My Fair MDs: Encouraging Doctors to Speak Plainly

Mikkael Sekeres, MD, MS
Director of the Leukemia Program at the Cleveland Clinic in Cleveland, Ohio, and editor-in-chief of ASH Clinical News

“An Englishman’s way of speaking absolutely classifies him.
The moment he talks he makes some other Englishman despise him.
One common language I’m afraid we’ll never get,
Oh, why can’t the English learn to … speak?”

—“Why Can’t the English,” from My Fair Lady

Hugh Rayner, MD, FRCP, a kidney specialist in the U.K., is my hero.

No, it isn’t because he recently wrote a tell-all that made it to The New York Times best sellers list entitled Great Glomeruli Through the Ages or The Narcissist Nephron. Rather, Dr. Rayner is spearheading an effort through the Academy of Medical Royal Colleges for doctors, particularly specialists, to write outpatient letters directly to patients, instead of to their general practitioners. These missives, reflecting more than 5 million outpatient visits each year, are “the most written letters” in Britain’s National Health Service.

Part and parcel (pardon the pun) with this direct mail guidance is a call for simplifying the medical jargon we often sling with abandon, so that your average Nigel can understand the content of these letters.

My admiration for Dr. Rayner stems from my own dalliances into circumlocution and the comeuppance I received from none other than my parents – both English majors when they went to college. I am now a reformed man.

Years ago, when I was in medical school, I began flexing my muscles with some of the new words and phrases I was acquiring. No longer did patients have heart attacks – they had myocardial infarctions. A new onset of chest pain of cardiac origin stressed the “an” of angina, losing its ability to rhyme with Carolina. Patients with low white blood cell and platelet counts were diagnosed with leukopenia and thrombocytopenia, which sounded both far more impressive and far more serious. Excited, I called my parents to tell them about the patients for whom I was providing care during my subinternship rotation.

“He was an old guy who presented with ANgina.”

“He had what?”

“ANgina! He had chest pain and he underwent a cardiac catheterization!”

“Do you mean anGINa?” my dad asked. “Why are you saying it funny? And he had a catheter placed? Did he have trouble peeing?”

When I started residency, my excitement about being introduced to patients with real medical problems and the new vernacular I gained during medical school turned to terror that I would actually be responsible for human lives. Rather than invoking these medical terms so I could roll them around in my mouth and learn to use them appropriately, I wore them like a suit of armor, as protection against anyone who might doubt my competence and think that the MD following my name stood for “major disappointment.”

I told patients their diseases were “idiopathic.” They left my resident’s clinic confused. I explained that they had a “chronic” condition. They started to worry, because chronic sounds bad. I cautioned that their organ function was insufficient, that their cardiac valves were incompetent. They felt bad about themselves. I used these words like a bludgeon, lest anyone think my white coat was a fanciful charade, and to keep my authority intact. Again, my parents intervened.

“My patient has idiopathic bone marrow failure.”

“Why are you calling your patient an idiot?” My mom asked.

“No, not ‘idiot!’ Idiopathic. It means we don’t know what caused the bone marrow to fail.”

“So now you’re saying your patient is an idiot and a failure?” she persisted, only half joking.

I took a deep breath, reminded myself that I lay for nine months under her heart, and that I shouldn’t let my sleep deprivation spark an angry retort. She used the break in our conversation to continue her line of questioning.

“Why don’t you just tell your patient that you don’t know what caused the bone marrow problem?”

“Well,” I stammered. “That would take longer to say.” Once out of my mouth, the justification sounded anemic.

“Mmm,” she said, in that way mothers say things without saying anything. It’s the perfect blend of disappointment, shame, and the suggestion to “maybe rethink that answer.”

Guidance from the Academy of Medical Royal Colleges covers the gamut of letter writing, from advice on clarity and readability:

  • Remove redundant words such as “actually” and “really.”
  • Use shorter sentences.
  • Stick to one topic per paragraph.

To advice on grammar and style:

  • Avoid the passive voice.
  • Don’t use stigmatizing words and comments that may offend people (“You have diabetes” is preferable to “You are a diabetic”).
  • Use a familiar start to letters, such as “It was a pleasure to meet you.”

This advice on letter-writing shouldn’t be ignored by those of us in practices in which we don’t pen many letters, relying instead on the ubiquity of electronic health records (EHRs) for others to learn of our deliberations and findings. EHRs are increasingly becoming “open,” meaning our patients can read the progress notes we write about them, sometimes only hours after an office visit.

The meat of the Academy’s manifesto gets at what my parents were trying to teach me: To use plain English instead of medical jargon, to define medical terms when we do use them (“You have an irregular pulse. This is called atrial fibrillation.”), to explain abbreviations, and to use English instead of Latin in the medication list (bye-bye, “bid”).

Once I started my hematology/oncology fellowship, I had shed all pretense of wherewithal, as the field has a language distinct even from the rest of medicine and because all my patients had just been handed a cancer diagnosis. Adding to their fear and confusion by using complicated terms that also were new to me would simply have been cruel. I slowed down, spoke plainly, acknowledged and shared in their grief, and helped them heal and rebuild. I admitted when we didn’t know a cause to their illnesses – without implying that they were idiots – and reframed the notion of failure, from their bodies having failed them in allowing cancer, to our occasional failure to fix what was wrong.

To put it plainly, I talk to my patients as if they were my parents, which is what my parents were trying to teach me all along.

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