Pay Attention to How Doctors Talk

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Brian Goldman, MD, knows how doctors talk. He has been an emergency medicine physician at Mount Sinai Hospital in downtown Toronto for more than 20 years.

He has interviewed hundreds of health care professionals on his weekly radio show “White Coat, Black Art,” which is now in its ninth year on CBC/Radio-Canada.

He also wants to talk. His provocative presentation at TEDxToronto was called “Doctors make mistakes. Can we talk about that?”

So perhaps it’s only natural that his latest book, “The Secret Language of Doctors,” is centered around the way health care professionals speak to each other. But he’s not talking about medical jargon; he’s talking about slang.

GOMERs. Frequent fliers. Code Brown. Cowboy. Single terms capture clinicians’ attitudes towards patients, each other, and the system. They express frustration. They promote discrimination. They create bonds.

“If you want to understand the culture of medicine, you should pay attention to how doctors and other health professionals talk,” Goldman told MedPage Today.

MedPage Today interviewed Goldman about his reasons for dissecting medical argot, his interactions with “The House of God” author Stephen Bergman (who Goldman labels the “Slangmeister”), and what he learned about his own use of language in the process.

MedPage Today: When did you decide that this was a book you needed to write?

Goldman: Let me start by saying that the book is part of a career path that I’ve been on since “White Coat, Black Art” has been on the air. I didn’t know it at the time but when I was pitching, my original pitch for the show was a pitch for a book. It was a book called “Medical BS.” Basically about the disconnect between what we say-what health professionals say to each other when they think patients and their families aren’t listening-and what they say in front of patients and families.

I’d say after the first 10 or 20 episodes I realized I was on a mission to explain and unpack, demystify the culture of modern medicine as an observer and a participant.

And then I started to think again about slang . . . I read “The House of God” hot off the press, when I finished medical school. It was published in 1978. Everybody at that time was reading it. And everybody remembered the words, the slang: GOMER, turf, buff, bounce back. It was authentic-sounding, not jargon of course. It was slang.

So I asked a very simple question: “What’s happened since that book? Did slang die?” I started to do some research to ask the questions “Are people still using slang and what are they inventing slang for?” And very quickly I discovered that there was a massive lexicon of slang, and it’s spoken by all kinds of health professionals. There’s slang specific to paramedics, to intensivists, to internists, to emergency physicians.

My thesis was: If you want to understand the culture of medicine, you should pay attention to how doctors and other health professionals talk. One way to find out how they talk is slang. If you pay attention to the slang, you’ll learn a lot about their attitudes towards patients they find frustrating, situations they find frustrating, problems with the system, problems with each other.

What I decided to do was to take a few archetypal terms-not the most exhaustive list-and go from those archetypal bits of slang and use them as the jumping off point to explore the culture out of which they emerge. If there’s frustrations about dangerously obese patients, why is that? And that’s a perfect example because it has the social and cultural underpinnings of our attitude towards people who are dangerously obese and how obesity is one of the last refuges of out-and-out prejudice against patients. It’s one of the few examples where you can do it and get away with it.

MPT: When you first told people about your idea, what kind of reactions were you getting about this book?

Goldman: I had reactions all across the board. Ranging from “I wouldn't be caught dead in a book like this” to “Giddy up, when can we talk?” It was a mirror of the reaction I had when I started doing “White Coat, Black Art.”

You make the assumption that health professionals who pledged confidentiality are terrified that they’ll say something that will come back to haunt them, because most health professionals I know are very sensitive to criticism. So that’s one kind of dominant view. But very early on I discovered that health professionals want to unburden themselves. They want to talk about what they do. They want to reflect on it.

I found very quickly that there were people who would not talk to me and people who would talk to me. I made a calculated decision early on, an all-encompassing global decision, that I was going to put all the residents off the record because I’m old enough to know what could happen to them if they were outed. And their careers could be in jeopardy. Because one day they’re going to have to look for a job and perhaps they’ll want privileges in a hospital. The easiest thing in the world would be to not hire somebody who talks to the media.

MPT: You mentioned that the animosity directed towards bariatric patients surprised you. Were there any other surprises?

Goldman: I had a lot of people express doubt about the existence of slang . . . And my answer to them was, “Well, have you heard the phrase frequent flier?” And they would invariably say, “Oh yeah.”

They don’t realize that it’s slang. It is. They think that slang has to be pointy, sharp-edged, and bitter.

I guess for me it was an education. It wasn’t just writing the book but also being educated about the work of Jeffrey Brenner and others like him who have attempted to figure out why certain people come back to the hospital. Now some of them are re-admissions, but a lot of them are people who simply don’t have a better place to go or they don’t have good follow-up . . . If you can address those reasons, find a better place for them to go, guess what? They stop being frequent fliers.

So for me the surprise was Jeff Brenner talking about what he’s done in New Jersey: bending the cost curve, intercepting patients. People who are repeat visitors. He calls them “super utilizers.” His group intercepts these patients when they’re admitted to hospital and on the way home to make sure they pick up their medications, they get their follow-up visits.

To me the slang is useful because it directs you to focus attention on a problem. Obviously, where I draw the line is in stereotyping human beings.

MPT: Do you think there is a chapter in the book that particularly resonated with you, in terms of your own behavior?

I would say the chapter on GOMERs. I was writing that chapter as I was taking my very frail, elderly patients to the hospital again and again. And I saw my own tendency to stereotype patients with dementia.

The education for me wasn’t just in talking to others and hearing their stories, but my own evolution through looking after my parents and seeing the health care system from the point of view of a son, of a middle-aged son of increasingly frail parents.

That doesn’t mean that I'm pointing fingers at my colleagues. By and large they took wonderful care of both my parents I think my sister and I would both agree. But I can tell you that the patients’ or the family members’ point of view is seldom front and center.

MPT: I want to talk about your interactions with Stephen Bergman. Why did you want to talk to him, and how did it go?

Goldman: I had many email exchanges with Stephen Bergman, and he can be a difficult guy to pin down because he’s a busy man, he’s still writing books . . . I was able to meet him, and I spent a couple of days with him and met him on several occasions.

I had actually, I had interviewed him about “The House of God” 30 years ago for the Canadian Medical Association Journal. The thing that was really interesting at the time was that he absolutely refused to give me his name. He was Samuel Shem [the pen name under which the book was published]. That’s how you reached him, that’s how you spoke to him, and that’s how I quoted him in my article. A lot has changed in more than 30 years.

He is a very interesting, deep thinker. He is a writer, I would say, first and foremost.

He was very generous with his time, he was very reflective. I think he was delighted that somebody was interested in the slang that occupied only really a few pages of “The House of God.” He had an ear for dialogue that made the reader believe that they were there on the front lines along with his characters.

Bergman is very concerned about issues in the culture of medicine . . . He helped us solidify the internal thesis of the book. That I was right to be writing the book.

MPT: There was a quote in the book from Bergman: “You can’t let the jokes be the reality. You can’t let the slang be the reality.” Are we running away with slang? Is it out of control?

Goldman: Oh yeah. I would say that in my opinion Bergman’s book was the virus that infected the culture of medicine. That’s not blaming him for what it’s become, but he made [talking slang] sound compelling and cool.

Slang existed before that, but there is no question in my mind that when you look at the history of slang in medical culture there is before “The House of God” and after “The House of God.”

I would say that once it’s okay for people to invent slang, you have no control over how they’re going to use it. And some of the slang that I encountered was witty-some of it described situations but didn’t stereotype patients. And others weren’t-certainly, referring to the patient as a cockroach. It’s not witty. Or [as] a troll. It simply objectifies and stereotypes patients and strips them of any kind of individual identity. Which I’d like to say doesn’t happen in the culture of medicine, but clearly it happens in some pockets of the culture.

MPT: You're a big advocate for transparency in medicine. How do you think your book folds into that theme?

Goldman: I’m a big believer in revealing what we think and what we feel because I think it’s good for the public, and I think it’s good for us. It’s good for us that we reflect, and it’s good for us psychologically and emotionally.

To the extent to which it fuels us to change things within, then I think it’s good for us and it's good for the system.

I think patients and families need to know the benefits of knowing the attitudes of health professionals, the frustrations of health professionals.

Who knows? Maybe they’ll advocate for change, maybe they’ll understand why health professionals are frustrated with certain situations. And sometimes maybe they’ll find another health professional to look after their loved ones. Any of those are possible.

Read an excerpt from The Secret Language of Doctors.

This article was first published on MedPage Today and reprinted with permission. Free registration is required.