. Moreover, classroom content often teaches that the proper terms are words that dehumanize 4,5. This cycle propagates a Medicalese that has become so esoteric it is bordering on gibberish 3. At the same time, critical thinking and logic are subtly discouraged by using these shortcut phrases. This linguistic negligence has the potential to permeate other aspects of care and may lead to medical error in unclear patient handoffs or misunderstandings when patients read their medical records 6,9,10.

I argue here for a more rigorous use of language in medicine that is clear, logical, relatable, and ultimately asks clinicians to think critically. Specific suggestions made here are not exclusive to us and reflect a long tradition of Medicalese reexamination 3–5,13,16,17. Many have fallen into the ease of using a phrase like ‘positive bowel sounds.’ But when this happens, thinking is implicitly suspended because ‘positive’ is not the correct adjective. Bowel sounds are either present or absent. When such equivocation is standard, what else slips through the cracks?