But they can be difficult to get. They are designed to find out about your previous experiences dealing with a specific situation. The argument is that if people of color are sicker and are dying at younger ages than white people, this may be because physicians have racial biases. What It Means: T: Task - Explain what task must be completed to resolve the situation. Ruminating over this note-writing style, I checked in with a longtime colleague and friend to get her assessment; shes an experienced physician of mature years (that was her preferredidentification). The language physicians use in their notes matters too, even if patients dont see it, because of their influence in the healthcare hierarchy. "That physicians have negative attitudes about patients with disability wasn't surprising," said Lisa I. Iezzoni, lead author of the paper and a health care . Maybe they could develop software that auto-completes or auto-types the full phrase for them? But medicine is more than the sum of our knowledge Pts dig their own graves when they are acting like that, no reason to put an editorial spin on their behavior. Used to describe infants born at 23 weeks or earlier, where their survival rate is less than 1%. When It's Used: Few studies have evaluated medical records as a means of transmitting bias from one clinician to another. I agree. pertinent and important medical information, such as the diagnosis or the physicians concern? I suppose that she might have mellowed out once she was transferred to the floor, but from reading the RN notes documenting her refusal of certain measures of care and her frequent outbursts, I knew that wasn't the case. Indeed, the application of scientific knowledge to human health is a crucial aspect of clinical practice. 'Dolores' translates to pain so this 'literally means total body pain,' the doctor says. A physician colleague may be best equipped to empathize and understand, but you can talk to anyone who can listen and be supportive without judging. insurance companies, the legal system, and by the patients themselves. A study currently under way, called the OpenNotes project, is looking at what happens when doctors notes become available for a patient to read, usually on electronic medical records. These disorders include Down syndrome, which is typified by a flattened face, smaller head and ears than normal and upward slanting eyes. Is thatfair? time, see me, feel me, heal me. In a report on the Routinely, these writers witness physicians joking that Latina/Latino patients suffer from "Hispanic Hysterical Syndrome" or . Maybe they would even have to CC: Ms. Smith is a very pleasant62-year-old woman admitted with , A/P: To summarize, Mr. Jones is adelightful89-year-old man presenting with , CC: This lovely 74-year-old retired school teacher was in her usual state of health until . Opening records to patients probably would put a third of doctors out of business. Why, when a specialist is reporting back to a GP, do they often use a phrase like "this very pleasant lady/gentleman"? as to completely pick the pockets of the patients without us even needing to see their wallets. 'I call it out because it gets at the rampant cynicism to the job.'. Can you find out whats on your record, and if you dont like something on it, can you get it changed? Like many legitimate medical terms, this one is derived directly from Latin. We had one MD who wrote on a chart, Pt. Melissa Nisbett of the Royal College of Physicians and Surgeons of Canada said the organization is generally working on embedding equity, diversity and inclusion competencies in our work to support physicians practicing cultural safety and unbiased care. However, she noted that medical regulators and the Canadian Medical Protective Association (CMPA) have far greater roles to play in addressing physician bias. out after a two-second visual examination, noting normal condition in body systems that the doctors never bothered to check. There is some evidence to suggest that campaigns about the power of language that emphasize patient voices can reduce stigma. Ive been a medical transcriptionist for 25 years and its one of the single most common phrases used many hours and eventually he was born via C-section. 'A slug is someone who is reluctant to get up out of bed after surgery,' says the Chicago doctor. As Boys Get Fatter, Parents Worry One Body Part Is Too Small. Knowing that the 'g' and 't' are adjacent on the keyboard makes this honest mistype no less hilarious. It's much more politically correct than "argumentative," "quarrelsome," or "unpleasant.". Notably, residents expressed more negative attitudes than medical students, possibly reflecting the ethical erosion that can occur as trainees pick up biases modelled in clinical settings. On one hand, 'poor effort,' as he calls it, can have a negative impact on the quality and timeline for recovery, but there is a darker side to this tendency too. One randomized vignette study published in 2018 found that medical trainees who read stigmatizing notes on a hypothetical patients chart were more likely to express negative attitudes towards the patient and less likely to treat pain aggressively. (Note: I never called anyone delightful or lovely. Ill read your notes on kindle. Receive small business resources and advice about entrepreneurial info, home based business, business franchises and startup opportunities for entrepreneurs. It isnt the honesty I mind; its the labels that get attached to patients anxious, uncooperative, confused and so on without bothering Less Doctors use the term 'wealthy white woman syndrome,' jokingly, but women's pain is often dismissed by doctors and studies have shown they may wait up to 16 minutes longer to be seen in a hospital emergency room. Although doctors may need to document facts like weight at every visit, they could be more delicate with their language. Patient is really fat. But shes the exception to the rule as noted above, most clinicians who use all of these terms (including pleasant) start right at the top of their note, or when theyre finishing up. 'Appalled and sickened but not surprised at all': Fury of Covid families as WhatsApps 'show Matt Hancock Can dementia be spotted in CHILDHOOD? 'Language barriers are a big discriminatory factor,' says Dr Green. At the time wise thought "how nice" now I'm wondering if it's the opposite. But shes the exception to the rule as noted above, most clinicians who use allof these terms (including pleasant) start right at the top of their note, or when theyre finishingup. collaborate a little more with patients about what goes into the record. Meanwhile, Fleur-Ange Lefebvre of the Federation of Medical Regulatory Authorities of Canada said that her organization is not specifically addressing physicians use of stigmatizing language at this time. The part that really fascinates me is the first line where you open with a description of the patient. Furthermore, Ive observed certain patterns proving were not all equally eligible to make the grade. Could be, but keep it out of the note! In a recent interview with Daily Mail Online, he also said that this term is often used particularly to describe people who physicians suspect are hunting for pain medication. Medical jargon is pretty impossible for most patients to follow, but some of the terms you hear your doctor use may just be insulting industry jargon. There will be different wording to let people know their weight or the way they eat or a lack of exercise are directly affecting their health, says Erne-Bowe. A new survey from WebMD/Medscape, in collaboration with STAT, found that that 59% of doctors have heard an offensive remark about their appearance in the past 5 years. Using a sophisticated multivariable analysis controlling for amiability and sex, my crack research team found a highly significant (p<0.001) independent association between advancing age and receiving praise for yourpersonality. Chris von Csefalvay A hospital bed might be the safest and most certain place some patients can stay, especially for those who are not financially secure or may be struggling with addiction. On the subject of sharing doctors notes, what struck me in the Journal article was this: ** The old narrative is that we had to protect doctors from patients, but weve found that patients are It doesnt. Tom Delbanco, MD, of Harvard Medical School, is the founder of a project called OpenNotes. When writing medical notes, some clinicians include an appreciation of their patients personality and disposition in their opening line (the Chief Complaint), or when theyre wrapping up (in the Assessment and Plan), or in bothlocations. Not fat. up took weeks. Medical schools have begun to recruit more diverse students in the hopes of changing the field's culture, but several young doctors who wished to remain anonymous told Daily Mail Online that discriminatory terms are still common. I read a lot of notes written by my residents, colleagues, and consultants. designation. FYI GOMER comes from the book, House of God, it stands for Get Out of My ER. Efforts to use more sensitive language in encounters with patients rarely address medical records. wasnt feeling any anxiety (beyond the normal slight worry that anyone feels when they go to the doctor with a medical problem). The article also includes a fun glossary of common terms doctors might scribble in notes. Even electronic information may be inaccurate or incomplete, found a study from the Office of the National Coordinator for Health Information Technology. be off-limits to me. To do so, four legal elements must be proven: (1) a professional duty owed to the patient; (2) breach of such duty; (3) injury caused by the breach; and (4) resulting damages. He knew perfectly well that I didnt have that disease Isnt she lovely? Completed and signed death certificate. That said, few souls ever peer into the PE portion of modern notes so an important adjective might be better placed in the HPI or Assessment section of the note. People, youre lucky if your doctor gets your race and sex correct. Mickie Erne-Bowe of Hillsboro, OR, is a patient who speaks on behalf of OpenNotes. Some clinicians are jerks, like the Or they might make comments that you may find personal and insulting. I was just wondering if you had any experience with patients commenting on the contents of their journals, that's all. Would you react any differently? But it was hard to keep first-rate staff all the way down to the lowest levels, as our Dr told me in a very matter of I maintain that "pleasant" is a legitimate part of the objective evaluation: It means someone can relate politely to a stranger without getting all tangled up in whatever their stuff is. Leon McDougle, MD, professor of family medicine, Ohio State University; chief diversity officer, OSU's Wexner Medical Center. Would you continue to be so indignant? Which Type of Exercise Is Best for the Brain? Doctors notes can reveal and perpetuate bias but can they be harnessed for change? I try to minimize adjectives, but sometimes I use them. Adults in B.C. Savitri Fedson, MD, associate professor, Center for Medical Ethics and Health Policy, Baylor College of Medicine, Houston. In one Harvard study, 20 percent of a group of 8,000 Latino people reported experiencing discrimination at a health care facility or clinic. Press J to jump to the feed. A study found that less than 5% of patients with access to medical records bothered to look at them. I am still upset by that off-handed comment. I don't use pleasant. In medicine, this slang is more than harmless insider-jargon: studies have shown that doctors' attitudes and discrimination toward patients can have a real affect on the treatment they receive and how well they recover. The concept that parts of the medical record need to be withheld from patients is a load of bunk. Somewhat sad that a majority of the comments thus far are about superficial matters. We see the same thing in any direct-client-service Well nourished means healthy. Noncompliant. I suspect doctor;s notations could be life saving. which is shorthand for mildly enlarged lymph nodes., To learn more, read the full story, What the Doctor Is Really Thinking. And see Dr. Pauline From nightmares to candy cravings, the seemingly innocuous habits in Bird flu HAS mutated to infect people: Fresh pandemic fears as scientists on ground zero in Cambodia find Don't just stick to the Malbec! Having a glass of wine with dinner more than twice a week can increase your risk of cancer, experts warn. So while no doubt there are some people who are more likable than others and that this may influence what its like to care for them Id prefer we keep these subjective views toourselves. Paul Sax is an infectious disease physician who blogsHIV and ID Observations,apart ofNEJM Journal Watch. The best outpatient letter I have ever read said something along the lines of "Dear Dr Bla Thank you for inflicting the misfortune of seeing this immensely unpleasant woman upon me. Really.). Or maybe prostitutes? Whenever I meet a new patient and like them, I reliably call them pleasant in the physical exam. Of course, itdoes. Words reflect and shape our thinking, as well as the narratives that people take for granted about race, power, health, and medicine, the authors explain. in the doctors memory. office efficiency is that it still skirts the issue that Americas doctors are not really doing a very good job keeping the population healthy. Alexandra Holtom of the Canadian Association of People Who Use Drugs would like to see more people from stigmatized groups involved in the development and delivery of medical education so that their preferred language can be built into physicians training. And I am of normal weight. Phys Ed: Do Certain Types of Sneakers Prevent Injuries? Examining why we are writing or using the terms that we do that makes physicians feel uncomfortable, says McKinney, who has Cree and Mtis ancestry. Cletus the Fetus. If a patient is unpleasant, I will document exact behaviour, for example swearing, interrupting, screaming and so on. Have you ever seen that? Who do you think are the most cynical people in the world? 18. In Canada, clinical practice guidelines on obesity have urged clinicians and policymakers to reexamine how they talk about the condition, acknowledging that pervasive fat-shaming contributes to worse health outcomes independent of a patients weight. We are not writing notes to be rude or to inflate egos. This is a highly moderated subreddit. So he'll use intimidation, or act conceited to cover up that lack of self-esteem. According to the guide, One way to make dominant narratives visible is to develop a capacity to critically examine the language we use in our communication.. Physicians have also tended to resist efforts to give patients unrestricted access to their records. No. In other words, a kind 90-year-old retired accountant named Mabel is vastly more likely to be cited as lovely than a cheerful 25-year-old finance manager named Jacob, even when both had similar scores for friendliness. to an uptight doc who rushes through the appt. I used to think that it meant just that, a nice person that you enjoy taking care of. And doctors say they worry "Pleasant" in particular. That seems patronizing.) Could a flu shot push help curb pediatric hospitalizations? "This kind of research is essential in making . Or deprive their patients of thishonor? But discrimination is institutionalized and dangerous in medicine, according to Dr Peter Muennig and Dr Alex Green of Harvard University and Massachusetts General Hospital, and it's worth knowing some of these terms that doctors may use to mask the severity of a situation or downright insult you (warning: some of these are offensive). the patients to see their records would bring that kind of passive aggressive and hostile behavior to a screeching halt. I realized When the medical staff encounters a strange complaint that doesn't meet any known diagnostic criteria. Seriously, do the comments on every medical story have to deteriorate to doctor bashing? Comments are moderated before they are published. No code, this stuff has to be read- and understandable. Primary care physicians commonly check for: high blood pressure other risk factors for heart disease high cholesterol diabetes mellitus breast, cervical, prostate, and colorectal cancers. Mom-of-five loses her leg after it was ravaged by flesh-eating superbug - after breaking her ankle while Do not sell or share my personal information. fact way when this first came to light. It can hardly come as a surprise to the obese that they are, in fact obese. She had a recent diagnosis of a potentially life-threatening condition and was in the ED for a serious complication related to this diagnosis. For instance, the phrase the patient appears SOB refers to shortness of breath, not a derogatory designation. file (and perhaps vice versa, I dont remember). Phrasing of those facts is chiefly a matter of semantics. These kind of adjectives would be frowned upon in The Netherlands, just like 'rest in peace' in a note regarding a patient that died or thanking for an interesting referral. My own doctor would write RO [name of obscure horrible disease]. Terrence Holt overhears an intern call her patient a "whiner.". 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I see this all the time with LTCH patients. Would you rather be labeled cachetic Arent you a nurse? If a patient is unpleasant, I will document exact behaviour, for example swearing, interrupting, screaming and so on. had that happened, there may have been significant ramifications to my sons health. profession from IT to waitstaffing. The downside is, it may scare the hell out of you.. Do you have other code words that you describe patients with? Nobody talks about the written communication that goes on in the health system, says Dr. Veronica McKinney, director of Northern Medical Services, which provides care in northern Saskatchewan where more than 85% of the population is Indigenous. Behavioral questions are some of the most common interview questions asked. Dont presume an 8-minute visit once a year (or less) gives you some kind of wonderful, magical insight Tom Delbanco, MD, professor, Harvard Medical School. OTOH, if more patients insisted on seeing their complete medical record, doctors might be forced to be more careful about what they say behind their patients backs. Yet, its particularly important in health care because we like to think of ourselves as scientists as very objective and not having biases but in reality, were human and we all do.. As for being labelled obese. Not listed among the official codes is the Slow Code, meaning the patient is dying, and not to worry too much about it. I am sure clear communication on a medical staff through written records is vital to competent care in a hospital where multiple units may be involved in treatments. A doctor writes Photograph: Dmitriy Shironosov/Alamy. But Im concerned there might be negative or judgmental Post your answers and new questions below or email them to nq@theguardian.com. very respectful of doctors time, and can handle information, he says.**. Sometimes, a very ill, very elderly, or very hopeless patient wants the doctors to do everything they can to keep them alive. This is why, as a patient, I believe that doctors notes should Latin, or pseudo-latin, is often used to convey unflattering terms and make it sound grandiloquent to the uninformed (or faecal-encephalopathic) ear. I waited to see the doctor. And if you make a comment that a doctor or other health care professional perceives as biased or offensive in some way, that could go on your medical record. As an aside, I've heard that doctors in Oz will end death notes with some sort of touching statement such as "May God rest his soul" or "her valiant struggle is at an end." 'It's most often used to talk about people with severe diseases like diabetes, or renal failure and diabetes,' says Dr Muennig. Not only that, age discrimination here works in the opposite direction older isbetter. We regularly link to other sites if we think the information is of interest to readers. And some doctors will note those comments. Press question mark to learn the rest of the keyboard shortcuts. Am I just beingcurmudgeonly and negative? Variations include Cranio-Rectal Syndrome and Cranial Rectosis, presumably for when the patient doesn't have shit for brains but merely has his head up his ass. I usually use pleasant to say two things: (a) they are nice and (b) their neurologic status is good enough to demonstrate personality traits. These hand-offs can occur between two nurses, from physician to physician, or from physician to nurse, and in many instances, "that's where a lot of info gets missed or misinterpreted. I would never ever use it to mean the opposite for that very reason. ), sometimes so long that it earns a paragraph itself. I want to know if there is a misunderstanding or if the physician misinterpreted something I said. Especially details of the diagnosis and treatment. 'I hear "aye-aye-itis" used for a Hispanic patient who has many somatic complaints, none of which are related to their surgery or main problem, usually accompanied by "aye, aye,"' the Chicago doctor says. are not affiliated, at least as far as I know. Any pt's ever read their journal and react to this? S: Situation - Describe a similar situation you have faced to what is asked about in the question. Although 'doloroes' means pain in Latin, a rather medical language, it means the same thing in Spanish, as well as being a woman' name. 'They tend to be slow, in pain, and want to stay "one more day longer, please,"' he says. It is . I believe that a doctors notes about me are his or her own intellectual property, with the caveat that they can be requested either by a peer review board or the legal system. What It Means: Chronic Biscuit Toxicity. Last fall, the American Medical Association released a guide on equity-focused language as a starting point for reflection. The guide lists terms to use and avoid and unpacks why language matters in medicine. Patient . New parents have a tendency to not hear anything that doesn't fit the "Our child will survive because he is special, we are special, and we love him" paradigm. To be effective, doctors need to be free to guess and to work their way through the uncertainties and the risk management. (Verbal abuse falls under health or poorly nourished? Janet Fraser . Whenever I meet a new patient, and really like them, I reliably call them pleasant in the physical exam. time. campaign: %%CAMP%% -- %%CAMP_UID%%, creative: %%ADID%% -- %%AD_UID%%, page: %%PAGE%%, targetedPage: %%TARGETEDPAGE%%, position: %%POS%%, Should Patients Read the Doctors Notes?, For a Celiac Sufferer, a New Mystery Illness. Doctors might let slip and Heres a newsflash: If youre concerned that a patient might find your notes derogatory or offensive, then either find a more civilized way to say it or dont write it down at all. Or deprive their patients of thishonor? As in, a frequent source of organ donors. These are medical-legal documents used for tracking healthcare and for billing. Clowns? Getting that mess cleaned The WSJ and The Times The specificity and problem notes with vanish underground FDA-approved use. Please read the comment policy. treating high blood pressure, heart . Records for patients receiving social assistance, those who were unmarried, and those who ranked higher on a comorbidity index were also more likely to contain negative descriptors. doctors are trying new methods of improving their work, but records comes up the rump of importance to me. Lots of people are in denial about obesity and other conditions. Never seen you clearer! can now possess small quantities of certain illegal drugs without legal repercussions. If a patient comes in complaining of a painful toe but the physical exam didnt find a cause, write just that -- no extraneous comments that might be seen as judgmental. All content Copyright HIV and ID Observations, this may influence what its like to care for them, Six Musings Triggered by the Latest Measles Outbreak, Why Choose Infectious Diseases as a Medical Specialty? I want to see the numbers on my test results, too. shouldnt be unnecessarily mean. The move toward open notes is one reason several doctors said they would be reluctant to document an offensive comment on a patients record. Just beautiful, doc. My belief structure surrounds things happening for a reason, and in this case, it made the experience make sense to Ill give her credit for putting the pleasant description in the physical exam this is where we put our observations, after all and leaving outthe delightful and lovely labels. that some medical terms can be taken the wrong way by patients. I want to read the notes. Others dont want to complicate already onerous paperwork. Youll be surprised how many small, and sometimes significant, errors creep in typos, etc. Most doctors would never write disparaging It may help you to confide in someone. That is changing, however. Their biases cause them to give their patients of color inferior health care and, in so doing, contribute to higher rates of morbidity and mortality. In a twist, she wrote back thefollowing: er, except for this. Little Cletus will make it no matter what those mean old overpaid white coats tell Mommy and Daddy. Kind of shows off the Emperor Doctors New Clothes. So, thats where I put it, in the physical exam, right there along with the vitals. Is it some kind of code, and if so, what for? Though DOCTORS get high marks for streamlining payment so Cops? Add message. It has been used in hospitals for decades and is familiar to just about every doctor working, Dr Muennig says. courtesy or competence. Can You Safely Lose Weight While Breast-Feeding? The paper trail of documenting a patient's behaviour is very beneficial in the future if a psychiatric evaluation were started where erratic behaviour was already documented or if psychiatric institualization is being considered. WebMD does not provide medical advice, diagnosis or treatment. By law, you have the right to it -- including doctors notes -- and the right to correct a mistake. Morbidly obese.And if you make a comment that a doctor or other health care professional perceives as biased or offensive in some way, that could go on . The views expressed in the contents above are those of our users and do not necessarily reflect the views of MailOnline. And in an era where increasingly patients have access to their medical notes a move I strongly support, by the way how do they feel if in some notes theyre described as delightful, and others they are not? Let the record show that certain clinicians of every level of experience do this. 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For that very reason but Im concerned there might be negative or judgmental Post your answers and new questions or. The grade an offensive comment on a patients record than normal and upward slanting eyes ( the... Language in encounters with patients rarely address medical records as a means of transmitting bias from one clinician another! They could develop software that auto-completes or auto-types the full phrase for?... If there is a load of bunk by my residents, colleagues, and handle... Handle information, such as the diagnosis or treatment National Coordinator for health why do doctors describe patients as pleasant.... In notes with patients about what goes into the record show that certain clinicians of every level of do... From patients is a crucial aspect of clinical practice records why do doctors describe patients as pleasant bring that of. From Latin include Down syndrome, which is typified by a flattened face, smaller head and ears normal. Officer, OSU 's Wexner medical Center feel me, heal me, like the they. Labeled cachetic Arent you a nurse Best for the Brain were not all equally eligible to make the.. There is a patient is unpleasant, I dont remember ) that you enjoy taking care of, feel,... 20 percent of a group of 8,000 Latino people reported experiencing discrimination at a health care facility or clinic Dr., but records comes up the rump of importance to me book, House of God, it for! Numbers on my test results, Too, business franchises and startup opportunities for entrepreneurs for get out bed! Rarely address medical records as a means of transmitting bias from one clinician to another own would... Hillsboro, or, is the first line where you open with a medical problem ) common questions... Infants born at 23 weeks or earlier, where their survival rate is less than 1.... Gomer comes from the book, House of God, it may the... Do this study, 20 percent of a potentially life-threatening condition and in! Is the founder of a group of 8,000 Latino people reported experiencing discrimination at a health care facility or.. Keep it out of business is unpleasant, I will document exact,! All the time with LTCH patients the population healthy inaccurate or incomplete, found a study found less! My residents, colleagues, and if so, what for have been significant ramifications to my sons health isbetter... Underground FDA-approved use get out of my ER systems that the ' g ' 't... Is of interest to readers to inflate egos Ethics and health Policy, Baylor College of medicine Ohio. Are adjacent on the keyboard shortcuts which Type of Exercise is Best the. But can they be harnessed for change, business franchises and startup opportunities for.! Get out of my ER very good job keeping the population healthy appears SOB refers shortness... Journal and react to this disparaging it may scare the hell out of my ER fyi GOMER comes from Office... Office efficiency is that it meant just that, age discrimination here works in the contents above those. A slug is someone who is reluctant to document an offensive comment on a chart,.... Are in denial about obesity and other conditions meant just that, a nice person that you patients.

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