Does the language of health care matter?

Disclaimer: Dammit Jim, I’m a nurse, not a linguist!
We’ve been arguing over the language of the healing professions for a long time. Providers. Midlevels. Doctors. Physicians. Physician Extenders. Do the semantics matter to the development of the roles? To the patient experience? To the politics and payment?

  In a 1951 article from the Medical Library Association, Thelma Charen took on the task of tracing the etymology of the word medicine. According to Charen, the latin roots of medicine are easy to follow, from medicina, to medeor or medicor: to heal or cure. Tracing the root back further to an ancient Indo-European root (MA, MAD —> MED), we land on “to think or reflect, to give care to”. This links medicine to meditate. Over time, language crystalized from the general idea of considered reflection to more specific applications, eventually to specifically caring for the sick. Interesting. Noble. Relatively free from baggage.  

What, then, about nurse or nursing? The line is less straight and narrow, and more fraught. Thomas Long takes us through it. Nutrice, latin for wet nurse (and also related to the word nourish), morphed into a more general term for caretaker of children— a female caretaker, specifically. In the medical context, Long notes, nurse first appears in Shakespeare. (I’ll leave aside the meaning as it relates to bees, though that might also be interesting to the sexual politics). So nursing, the profession, is linguistically linked to nursing, the act of feeding the child from the breast. And thus linked also to female-ness. Of course, just tracing the history of a word doesn’t capture its full meanings, but it’s not irrelevant. Not at all. Those of us who practice nursing will tell you that there are persistent biases related to power and gender that plague our profession. The health professions (notably medicine) have been slow to understand nursing as a mature, serious, and independent profession with its own ontology. Nursing’s metaparadigm includes the concepts of person, environment,health, and nursing— note the absence of “disease,” “orders,” “bedpans,” or “hospitals.”

The language isn’t neutral. It’s steeped in meaning and history. And it’s part of our cultural understandings of professional roles. These days, people like to say that health care is a team sport. Some organizations (you can guess) want to append that to say “and a physician is the team captain”. But that’s not always wise— physicians make great captains, in some contexts— but so do nurses, counselors, pharmacists, or physical therapists, in others. It doesn’t need to be a turf war or a hierarchy. Let’s all stick to the roots of our roles, evidenced in the language of medicine: Reflection. Caring. Let’s carry it forward into our professional practice, our praxis, and our teams. Let’s think about our unique bodies of knowledge and our relationships to our patients, and let that guide our teamwork. And let’s be careful, considered, and kind with our language. Do we all have to agree? Of course not! But let’s agree to be willing to listen and reflect.

What we talk about when we talk about research findings in the news

What happens when journalists report the findings of a scientific study to the general public? Often, the findings are stated out of context, broadly interpreted, and stripped of the nuance and uncertainty that characterize much of scientific research.  Should this scare us back from publicizing findings to a wider audience than you might typically find in a scientific journal? Or is publicity critical to uptake?

What is our responsibility as scientists to communicate our findings, not only through dedicated dissemination and implementation planning, but also through the popular press?

Here’s a recent example. JAMA published the findings of a study by Mandager et al.  on the association of cardiorespiratory fitness (CRF) with long-term mortality. CRF was measured by exercise treadmill testing in a sample of over 120,000 patients who were having this test done anyway as part of their care (that means these people were mostly being evaluated for symptoms potentially related to cardiovascular disease). The investigators quantified CRF as peak estimated METs. They separated by sex and age to calculate percentiles and then stratified CRF based on those percentiles. They used public and hospital records to determine mortality. Median follow-up was 8.4 years. The investigators concluded that CRF was significantly inversely associated with all-cause mortality (i.e., the fitter you are, the less likely you are to die). They went on to state that low CRF was as risky as or riskier than diabetes, CAD, or smoking. They also noted, importantly, that “there does not appear to be an upper limit of aerobic fitness above which a survival benefit is no longer observed”, but “there continues to be uncertainty regarding the relative benefit or potential risk of extreme levels of exercise and fitness”. They go on to offer several other sensible caveats, including that the study population may not be representative of the general population, and there are potentially significant unmeasured factors in this retrospective study. All things considered, though, this seems to represent very good news: a modifiable factor is strongly associated with increased longevity in a large sample with a long follow-up.  Bravo!

So how did this get reported in the popular press? Gizmodo’s headline reads “No Such Thing As Too Much Exercise, Study Finds”.

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On Alignment

What do you think of when you hear the word alignment? The wheels on your car? Your body position in a yoga pose? I bet it’s not online education. . . but hear me out.

Because I believe breakthroughs come from cross-pollination among disciplines, I’m going to borrow this concept from Quality Matters— which is a system for evaluating the quality of online courses. In this context, alignment refers to the relationships among course objectives, unit or module objectives, instructional materials, learning activities, and assessments. Are the outcomes measurable and appropriate, at both levels? Are the course components aligned with those outcomes? This sounds basic, but it can be surprisingly challenging to achieve. Mapping out these connections can be difficult– and enlightening. I’ve done it as both a course instructor and a peer reviewer for other courses, and found it enormously valuable.

So let’s distill this idea down to the basic components: set high-level goals, set smaller goals to support the big goals, and choose actions and assessments that align with those goals.

Where else can we use this simple structure to improve things?

  • Clinical management. The patient’s “big-picture” goals are surprisingly frequently absent from the conversation. But patient-centered care demands identifying goals for health and for life. A care plan that doesn’t include an assessment of goals is in peril before it even gets off the ground. And I don’t mean goals like “get A1C less than 7%”. I mean goals like “extend my healthy lifespan so that I can travel in retirement”. That might be a radical shift and it might alter management. Or it might mean the same basic management plan is perceived very differently by the patient. I’ve written about the concept of concordance in healthcare before– it’s similar. Aligning our plans to treat, follow-up, and assess our patients with our shared goals, both long-term and more immediate, is crucial to effective care.
  • Career trajectories. I recently wrote about the challenges of focus in an academic/clinical career.  What if, instead of a single-minded focus on a narrow area, each opportunity is considered in terms of alignment with “big-picture” goals? This approach allows for more bricolage (which, BTW, can make work relevant and grounded), more cross-pollination, more serendipity, more diversity– without falling into a scattered mess. I have a couple of broad interest areas and goals, and I find that rather than continue to narrow into extreme sub-specialization, I prefer to exist as a practicing member of the communities I’m a part of, and participate in projects that align with those areas.
  • Self development. This is what tools like the Passion Planner promote– making big goals, identifying smaller pieces of those goals, and taking steps to move towards them. The act of identifying goals, and identifying small steps, is enormously powerful in making progress. It takes deliberate thought and reflection, but the outcomes of small actions over time that are all aligned with a goal can be mind-blowing.

So there you go. Take a simple principle, and see how powerful it can be in different contexts. Think about how Atul Gawande used a checklist strategy from aviation to improve surgery, and think about what big ideas might disrupt your regular practices.

From hard targets to risk models: Who are we helping?

There’s something appealing about a threshold-based approach to treatment: if your cholesterol is over 200, it’s high. If your blood pressure is over 140, it’s high. If you A1C is over 7, it’s high. It’s clean, easy to understand and easy to communicate. But is it helping to improve meaningful outcomes, and is it doing so equitably? Does 140 for me create the same problem as 140 for you? Is 141 worlds away from 139? These aren’t easy questions to answer. It complicates the already complicated conversations around taking medications for prevention.

We’re starting to see evidence across different conditions that risk-based approaches to treatment, i.e. those that treat based on aggregation of multiple risk factors into a predicted risk of some adverse outcome, might be better. The first major test-case for this was lipid guidelines, but recommendations for other conditions are starting to change too:

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dealing with death.


In Tucson each November, there is an event called the All Souls’ Procession. It’s a relative of the Mexican holiday Dia de los Muertos, but it’s a distinct and unique experience. People come together and walk through the city with floats, puppets, photos, banners. They dance, chant, drum. They paint their faces and wear costumes. There’s a giant urn. There’s a celbratory aspect, but also a solemnity. There’s a shared sense of loss and solidarity. It’s moving and remarkable.

In most of America, anxiety around death is rampant. There are huge silicon valley projects dedicated to promoting longevity. We talk about “not giving up” and “fighting.” We put 85-year-old people with failing organs on ventilators and tube feeds at great expense, both in finances and in human suffering. We use euphamisms like “passed on”.  We generally don’t think and talk about the fact that death is a presupposition of life— the thing that, by oppostion, defines it, and the place that it ends. Life and death are in this way inseperable. It’s a strain on our society, I think, to stick our fingers in our ears and ignore this.

Of course there are people who resist this tendancy to avoid thee idea death. Continue reading

Why patients clash with doctors

I’ve seen several loved ones frustrated by interactions with the medical system lately, and after my initial knee-jerk reaction of “how dare they mess with one of my people” and “we have a shitty system, and we probably always will,” I got to thinking more about it. Why do people who are seeking help from a medical professional so often walk away feeling demoralized and disrespected, in addition to whatever problem brought them in in the first place?

Generally speaking, people choose careers in medicine because they want to connect with and help others. Medical school is grueling, and expensive, and people generally don’t do it if they don’t have some inclination towards service of others. Likewise, people seek out care from physicians because they want to feel better. Something isn’t right, and physicians are there to tell you what it is and how to fix it. They’re not stupid or lazy, just sick. By and large, this all lines up. So where do things go wrong? Let’s check out this handy chart:

Medical Visit


A few thoughts:

  • Doctors expect to be able to fix any “real” problem. This is how they’re trained— “true disease declares itself” is a common mindset.
  • Patients expect doctors to be able to fix any problem. All problems are “real.”
  • Some problems are well defined and understood within the structure of allopathic medicine.
  • Some problems are not well defined and understood within the structure of allopathic medicine. But they are not less real!
  • When patients present to doctors with problems from column b, things can go bad. Patients feel like they are not being listened to, taken seriously, or understood. Doctors feel like patients are being non-compliant, have unreasonable expectations, or are hypochondriacs. Everyone thinks everyone else is a jerk.

So what’s the root of this mess?

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