“What is your duty in the matter of telling a patient that he is probably the subject of an incurable disease? ... One thing is certain; it is not for you to don the black cap and, assuming the judicial function, take hope from any patient – hope that comes to all.” – William Osler, pre-eminent physician of the 20th century
The quote above, one of many aphorisms attributed to William Osler, is a reminder that language is one of the most powerful tools in medicine. As the basis for communicating with patients, choosing to use patient-centred language has been shown to positively influence patient outcomes. The “doctor as drug” is a well described placebo phenomenon.
But the opposite is also true. A recent article in the journal Medical Humanities is a reminder that failure-based language is all too common in medical discourse. When a medication or treatment does not produce the desired outcome, doctors are quick to label it a “failed treatment”.
“Failure-based language can profoundly discourage patients who hear it. When we use terms such as ‘failed treatment’, either verbally or in clinical documentation, we risk making patients feel it is their fault for not achieving better outcomes”, the Harvard University authors write.
READ MORE
They give as an example a patient with the bowel condition diverticulitis, who has spent days in hospital on a strict diet and treatment without improvement, being labelled as someone who has ‘failed conservative management.’ The decision to proceed to surgery is conveyed as a personal failure by the patient rather than a natural progression of the disease. Telling patients they have failed to respond to treatment is loading them with unnecessary guilt: the issue shouldn’t be one of who failed, but rather what failed.
Failure based language undermines the therapeutic relationship, which needs to be based on trust, empathy and collaboration. In a neat juxtaposition the authors ask doctor readers to imagine how they would feel if a patient said to them ‘you failed to give me the correct medication to control my high blood pressure’.
I suspect many physicians would feel such a statement to be unfair, untrue and even accusatory. The unhelpful language of failure has unfortunately found a home in cancer care. In 1971, the then US president Richard Nixon publicly declared “war” on cancer and referred to it as a “relentless and insidious enemy”. It has evolved pretty much unchecked since then. We speak to patients about “killer cells” and “magic bullets”. We refer to “beating illness” and remind people to “keep up the good fight”. Those who don’t, by implication, become failures.
How can we reframe the narrative of failure based language?
When treatments do not work, doctors must non-judgementally ask patients why they think a treatment hasn’t worked. When a treatment does not achieve its intended outcome, doctors can emphasise the progress made during each step of treatment. For instance, one may say, ‘while the medication we tried did not work as well as we had hoped, it still provided valuable information that will guide our next steps’.
The authors provide some useful alternative wordings for use in people’s charts that do not imply blame or inadequacy. In paediatrics, the term ‘failure to thrive’ is a diagnostic term for a child who isn’t gaining weight. They suggest “growth faltering” as a less judgemental option. Rather than label someone as ‘patient failed therapy’, they propose ‘the therapy did not work as hoped’. And rather than the somewhat bald, “patient did not tolerate x medication’, they suggest ‘the patient experienced uncomfortable side effects from x medication.’
Teaching the next generation of medics about the pitfalls of failure based language is an important reframing step. And it would be worth looking at electronic medical record systems to see if they could be prompted to avoid negative language.
Doctors must make a conscious effort to remove failure-based language from the collective medical lexicon.
