Words are incredibly powerful. So few symbols can evoke such deep feelings and rouse such great emotion – I have a dream. Language is the great achievement of who we are. But while you, I, and everyone else employ the same words to communicate shared ideas, what those words mean precisely to each of us among the many views and opinions that make us unique individuals can be quite different.
What if the language that we use in healthcare creates a bias, and produces real impact in how we help sick people? Would fixing the language to erase that bias become the cheapest and easiest improvement imaginable?
I know there are phrases that I interpret, mistakenly, as shorthand for more complex ideas. And I think there are some bigger examples that affect all of us more than we might believe.
One troublesome word is noncompliant. If a patient has been labeled noncompliant, he must not really want to get better. I can belabor the same points ad nauseam, it will not mater. This is of course an unfair mischaracterization of any individual. But we’ve all heard it, and we’ve all said it, and we’ve all thought something like this before.
Because we’re motivated to do the most good for our patients but also limited in time and resources, we make a subconscious, egalitarian decision to invest a little less into the care of this patient – we know we can do plenty for the patients who want to get better, so we should focus more on them, to maximize our own impact.
We should erase noncompliance from our collective vocabulary – not in the name of sensitivity, but because using it allows us to circumvent the real issue. When we accept a patient’s noncompliance, we have failed to address the root cause of his disagreement with or inability to follow our recommendations.
Another that gets me is telemedicine. I know that technology will change healthcare. Still, when I hear about a telemedicine consult, I picture a clunky and ineffective process that can’t possibly be as good as a provider’s real presence. I am of course wrong here as well: these tools are validated and help expand the reach of specialist providers.
I don’t know where I developed this bias, just that it’s there and that it’s not unique. I wonder how I would feel if my family member were evaluated, say, through a screen by a teleneurologist in the ER, who has the final say on whether or not to give tPA. I think I’d rather hear that they’d be evaluated by a neurologist, and that the best one available was remote. I realize also that this is irrational.
But these are small fries. There are bigger distinctions to make, and they are not semantic.
When do patients become patients, and when do they revert back to being just people? Aren’t they people all along? Is an individual with a chronic illness still a patient between care episodes? If I’m not sick, do I become a patient when I go for a physical? What about a person on the threshold of a diagnosis? A man warehoused in a nursing home for social reasons?
We should erase the notion of being a patient altogether, and talk only about people. This could change how and when we engage with people – each other – and facilitate a more proactive culture of wellness. It might change ideas about responsibility for health decisions. It would absolutely change our biases about where people need to be when they’re engaged with health services.
But for that matter, what is healthcare? Is it a label for any interaction aimed at improving someone’s well-being? Is it limited to exchanges between sick people and licensed professionals? Is it the sum of services provided within the walls of the healthcare system? (And haven’t we created those ourselves by defining what insurance pays for?) What about services done in a hospital, by a provider, paid for by insurance, that aren’t necessary in the first place?
When we talk about the healthcare system, we all more or less mean the sum of experiences between patients and providers, in hospitals, clinics, or other designated settings, involving services which are intermediated by insurers. And there are some colossal problems to unpack here.
Imagine that a patient, at her yearly physical, has no complaint beyond that she feels out of shape. On paper, she may not meet the criteria for any diagnosis. Many providers can help her now, and can do much more for her today than they can a year from now, but they won’t be doing healthcare – at least not in the way we’ve allowed it to be defined by codes and payers. Maybe what this patient means is that she feels the symptoms of early insulin resistance, that she’s at risk for and on the precipice of developing diabetes, but it’s not her job to know or tell us that: it’s our job to tell her and to do something about it.
Insurance won’t pay for healthy food or exercise education, and that means care of that type happens outside of the healthcare system. The existence of codes attached to diagnoses on paper literally stops us from doing the right things to care for this person. Paradoxically, a system which is supposed to enable care is now preventing it.
There are too many individuals at home right now deteriorating in functional capacity who we will not know about until they fall and become patients. Even if we could identify them today and engage with them before injury, thereby preventing a massive and costly sequence that shortens lifespan and creates lasting limitation, we wouldn’t be doing healthcare as it stands.
Would we be providing care to people who need it, at the right time, and in a way that could impact them more than anything we might do after the fact? Absolutely – but not in a way that the healthcare system is designed to operate (i.e. receive payment for).
If we started from scratch today and redesigned the delivery of health care, we would never build what we have now. We would never use the words that we do because we would never arrive at these inverted concepts. We might not build a healthcare system at all, but instead engage with people proactively, at home. Instead of paying for procedures and hospitalizations, we would create a population budget like we do for education. The important thing is that we wouldn’t impose the barriers that exist now, and we wouldn’t think of people as needing our help only after they become sick and can be called patients.
Nothing became this way on purpose. We evolved to where we stand through dynamic societal pressures and adapted to succeed in relation to the payment models presented to us. The language that we use, which has meaning only in this context, connotes very real bias that influences health decisions enormously. We won’t ever stop calling people patients or talking about the healthcare system, but we should be mindful of the ideas attached to those words, and always question whether the choices we make might be different if we could erase those preconceptions.