Providence, Rhode Island (Summer 2016)
Language, both spoken and written, plays an enormous role in the education that we absorb from our predecessors and pass on to our successors. I realized this early on during my clinical rotations as a medical student, as I stared, lost, at the fishbone diagrams scratched out in residents’ notes as shorthand for noting lab values and struggled to follow a presentation of a patient’s course that was rife with acronyms and abbreviations. In her book, “What Doctors Feel,” Danielle Ofri relates an anecdote of a medical student listing physical exam findings and, upon encountering the common notation “↓↓ testes,” which indicates that both testes are appropriately descended, announced instead, “the patient had extremely small testes.” It is an amusing story as there is no way that the uninitiated could independently guess the meaning of the notation, yet for this poor medical student, it was likely a glaring and all-too-public reminder of how far from initiated he remained, despite his long hours and hard work. As our white coats lengthen and our fluency with eponyms, stock phrases, and jargon advances, it is not only our knowledge that grows but also our sense of belonging within a group.
But while language can serve as the secret handshake among members of one community, it can also ostracize and alienate those outside the group, sometimes with harmful effects. As much as the medical community perpetuates the spreading of and reliance on jargon in its communication among practitioners, in educating its newcomers it does emphasize the need to avoid this language when speaking with patients and their families. One of the doctors who interviewed me when I was applying to residency challenged me during the interview to explain a complex medical topic in plain English. However, the zone between jargon and plain speech — what one could refer to as medical colloquialism — remains fraught with pitfalls that can lead to grave misunderstandings.
Midway through my residency, as the senior resident leading a team on the general pediatrics wards, I visited a patient who had been admitted overnight. It was a baby that had come to the Emergency Department because of a fever, and given his young age, he had received the standard workup including tests of the blood, urine, and cerebrospinal fluid, and been admitted for several days of intravenous antibiotics. When I met the baby’s mother in the morning, I found she was extremely upset about an interaction that had taken place in the Emergency Department the night before. One of the physicians, in explaining the spinal tap that would have to be performed, had tried to reassure the mother that this was all very routine and that she was very skilled in the procedure, having done it many times. “It’s our bread and butter,” the physician had said.
At this the mother had become irate and tried to refuse the test, ultimately acquiescing only after much reassurance. “It’s her bread and butter?” she railed the next morning, still angered by the experience. “It sounded like that doctor only wanted to do this test on my baby to make money!
I spent much of the time before rounds that morning lending a sympathetic ear to the mother and offering what I hoped was a convincing explanation of what I knew the other physician had meant: that a spinal tap is part of the standard of care for a very young infant with a fever and is one of the standard procedures in which all pediatricians – especially pediatric emergency medicine subspecialists – are thoroughly trained. That although the procedure sounds frightening and dangerous, it is actually quite safe. That the physician had not wanted this mother, already worried for her sick child, to add to her list of concerns.
“Bread and butter” is a term we use quite frequently in medicine to describe procedures and illnesses that we encounter commonly and have ample experience and comfort in managing. In pediatrics this includes asthma, croup, gastroenteritis, otitis, strep throat, and cellulitis. And, in infants, rule out sepsis. These are all conditions that we handle over and over throughout our training and practice, and that we encourage medical students to make sure they see during their clinical rotation to get a good feel for our specialty. They are what we refer to as “bread and butter pediatrics.”
It had never occurred to me that this phrase could cause confusion. It’s not really jargon, and it doesn’t refer to a body part or a test that would be unfamiliar to a lay person. But when I looked it up later to try to understand why it had evoked such a strong reaction, the reason was clear in the standard English definition: “a means of sustenance or livelihood” according to the Merriam-Webster Dictionary. Little wonder that this mother had become so angry when it was used to explain the test our hospital proposed to perform on her child.
Yet again, I saw language can be both a tool and an impediment. A standardized script can facilitate the smooth and thorough evaluation of a critically ill patient or it can hinder the efficacy and — less crucial but still significant — the confidence of those unfamiliar with it. A phrase that on the surface appears harmless and benign in its lack of jargon, can evoke anger, indignation, and a host of other emotions when passed between people who operate in spheres where the same words carry very different connotations. The language we use to describe and to teach medicine, it turns out, is no more black-and-white than medicine itself. The words we use can open the door to communication with some and shut it definitively on others, hinging our success as physicians and educators not just on the words but on how we use them.
Rebecca MacDonell-Yilmaz earned a Bachelor of Arts in French Language and Literature as well as a Master of Public Health from Dartmouth College. She completed her medical degree at Stony Brook University School of Medicine and her pediatrics residency at Brown University/Hasbro Children’s Hospital, where she subsequently served as Chief Resident. She lives in Providence, RI, with her husband and two sons. Her prose and poetry has appeared in Pediatrics, Annals of Internal Medicine, Journal of the American Geriatrics Society, and The Writers’ Circle literary journal.