Editor’s Corner
My Fair MDs: Encouraging Doctors to Speak Plainly
“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?”
H
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the American Society of Hematology
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14
ASH Clinical News
—“Why Can’t the English,” from My Fair Lady
UGH 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 mil-
lion 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 circum-
locution 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 provid-
ing 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 ar-
mor, 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 incompe-
tent. 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.
Mikkael A. Sekeres, MD, MS,
“Mmm,” she said, in that way moth-
is director of the Leukemia
ers say things without saying anything.
Program at the Cleveland Clinic
It’s the perfect blend of disappointment,
in Cleveland, OH.
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 prac-
tices in which we don’t pen many letters, relying instead on the ubiquity
of electronic health records (EHRs) for others to learn of our delibera-
tions 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 de-
fine 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 compli-
cated 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.
Mikkael Sekeres, MD, MS
Editor-in-Chief
December 2018