Medical word use in clinical encounters The Harvard community has made this article openly available. Please share how this access benefits you. Your story matters Citation Koch-Weser, Susan, William DeJong, and Rima E. Rudd. 2009. “Medical Word Use in Clinical Encounters.” Health Expectations 12 (4) (December): 371–382. doi:10.1111/j.1369-7625.2009.00555.x. Published Version doi:10.1111/j.1369-7625.2009.00555.x Citable link http://nrs.harvard.edu/urn-3:HUL.InstRepos:33942517 Terms of Use This article was downloaded from Harvard University’s DASH repository, and is made available under the terms and conditions applicable to Other Posted Material, as set forth at http:// nrs.harvard.edu/urn-3:HUL.InstRepos:dash.current.terms-of- use#LAA doi: 10.1111/j.1369-7625.2009.00555.x Medical word use in clinical encounters Susan Koch-Weser ScD,* William DeJong PhD and Rima E. Rudd ScDà *Assistant Professor, Department of Public Health and Community Medicine, Tufts University School of Medicine, Professor, Department of Community Health Sciences, Boston University School of Public Health and àSenior Lecturer, Department of Society, Human Development and Health, Harvard School of Public Health, Boston, MA, USA Abstract Correspondence Objective Doctors often use medical language with their patients Susan Koch-Weser despite findings from a variety of studies that have shown that Department of Public Health and Community Medicine patients frequently misunderstand medical terminology. Little is Tufts University School of Medicine known about the patterns of medical word use by doctors and 136 Harrison Avenue patients during clinical encounters. Boston MA 02111 Methods A content analysis of 16 verbatim transcripts of first USA clinical encounters between rheumatologists and newly referred E-mail: [email protected] patients was conducted to assess how doctors and patients intro- Accepted for publication duced medical words. Medical words were identified via a computer 12 April 2009 program using a defined list. Keywords: content analysis, doctor– patient communication, health literacy, Results Doctors did not introduce or use more medical words than medical terminology patients, but the types of words that doctors and patients introduced did differ. The majority of patient-initiated medical words occurred during the history taking (94%). Doctors did not explain, or use as part of an explanation, the majority (79%) of the medical words they introduced, and patients seldom responded in a way that would indicate whether or not they had correctly interpreted those terms. There was relatively little repetition of medical words within or even across encounters. Conclusions This study provides insights into how the use of medical terminology could contribute to misunderstanding. Find- ings suggest that steps already promoted in the literature to improve doctor–patient communication may also ameliorate potential prob- lems arising from the use of medical terminology. terms are now widely used (e.g. ÔautopsyÕ and Introduction ÔorallyÕ),2,3 many other relatively common med- Medical terminology is often complex, and ical words continue to be problematic.3–9 For within the health-care context everyday words example, one study found that only 28% of pre- can take on specific and uniquely clinical operative anaesthesia patients correctly inter- meanings.1 It is not surprising, then that patients preted the term ÔfastingÕ.7 Unexplained medical find it difficult to understand the words that terminology can also be a barrier to effective their doctors use or misinterpret their meaning. communication in clinical encounters, leading to Although some medical words have entered the patient anxiety10 and potentially poorer health general vocabulary so that once unfamiliar outcomes. Ó 2009 The Authors. Journal compilation Ó 2009 Blackwell Publishing Ltd Health Expectations, 12, pp.371–382 371 372 Medical word use, S Koch-Weser et al. Despite its complexity, doctors persist in using patients must accomplish specific communica- medical language with their patients, perhaps tion tasks. Doctors should seek to understand a because of its precision or to assert their patientÕs underlying beliefs and usual coping authority.10,11 In an analysis of transcripts from strategies so that they can describe the models over 300 clinical encounters, the 40 participating that guide their medical conclusions and treat- doctors used Ôtechnical termsÕ in every encoun- ment choices in ways that facilitate the inte- ter.12 Surprisingly, the studyÕs authors concluded gration of the new information with a patientÕs that this terminology was not problematic, models of disease and past experiences. At the asserting that the terms used were well known or same time, patients must express themselves that the transcript showed that the attending and participate in decision-making. Such com- doctor either explained them or dismissed them munication requires a high level of information as not worth knowing. In counterpoint, a survey exchange between doctor and patient21 and in in one hospital setting found that, although a typical clinical encounter most of the time is doctors thought that they were using Ôeveryday spent exchanging information.22 Yet, we know languageÕ with patients, both patients and nurses very little about how medical words are used by thought that the doctors most often used Ômed- doctors and patients in clinical encounters, ical languageÕ.13 The Medical Expenditure Panel medical words upon which the success of the Survey found that only 58% of patients reported exchange may depend. that their health-care providers explained things Early research studies in the health literacy in an understandable way.14 field used short and easily administered Medical words may be particularly problem- approximations of reading skills, such as the atic for the 46% of US adults who, according to Rapid Estimate of Adult Literacy in Medicine the 2003 National Assessment of Adult Literacy (REALM), to assess patientsÕ literacy skills.23 (NAAL), have limited health literacy skills and The REALM is a medical word recognition test, cannot consistently perform text-based tasks and its use has demonstrated that patients in a related to health-care access and health promo- variety of populations have difficulty reading or tion.15 NAAL assessed health literacy on the pronouncing medical words.23–31 Such patients basis of print-based tasks calling on reading and may not be able to understand their doctors computational skills. The Institute of Medicine when they use medical terminology.32 (2004) highlighted that health literacy is more The pattern of medical word use by doctors than reading, and includes speech and speech and patients is likely to be shaped by the par- comprehension skills as well. At the same time, ticipantsÕ respective roles and to vary as the reading skills often offer a strong proxy of encounter progresses from the history, through broader literacy skills, because reading is the the examination, and to the discussion of diag- most efficient way to learn vocabulary.16 Adults nosis and treatment options. Role theory posits who read a lot, not surprisingly, tend to have that people behave, and expect and encourage larger vocabularies and greater verbal fluency.17 others to behave, according to patterns of This study focuses on vocabulary in medical behaviour they have learned from social con- encounters. In choosing what words to use, texts.33 In clinical settings the roles played by speakers make assumptions about their lis- doctor and patient will be separate and mutually tenerÕs knowledge base.18 Doctors and nurses validating. As the professional, the doctor often overestimate patientsÕ health literacy expects and is expected to demonstrate expertise. level19 and their knowledge of medical termi- One way of fulfilling their role as medical expert nology.2 A variety of studies have examined is to use medical terminology; if the terminology clinical communication and patient under- functions in part to help the doctor Ôbe a doctorÕ standing, but only a few have examined the they may sometimes leave medical words unex- patterns of medical word use by doctors and plained. Patients, who may not understand all patients. According to Daltroy,20 doctors and the medical terminology used, in their role as Ó 2009 The Authors. Journal compilation Ó 2009 Blackwell Publishing Ltd Health Expectations, 12, pp.371–382 Medical word use, S Koch-Weser et al. 373 patient may be deferential to the doctorÕs Methods expertise and hesitate to interrupt to ask that terminology be explained. Data During history taking doctors seek informa- tion from their patients and may introduce The data presented here were originally collected medical terms in their questions. When giving as part of a study of doctor–patient communi- their history, patients are the ÔexpertÕ and those cation in a rheumatology clinic.34 The doctors familiar with medical vocabulary may be likely and patients were audio-taped during their first to use medical terms to describe past treatments clinical encounter. The audio tapes were tran- and illnesses. After the examination, doctors scribed by medical secretaries and then exam- discuss their conclusions and recommendations ined for accuracy by clinically trained reviewers for action, potentially introducing still addi- familiar with arthritis-related terminology. tional medical terminology. During this phase of The original study was approved by the hos- the encounter patients may be less likely to call pitalÕs