Words Matter: Making Sense of Health Equity Language

Activity Transcript

Hansa Bhargava, MD:

Welcome to Medscape Education's Health Equity series. Today we'll be speaking about Words Matter: Making Sense of Health Equity Language. I'm Dr. Hansa Bhargava, chief medical officer of Medscape Education. I'm really excited, as today's guest, we have Dr Gerald Harmon, [immediate past] president of the American Medical Association. Gerald, thank you so much for being here today.

Gerald E. Harmon, MD:

Hansa, thank you for inviting the AMA to speak to this very important issue.

Dr Bhargava:

Before we get started, I know the audience would love to hear a little bit about your background.

Dr Harmon:

Well, my background is relatively nondescript. I'm a family medicine specialist in rural South Carolina. Except for the longevity, that's a little less nondescript. I've been doing this for 40 years and that's just been my real calling, to be a family doc and to help so many people in my state and neighborhood and to have an opportunity also to work within the organized medicine platform, like the American Medical Association, for the last decade as well.

I'm an active family doc. I've done the full spectrum of family medicine. Early in my career I was delivering babies, doing minor and relatively major surgeries, because this was a small town in America, just a handful of physicians, and then we've progressed now that I'm doing more traditional medicine. I'm not delivering babies, but I'm working in the hospital, I'm seeing patients in office setting, and I work with a multi-specialty group as their vice president of medical affairs.

Dr Bhargava:

Wonderful. Well, thank you so much for all the great work you've done. It is much appreciated by everyone. Let me jump right in here and we are going to be speaking about words and the narrative. Let me just ask you, why does narrative matter in clinical practice?

Dr Harmon:

Very good point. First off, doctors use words, use communication as one of their clinical skills, almost as much as they use scalpels and stethoscopes, they communicate. They need to be able to interview patients, they need to understand their patients' situations, and the way to gather data is the classic history-gathering. We need to be able to interview and ask appropriate questions of our patients in order to form a more exact diagnosis and then be more appropriate in delivering care for those individuals.

We've been paying a lot of attention over the last decade on underlying narratives that our words and these languages reflect. This language concern is not about political correctness or about the right word or the wrong word, it's about thinking about, on a larger level, what we need to communicate and what we need to ask our patient population. So, language clearly matters. We are leaders in the community. A lot of my doctor colleagues say, "Hey, I don't want to be a professional communicator. I'm not going to be a community leader or any type of public voice, so let me just handle my information the way I want to do it. I'm not really interested in being told how to ask questions and interview."

I would contradict that and say that physicians, by their very advanced degree and standing, we are influencers, we are leaders, we are public speakers, and we're quoted, we're respected. There's a trust in our words and our trust in the medical advice that we need to be responsible and accountable for. So it's very important to be exact and be as intentional as we can be in our words.

Dr Bhargava:

Yeah, I think that is so true. Communication is key in our profession, and it doesn't matter about whether you're in academia or a community leader, as you said, Gerald, I think all of us need to do that and communication is key in just even understanding the patient. Also, communicating to them because compliance and when the patient leaves the office is a big part of treatment. So if we're not actually making that relationship because we're not using the right words or acknowledging the conditions, then I think, unfortunately, we're not able to do as good a job as we want to do.

Dr Harmon:

Well, clearly, and I find this almost daily in my personal medical practice. One of my other opportunities is I get to teach and precept family medicine residents here in a relatively young family medicine community, we have eight PGY1 openings every year. We've graduated two classes. We're on our sixth year now of a 3-year residency, and I find the opportunity to teach language and considerations of language to these young doctors in training really rewarding to watch them evolve in their clinical skills and their history-taking skills to an advanced degree beyond what they might have learned in medical school.

Dr Bhargava:

That's wonderful. Speaking of communication and speaking about equity-focused alternatives, different words, outdated terms, do you feel that physicians and clinicians are open to using these terms, the learning curve that must happen in order for us to be as up-to-date as possible in our communication style?

Dr Harmon:

Yes, they are, and it's interesting. We're scientists. You and I are scientists. We're always going to be continuously learning. We use the words like continuous learning organizations and life-long learners somewhat cavalierly, but at our very core, we're scientists. That's what drove us into the healthcare profession. We're also humanists. We want to serve mankind and fellow persons. If you look back at what I wrote in medical school, what you wrote in medical school, what almost every graduate of medical school in the world writes, "I want to serve humanity. I want to give back to my colleagues and my community." And that's the basic core of why we're in healthcare. If you think about it, we're going to stop learning when we get that degree or get our training, then that's really antithetical to the profession and to the oaths that we take.

I do find that when I make suggested commentary to my patients, I did it today, I made it to my young second year resident who introduced a patient to me, not in the patient in the exam room, but talking about the patient outside the door. They said, "Dr. Harmon, this is a 58-year-old epileptic, asthmatic, diabetic." I said, "Well, I understand. Let me just tell you how we need to look at this, because what we have in here is a 58-year-old that's suffering from recurrent seizures, who's suffering from recurrent asthma, and who has problems with her diabetes. So she shouldn't be thought of as that type of description. That should be a person, a human with those disease components." Then they thought about it for a minute, said, "You're right."

That's a very simplistic answer, but it also can be taken more seriously when we talk about persons with substance use disorder. I don't need to have my young doctor introducing a patient to me as a 42-year-old drug addict. What I want to hear is they are a patient with substance use disorder recovering that's here for maintenance of their therapy to recover and maintain recovery. And that's a whole different perspective. It doesn't necessarily impugn the dignity or the intelligence of the physician asking the questions, it just makes them thoughtful about how to address this human that has this disorder.

Dr Bhargava:

Those are such great examples, Gerald, really. Just reframing the language makes such an important, it makes such an important point, but also, I think it invokes empathy and compassion, which are essential for us as caretakers. And as far as dealing with humans, I think that's such an important element of what we do.

Dr Harmon:

I do enjoy my stories because they are based on lived experience and real experience. Another one that happened again this morning with a different resident physician, was presenting to me about a 62-year-old female and was presented to me as non-compliant with her blood pressure medicines and her seizure medicines. She said, "The patient just doesn't know exactly what she's taking. She takes them on her own. It should be taken daily and she takes it on a PRN basis as necessary." She said, "This is so frustrating. She's so non-compliant."

I said, "Well, again, let's think about this. This word non-compliant, while descriptive to many physicians, also puts an institutional bias in the patient that the problem is she's just not going to do what we say. When, really, when we're thinking about it, it might change to non-adherent, not adherent to medical advice because maybe we're not making it presented to her in a language that she can understand and appreciate." So I said, "Let's go in there." When we talk to her, don't say, "You've got to quit taking these medicines wrong." Say, "Hey, let me ask you how we can improve your diabetes, your blood sugar levels, how we can improve your breakthrough seizures by taking these in an especially timed manner." Let's go over this and approach her as a person with misunderstanding, not as someone who just makes up their mind to be non-compliant.

Dr Bhargava:

Such a great example again. Again, it really reframes the patient as a person, and that is just so essential because, just as you indicated, in order to help that patient, we actually have to be communicating in her language, understanding what her issues are, what could be the challenges in not being able to adhere to the medication. And just by reframing those words, that makes us open up our minds.

Dr Harmon:

Those are examples of how we can change it on a day-to-day basis, but I think the bigger construct here and the bigger discussion we are having today is also about the ability to change. Language evolves and it should always be taken in context. It's not fixed, it's not literally carved in stone, although some memorable words are indeed carved in stone, no question of that. But that language evolves like everything else. And when we think about things, there may be an inherent bias in the way we approach things.

If we think of the language as opposed to, let's say, “a minority person or a low-income, undereducated person living in a minority community,” and you paint that structure, that picture, that mental picture with your words, you might inherit and apply an institutional or social bias to that individual that's absolutely wrong.

What I think our language needs to think about, this person who is marginalized, who has been unable to access adequate healthcare, lives in a place where we don't have broadband so they can't get telehealth and they can't necessarily get transportation. There's limited transportation. Those who live in an island in rural South Carolina or in a swamp area where they're restrained from geographically or accessing healthcare. This person who is marginalized and unable to access care that's had poor nutrition in his or her life is having problems with diabetic control or problems with blood pressure control.

And then you think of that individual and you think about the reasons that they're there and you ask yourself the question, "How can I make this person better? Well, how can I prevent this person and future people from becoming that person? How can I look upstream and figure out why these folks are in the river of health inequity and health disparities?" Language is one of the ways we can change our thought processes and apply solutions.

Dr Bhargava:

Yeah, absolutely. It is correct what you say in terms of the changing nature of language and the effect it has on just how we view it, how we view the situation. So it's not just about calling asthmatic the person with a person with asthma, but it's also about reframing what the person is doing as well in the context of the inequities that they might have.

This has been a great conversation. I do want to ask you, for the clinicians who are listening, and I think clinicians are lifelong learners and I think that we do want to change and we do want to learn how to better ourselves, what resources are the further awareness and understanding of health equity language?

Dr Harmon:

The AMA is really good about making resources available for physicians, including practicing physicians and for educational systems with physicians in training and medical students. We have on our, what we call the AMA Ed Hub, that's a very good resource. You could get on the AMA Ed Hub, on the AMA website, and you don't have to be a member, although we encourage you to at least sign a board, but it is clearly something that's available to all physicians. They’re called Steps Forward Modules. We have some self-programming modules that are available in PowerPoint and PDF documents and online learning documents that talk about language and health equity.

In early of 2020, we released a health equity plan to address structural racism and health disparities in America. It was a very good plan with five pillars [strategic approaches] in it. And then a couple of months later, we released a health equity language document. That's available on the AMA website. It's been very well received. It's a very thought-provoking document that's designed to stimulate thought and a broader conversation about what causes health inequity, how can we address and end health disparities, and language is one of the tools we can use. It's actually been similar to something the CDC has recently brought up last year that uses similar language documents.

So, the AMA has resources, the CDC has resources on their website, and I find them to be very effective tools that I use periodically. It's not like I can remember this stuff day-to-day. I'll go back and refresh my perspective, and I think it always guides, then, my decision-making for some time thereafter.

Dr Bhargava:

Well, that's great. It sounds like there's a lot of resources out there and I encourage our audience to go take a look at those resources. This has been a great discussion, such an important topic. So not only being aware of health equity, but also making the change yourself to change the language, because it actually invokes thought, compassion, empathy, and just gives us a reframe of the patient. Is there any final words you'd like to add, Gerald, you've been so helpful?

Dr Harmon:

Hansa, I want to tell you, we talk about it, and you and I both agree, we're all scientists. We're all wanting to learn, we all want to be better than what we do. If someone comes up to me and say, if I'm a surgeon and I've got a new stapler, and of course, we've had new stapler techniques, we've had new skin closure techniques, who had thought 20 years ago that we would be closing wounds with glue, instead of sutures and things like that and we have all manner of technology at our hands available. Just as we've developed our technology, just as we've developed better electronic skills and physical skills, this language, this communication awareness and approach to health equity and to addressing our language is one of our tools to enhance adherence and to benefit all Americans. This is a really important tool too, and I encourage every physician to think about changing and improving his or her practice with more awareness of what words mean and why they matter.

Dr Bhargava:

Absolutely. Such an important task, and thank you for all your work that you're doing in this regard. Again, thank you for your time. You're a very busy person and we have really enjoyed having you. I know the audience feels the same. Until next time. This is Dr Hansa Bhargava.

This transcript has not been copyedited.