Benefit of the doubt.

I have been listening to how we refer to and talk about patients, and I am concerned. The argot or slang I am worried about is often demeaning, dehumanizing, or accusatory. Much of what we say and write, I believe, is a subconscious desire to shift the responsibility inherent in the physician-patient relationship from ourselves to our patients. Our language often reflects an attempt to make the patients responsible for their diseases, for what we do to diagnose and treat them, and, indeed, for the complications of these tests, treatments, and procedures and even the outcome of their illnesses. This manner of speaking is commonplace with students, house staff, faculty, and private practioners. The following examples are frequently heard in elevators, on morning report, during attending rounds, informal conferences, grand rounds, and idle conversations: This Patient Needs/Deserves. “This patient needs a liver biopsy because his liver is enlarged and his liver test results are abnormal, and we don’t know what is wrong with him.” I know of no patient who needs a liver biopsy. We physicians need a biopsy specimen of the patient’s liver to obtain information to enable us to diagnose and better treat the patient’s illness. The patient would be better off and at less risk if we didn’t need to do this invasive procedure. “Mr. Jones has been having transient episodes of blindness in his right eye. He has a bruit in the right carotid artery. Mr. Jones deserves a carotid arteriogram.” He evidently has worked hard for it and he has earned it. He rates, merits, and is entitled to it, and so a carotid arteriogram will be awarded. A written example of deserving patients is found in a recent article in the New EnglandJournal of Medicine [ 11, where the authors write “. . . we propose that every patient with unexplained anemia deserves a therapeutic trial of thiamine in high doses.” The Patient Failed. “This patient has oat cell cancer of the lung. We gave him the best combination of chemotherapy we have and he failed it.” Of all the things we say that put the onus on the patient, this bothers me the most. The patient didn’t fail, the chemotherapy did, we did. The cancer prevailed. It saddens my heart that we blame the patient when what we do is ineffective. A written example of a patient’s failure is found in a recent Journal of the American Medical Association [2], where the author writes “I remember Bradley, a young leukemic patient who had failed all standard and experimental chemotherapy.” The Patient Claims/Denies/Admits. You would think the patient was a defendant in a court of law. “This patient claims, Judge, your Honor, that she has been having more and more chest pains for the past two weeks. She further claims that she has been getting short of breath with exertion and wakes up at night smothering despite the medicine that was prescribed. She denies that she has been off her diet, or that she has been eating potato chips, bacon, or salty peanuts. She does, however, admit to drinking two cocktails every night. She used to smoke two packs of cigarettes a day but claims she quit 10 years ago. What is your verdict?” The Tune-Up. “Well, Mrs. Smith, it appears that your diabetes is out of control and you have mild congestive heart failure-nothing serious. I think we will be able to tune you right up. If everything goes all right, I want you to come back in one month for your 50,000-mile check-up.” I will not be surprised if advertisements for “tune-up specials” for certain diseases begin to appear. For example, “Special! Get a tune-up for your bronchitis and emphysema-half price-this week only!” This Patient is Noncompliant. “This patient has hy-