How to Change the Language You Use to Discuss Your Patients, and Why It Matters

During the initial consultation with a new patient presenting with pelvic pain, you frantically scribble notes:

Denies pregnancy
Denies recent weight gain
Denies bicycle injury
Denies endometriosis
Suspected stress management issues
Suspected sexual abuse victim

 After treating the patient for two months, you write out notes documenting her progress:

Admits slight pain scale improvement but denies quality-of-life improvement
Suspected HEP noncompliance
Firmly denies past abuse, claims not under high stress

Two new rules for building trust with patients.

 Rule #1: Stop speaking Clinicianese.

 You gather background information on your patient, including pregnancy, birth control usage, and the date of her LMP.

DON’T:  Patient denies a pregnancy.
DO:  Patient reports that she is not pregnant.

Patients want to feel heard, understood, and trusted.  If a patient says she’s not pregnant and you write that she “denies a pregnancy,” it sounds like you don’t trust her.  You’re documenting that you asked and she answered, but you’re leaving room for the possibility that she is pregnant and simply, well, denied it.  The note insinuates accusation and distrust.

You have been retained to help the patient, not to investigate her.  By using accusatory language, even in your personal notes, you reinforce an anti-helpful dynamic that is far from a partnership.  If your goal is to build a relationship with your patient, then speak with her in plain language, document your notes using non-judgmental words, and trust her.

DON’T:  Patient denies a pregnancy and claims adherence to her birth control pills regimen.
DO:  Patient is not pregnant and adheres to her BCP regimen.

Rule #2: Support, don’t accuse.

You ask your patient, “Have you or any family members ever had endometriosis?”
She says, “Nope.”

DON’T:  Patient discloses no history of endometriosis and denies a family history.
DO:  Patient has never been diagnosed with endometriosis, and she is unaware of a family history of the disease.

Imagine that your patient is ultimately diagnosed with endometriosis, and when she receives her diagnosis, an aunt shares that she too has suffered from the disease.  Had you documented that she failed to disclose a history of it and that she denied a family history, this new information would seem like a contradiction.  It would suggest that she had hidden information from you.  Rather, if you partner with your patient in her care, then new discoveries (i.e. an endo diagnosis) will be documented as just that – new information.

Then you suspect that this same patient isn’t following her HEP.  You think that if she were, her range of motion would be improving quicker.  But, it’s also possible that she’s adherent to her HEP and it’s just not helping her.  Remember that coming to appointments is a big commitment in time and money – your patient wants to get better.  So try to avoid being accusatory, and try to get to the bottom of what’s going on. 

There’s two issues I’d like to address here: asking the question politely, and documenting the response in a respectful way.  Don’t accuse her.  Support her.

DON’T:  You aren’t really keeping up with your home exercises, are you?
DO:  Your HEP should be helping more than it is, so would you like to review it and see if we can tweak it to get you feeling better faster?

DON’T:  Suspected noncompliance with HEP.  Patient claims 3x/week adherence with no ROM improvement.  Reiterated importance of HEP compliance and reviewed exercises again.
DO:  Patient performs her HEP 3x/week, but her ROM isn’t improving.  We’ll revise the HEP to include a weekly yoga class with her friends.

Yes, in my examples, the actual outcomes are different.  That’s because listening to the patient is likely to yield different outcomes.  In this hypothetical example, she shared with you that she’s doing her HEP but finds the exercises hard and boring.  She lamented that she wished she was healthy enough to join her friends for yoga after school drop-off.  You think this would be an excellent addition to her regimen and would really advance her recovery, so you include it in her treatment protocol. Your support for her participation in turn boosts her confidence and increases the likelihood that she’ll comply.

That’s just bad customer service.

Remember that your patients are your clients, and keeping them satisfied requires you to treat them like customers!

If your conduct around your patients would get you fired as a restaurant hostess or would net you a single-star review as an Uber driver, it’s probably inappropriate in a healthcare clinic.  In other industries, it’s seen as wildly inappropriate to accuse and judge your customers, and to then document it in such a hypercritical manner.  Why isn’t it rude for providers to do so?

As we move into relationship-centered care models, we need to focus more on acting like people in relationships.  That means we don’t say mean things behind people’s backs (“suspected noncompliance with HEP”), and we trust when people say they’re not pregnant (“denies pregnancy”).  We allow for the relationship to grow organically in such a way that the patient can disclose new information as she becomes comfortable, and you create a safe environment in which she can share those most personal details.  The key here is that you ask questions not just at her initial consultation, but each time you see her, and you create an ongoing and dynamic dialogue about her health, which you document in a respectful way.

This blog is made for educational purposes and is not intended to be specific legal advice to any particular person. It does not create an attorney-client relationship between our firm and the reader. It should not be used as a substitute for competent legal advice from a licensed attorney in your jurisdiction.