The Power Of Ordinary English To Improve Healthcare

For non-physicians, medical terminology can be frustratingly opaque. One of my friends is a highly-educated computer professional who knows multiple programming languages, but he has also told me, “I don’t speak ‘Doctor’.” When physicians communicate with patients using cryptic medical jargon, patients can easily misunderstand the intended meaning.

Medicine is one of the few fields where “negative” often means something good, whereas “positive” means something bad. A recent study by Dr. Rachel Gottleib and colleagues in JAMA Network Open showed how frequently patients “misunderstood and often assigned meaning opposite to what the clinician intended.” In particular, they studied jargon that might have one meaning in ordinary speech, but a different meaning in medical discussions.

Some of their specific findings were interesting. For example, most non-physicians (96%) knew that a negative cancer screening result meant that they did not have cancer. However, “fewer respondents knew that ‘your tumor is progressing’ was bad news” (79%) or that “positive nodes meant their cancer had spread” (67%).

For radiology terminology, some misunderstandings were even worse. 80% of patients knew that an “unremarkable” chest x-ray was good news. But only 21% understood that a chest x-ray described as “impressive” was bad news.

Similar misunderstandings occurred with the term “occult”: “More people believed that the phrase ‘had an occult infection’ had something to do with a curse than understood that this meant that they had a hidden infection.”

Dr. Gottleib and colleagues note that a major source of the problem is that physicians often do not realize they are using terminology that can be easily misinterpreted by non-physicians — a phenomenon known as “jargon oblivion.” One of their paper’s key take-home points for physicians is that “by better understanding what medical terms and phrases patients do or do not comprehend, we can expand our jargon identification toolkit and ultimately improve our communication with patients.”

Following the theme of improving communications between doctors and patients, I was encouraged to learn of a study by Dr. Shanmukha Srinivas and colleagues in the American Journal of Roentgenology performed jointly at UC San Diego and at Stanford University, studying how to improve patient understanding of medical procedures by using “Patient Decision Aids” (PDAs) carefully crafted in ordinary English. These PDAs were created by the non-profit educational organization, The Interventional Initiative; interested readers can view online versions here.

Dr. Srinivas and colleagues studied the effect of giving patients about to undergo invasive interventional radiology procedures special two-page brochures written at the “sixth- to eighth-grade health literacy level” describing the usual benefits, risks, and alternatives to the procedure, prior to having the standard informed consent meeting with their physician. The interventional radiologists performing the procedures were blinded as to which patients did (or did not) receive the educational brochures beforehand; the physicians spent the same amount of time with the patients discussing the procedure and obtaining consent.

Interestingly, the researchers found that “patients who received a PDA before the visit reported significantly greater understanding of the procedure and its benefits, risks, and alternatives and were significantly more likely to feel that the clinician listened to them and answered all questions.” Furthermore, the use of the PDA did not slow down the workflow and required no “additional time or effort by the clinicians performing the consent conversations.”

Dr. Srinivas and colleagues noted that the key was well-vetted instructional material aimed at the “sixth- to eighth-grade health literacy level.” Unfortunately, they observe that most hospitals and medical centers typically provide educational material to patients “written above the mean reading level, with readability scores that were assessed as fairly difficult or difficult.”

One of my medical school professors used to emphasize that communications occurs only when the receiver has understood the intended message, not when the sender has transmitted the message. A doctor can use a thousand beautifully eloquent words to describe a procedure or a test result. But if the patient doesn’t grasp the intended meaning, then no communication has actually occurred! The work of Dr. Gottleib, Dr. Srinivas, and their associates has shown how practicing physicians can more reliably communicate with their patients.

Of course, communications is a two-way street. Whenever patients can more accurately communicate their symptoms and concerns to their physicians, both will benefit. Physicians are trained to ask questions to elicit informative answers from patients. But patients can help if they learn basic methods of describing symptoms that will allow their doctor to more quickly narrow down the possibilities that could be causing their problems.

For example, Anne Asher, CPT, has written a nice guide for patients on how best to describe back pain to their physicians. Her article gives suggestions on how patients can describe various aspects of pain, including the intensity, location, timing, and quality of their pain. Words that describe timing might include “constant, intermittent, at night only, etc.” Words that that describe pain quality might include “flickering”, “sharp”, “dull”, “shooting”, etc. (More examples can be found at the McGill Pain Questionnaire.)

Patients can also describe their symptoms in terms of how it affects their daily life activities — e.g., “I can no longer reach down to put my shoes on my feet because my back hurts too much when I bend that way.”

Again, patients do not necessarily need to know all the nuances of medical pain vocabulary. But to the extent they can use their own words to describe their internal experiences, they and their doctors can more fruitfully work together to arrive at an accurate diagnosis and an effective treatment plan.

I am a radiologist who specializes in interpreting MRI and CT scans. But I also recognize that the most effective tool for quality patient care is good communication between patients and doctors. A few well-chosen words can be worth a thousand high-tech pictures. The English language is a wonderful communications medium, and the skillful use of ordinary language can be a powerful tool to help both patients and physicians alike.