Connotations and Denotations

Not only is driving my wife to and from work a great way to connect and decompress from the workday, it also is a great source of random observations and conversations.  For example, this morning, while driving past a farm, she wondered what precautions farmers were taking to protect their livestock during the current smoky conditions.¹ She observed that horses that we normally see were not in their usual pen by saying “I see the horses are not in their cage.”  This started a conversation about the different connotation that ‘cage’ and ‘pen’ had. This, then, got us thinking about a pattern that we see in healthcare, where, in an effort to be precise and clinical, healthcare workers will use words that carry unintended connotations that can, in turn, lead to confusion, frustration, and irritation in patients.  One of the ongoing themes in my essays is the problematic gaps in effective communication, so I thought I would explore some of these words and phrases. 

Effective healthcare communication can be challenging in the best of circumstances, as complex medical concepts about life-threatening conditions can create comprehension issues.  There are also words and phrases that are used precisely because they seek to be clear and unincumbered with baggage.  But intentions notwithstanding, those words often have additional meanings to the patient that can lead to miscommunication. 

I will explore some of these words or phrases here.  (Knowing me, this could become a series of essays.)  My message is not to avoid these words, since avoiding all words with connotations is impossible.  My intent is to call out how some words may trigger suboptimal responses and may generate more heat than light.  I am not expecting clinicians to be codependent, but to simply realize that when they use these words, they should likely be prepared to provide additional context or explanation and not imagine that the words will clearly stand on their own. 

Obese

Obesity is a word that has a medically clear definition, related to BMI and other measurable elements.  But like a lot of clinical words, this one also has a more basic connotation.  For many people, the word has less an aura of medical condition and more an aura of schoolyard taunt. 

Everyone can see the tension here, between a clinical description and a juvenile judgement.  It is why I started with it.  It is also is an example of the learning curve that clinicians have had to make with the advent of easier patient access to personal health records.  Physicians would document in a record in clear plain language that was designed to simply document facts and concerns.  There is a conversation to be had about whether this language did as much harm as good when it came to prejudging a patient, but I will leave that for another day.  For the moment, I worked on the committee tasked with operationalizing patient ease-of-access laws in a health system.  I oversaw patient complaints and grievances and was literally in the room when physicians were presented with the patient complaints that their doctor called them FAT.  They would push back, pointing out that they said OBSESE and not FAT, which led to a long conversation about whether they were being oblivious or purposely blind to how the word would be interpreted by their patients.

What was further interesting was that many physicians were defensive about the word use, claiming that “political correctness” was going to ruin accurate execution of appropriate healthcare.  Some pointed out that they hoped the word would act as a wake-up call to their patients.  I pushed back on this, saying:

• In my experience, fat people generally know that they are fat, and,
• It felt like the physicians were trying to be confrontational. 

To me, it was concerning that, for at least part of the group, this usage was meant to be purposely antagonistic.  After a few minutes, though, we came to a collective decision about how to move forward and that didn’t mean not using the word, but by providing useful context for the word.

Non-Compliant

As I have pointed out in the past, most healthcare exists outside the field of view of clinicians.  Whether it is taking prescribed medications as-instructed or if it is making appropriate modifications to behavior or it is keeping up-to-date with necessary screenings or vaccinations, there is a lot of work to get and stay healthy.  Most of this effort exists outside of the twenty-minute trip to urgent care or a yearly wellness visit to a primary care provider. 

Non-compliance is a medical term to categorize a patient as either following instructions or not following instructions.  When I was in Quality, I built forecasting models to predict whether someone would remain compliant or fall out of compliance.  Since most metrics were about percentages of patients who did what they were supposed to do or not, a lot of conversation in Quality was simply about whether someone was “numerator compliant” or not. 

The challenge here is that the word “compliance” carries with it an assumption that there is an active, concrete choice involved.  Merriam-Webster defines it as “submissive” or “conforming to requirements.”  Someone who readily obeys rules or meets specific standards or laws.  Being non-compliant, then, at the very least, implies a decision by the person not to adapt the rules or standards.  Patients who hear that they have been labeled as non-compliant will often say that they feel scolded or judged.  Some will say that they are being called willful or weak.  When I have talked to patients and asked them why they don’t follow their doctor’s instructions, they often give me one of three reasons.

1. They were unaware that they were not following their doctor’s instructions.  Perhaps the compliance was complicated.  I have spoken in the past about how optimal diabetes testing and management has many steps, including kidney function tests, eye exams, A1C testing, etc.  Patients may not know all of the things they are expected to do.  Or, in the case of diabetes, they assume that their provider will tell them when they need to get an eye exam or an A1C test.  They are not aware that they need to own important pieces of diabetes management.  Diabetics, especially those new to the diagnosis, may not realize that an eye exam is not just a nice thing to have, but critical to managing care.  By not saying, “This is important for you to do” and then judging them for not doing it can be seen as a NIGYYSOB moment. 
2. Being non-compliant was not a choice, but an artifact of the real world.  Given that mammographies are (from what I hear), uncomfortable and can be embarrassing for some, the implication is that a woman not getting one is an active choice to not have their boob squished.  But I have discussed that forecasting compliance with this is far more complicated than that.  Tests like this exist as simple on/off switches.  Either you have had a mammography in the past two years, or you have not.  So, if you had one 22-months ago, you are compliant.  No one notices that you are in danger of being out of compliance in two months.  Once you fall out of compliance, even if you want a mammography, it may be difficult to get one simply because no in-network facility can see you in a timely fashion.  The other challenge that patients have experienced is that, even if they are thinking ahead and want to schedule one while you are still complaint, your insurance company may balk, because technically are you are still within the 730-day window.  This essentially means that, even if the stars align, all women will be out of compliance for one day as their insurance clock resets.
3. Failure is an option.  In interviews, patients have expressed frustration that being labeled as ‘non-compliant’ because it implies that they are not trying.  In reality, they are trying and while they are not always fully successful, they may still be making progress.  They feel like they get no partial credit if they demonstrate some weight loss, even if it isn’t “enough” weight loss, or smoking reduction even if it is not smoking cessation.  The impact of the social determinants of health, like availability of transportation, safe public spaces, access to nutritious foods, etc., can further impact how successful a patient can be.  It is only recently that healthcare systems are taking these compounding elements into account.

Discharge

The simple act of discharging a patient from a hospital can lead to confusion.  While most patients look forward to the day they get to go home, the process itself can seem complicated, drawn-out, and overwhelming.  I remember when I was discharged from my hospital stay, it felt abrupt.  In about 30-hours I went from being so sick that they didn’t let me leave to the valet tossing me my car keys, saying that I don’t need to go home, but I can’t stay here. 

There are two main ways this word can confuse patients.  First, it carries with it a finality.  While hospitals will offer some patients care-continuity support, like a nurse navigator, the only follow-up most patients get is a folder stamped with the words “discharge instructions,” assistance booking a follow-up appointment with their primary care provider, and, maybe, a post-discharge phone call.  While most clinicians will stress that this is not the end of the care they are receiving, to many patients it feels like it is.

Secondly, the word can carry a negative connotation, where someone is being kicked out for cause.  For example, when a patient is discharged or dismissed from a clinic doctor’s patient panel, they are essentially being fired by the doctor.  Being discharged from a hospital, especially when the patient may not feel personally comfortable or ready for being released, can feel like a hostile act. 

Provider

Turnabout is fair play, so let us discuss a word that is like nails on a chalkboard for some doctors.  I, frankly, was not aware of this frustration until I read an essay by my friend Karen on the topic.  She was inspired in part by an essay² in the Annals of Internal Medicine, called “Physicians are Not Providers.”  In this article, the authors are in essence making two points.  First is that the word “provider” clouds the expertise of the person providing healthcare.  Second, that the word minimizes the importance or selectivity of possessing the specialized skill of delivering medicine.³

Having taught in universities, this seems akin to how some would bridle at being called “teachers” instead of “professors.”⁴ I can see the difference between “provider” and “physician” as well as “teacher” and “professor.”  But what these folks all are doing is simply reading connotation to a word that is used to describe a population as broadly and inclusively as possible. 

In any setting, a patient is likely to see a number of different people who are providing care, from a rooming nurse, phlebotomist, and doctor in a clinic setting, to the sea of healthcare professionals that they see in a hospital setting.  There are two things these people have in common.  First, they are all trying to provide care for the patient.  They all have specific functions, responsibilities, licensures, etc., but all are united in helping the sick get well.  Second, often the patient has no idea who that person is.  The old line is that, to a patient, everyone is a nurse, including all the lab techs and half of the doctors.  Patients will use the term “provider” as a catch-all, since they are often talking about ALL the experiences they have had and all the information they were given.  They mean no offense at the term, so much as it is a simple shorthand to summarize a collection of professionals.  I use the term for a slightly different reason.  I am interested in not excluding anyone from attention and responsibility.  If I talk about communication strategies, like I am in this essay, I am interested in making sure that nurses, transport, food and nutrition services, phlebotomists, therapists, etc., are all on notice that what they say and how they say it matters. 

Let me restate, this essay is not about using euphemisms or being indirect with language.  There are incredibly important reasons why it is critical to be precise and clear in the language we use in healthcare.  My point in this essay is that precision and scientific clarity are not the only praiseworthy values in communication.  As James Harbeck said, “all communication is behavior designed to cause behavior in another person.”  Communication in healthcare is not just about being pedantically accurate; it is about helping all involved to understand what the right next behavior looks like.  Not understanding this, not embracing it, seems willful.

¹For those not aware, we, like now most of the Northeast, are blanketed under thick smoke from the Canadian wildfires. 

²I am sure that the authors may pick-nits with me over calling this an essay rather than an article, let alone a referred-journal article.  Since I read this as more of a position paper than a piece of rigorous research, I think “essay” is appropriate.  Does this make me sound a bit petty and pissy?  Perhaps.  You can go read it yourself, in Annals of Internal Medicine Volume 179, Number 4, provided you can prove that you are a human.

³I think it bears pointing out that, in an article about how dismissive broad labels can be, it was a commenter who pointed out that these same doctors who are defensive about titles are equally dismissive when they use phrases like non-physician provider (NPP) or “midlevel” instead of, say, Nurse Practitioner or Physician Assistant.

⁴Or even me, if I might be called a “blogger” instead of an “essayist.”