Do no harm: Researchers help doctors identify words they should never say to patients

In a recent paper published in Mayo Clinic Proceedings, Texas A&M University Distinguished Professor of Marketing at Mays Business School Dr. Leonard Berry and co-authors from Henry Ford Health in Detroit assert that in spite of rapid progress in the treatment of serious illnesses such as cancer, advanced heart failure and end-stage pulmonary disease, certain "timeless" aspects of the patient experience remain, like fear.

"Communicating the nature, purpose and intended duration of often complex treatments, and setting realistic expectations about what they offer still comes up against timeless patient experiences: fear, intense emotions, lack of medical expertise, and the sometimes unrealistic hope for cure," they write. The "intense, daunting nature of these conversations" may cause clinicians to resort to learned communication habits or declarative statements.

Even a single word may scare patients and families, make them feel disempowered, and possibly negate the effectiveness of shared decision making.

"Because seriously ill patients and their families are understandably frightened, they 'hang' on every word their doctor will say," notes Berry, a senior fellow at the Institute for Healthcare Improvement. "Serious illness is not only a matter of physical suffering, but also emotional suffering. The doctor's behavior, including their verbal and nonverbal communication, can exacerbate or reduce emotional suffering."

Berry said all too often, doctors use insensitive language in communicating critical information, and commonly do so without realizing the needless alarm or offense they have inflicted.

Never Words

Patients and families need to feel "psychologically safe" in communicating with health care professionals, Berry said, including in expressing concern about the proposed treatment plan or in conveying their fears. The researchers say if doctors respond using "never words," they may undermine patients' and families' confidence to speak freely.

"Never-words are conversation stoppers," the researchers write. "They seize power from the very patients whose own voices are essential to making optimal decisions about their medical care."

Utilizing clinician surveys, the researchers identified never words, including:

• "There is nothing else we can do."
• "She will not get better."
• "Withdrawing care."
• "Circling the drain."
• "Do you want us to do everything?"
• "Fight" or "battle."
• "I don't know why you waited so long to come in."
• "What were your other doctors doing/thinking?"

In another study specific to cancer care, clinicians were asked for words or phrases they would never use with a patient, with the top results including:

• "Let's not worry about that now."
• "You are lucky it's only stage 2."
• "You failed chemo."

'"Let's not worry about that now' is not only a non-answer to a patient's legitimate concern, it's dismissive," the researchers said. Pointing out that cancer is in an early stage is "presumptive, assuming the patient should feel gratitude, without allowing room for the patient's anxiety and fear in having cancer." And, Berry said, patients do not fail chemo; chemo fails patients.

What Doctors Should Say Instead

Health care professionals can start a dialogue by inviting honest, thoughtful inquiries and responses from patients and families. "They should learn to recognize words and phrases that unintentionally frighten, offend, or diminish agency and work to reimagine their own communication," the researchers stated.

Berry says such an opportunity can arise when doctors encourage patients to speak up. "Something as simple as, 'What questions do you have for me?' rather than, 'Do you have any questions?' invites candid conversation," he said.

As for the never words, the researchers recommend alternative language, as well as the rationale, for each. For example, instead of, "She will not get better," the doctor could say, "I'm worried she won't get better." The rationale being the provider will replace a firm negative prediction with an expression of concern.

Using words like "fight" and "battle" may imply that sheer will can overcome illness and patients may feel as if they're letting loved ones down by not fighting hard enough. Instead, doctors could say, "We will face this difficult disease together" to make it clear patients have a team behind them.

Spreading Awareness

Medical groups and educators can bring attention to never words in multiple ways, the researchers said, including by integrating the discussion into courses and professional development.

"The emphasis in medical school is understandably on the science of medicine, but it is so important to incorporate communications training into the curriculum," Berry said. "A key opportunity is medical school students and graduates having superb patient-centered, skilled communicators as role models in their clinical training during medical school and residency."

Mentorships are also invaluable as more experienced doctors can share communication techniques that they've found to be successful and which to avoid. The study notes, "Mentors can not only disclose harmful phrases that they personally have abandoned and replaced by more generative phrases but may also model walking back language that lands poorly…Such mentorship facilitates progress in how future generations of clinicians interact with patients and stimulates open dialogue about the added suffering and disempowerment that poor, unmindful communication can cause."

Collaborators on the study are Dr. Rana Lee Adawi Awdish, critical care physician and medical director of care experience, Henry Ford Health; and Dr. Gillian Grafton, advanced heart failure and transplant cardiologist, Cardiac Intensive Care Unit, Henry Ford Health.