CMDA's The Point

A “Bot” Too Far

July 27, 2017
Photo: Pixabay

by David Stevens, MD, MA (Ethics)

Words are important. The words I use to describe my patients, even if I am only thinking those words and not speaking them, affect how I feel about them and how I treat them. I’ve known this for a long time, so I work hard to guard both my thinking and my speech as I care for patients. I don’t consider myself prone to making snap judgments about people based on their appearance—that is, I don’t see myself as biased.

So last month, as I was listening to a talk on “Addressing Weight Bias in Healthcare” given by Dr. Scott Kahan as part of a conference on treating obesity, I didn’t think I was one of the physicians whose speech reflected a negative attitude. When the speaker stressed how much better it is to say, “This is a woman with obesity,” rather than, “She is obese,” I nodded assent. Surely I always describe my patients as human beings with a disease, rather than equating them with the disease itself.

Yet only an hour after that talk, while speaking with a different presenter about a patient, I said, “He is obese.”

“He has obesity,” she gently corrected me.

“Yes,” I said, flustered. I hadn’t even known I had said it. So much for my smugness.

Unfortunately, in our society people with obesity are considered fair game as targets of stigma. That is, it is socially acceptable to be prejudiced against people affected by obesity, treating them with disdain and considering them lazy, weak-willed and unintelligent. Yet the causes for obesity are complex—including environmental and genetic factors—and one glance at people’s outer appearances cannot possibly give anyone enough information about them to justify treating them in a negative manner. Doing so is to be prejudiced.

And we who are following in Christ’s footsteps can look to Him as an example on how to treat those who are devalued by the rest of the world. Jesus’ encounter with the woman at the well in John 4 is a case in point. She had three strikes against her: she was a woman in a male-dominant culture, she was a Samaritan whom the Jews considered “half-breeds” and she had a scandalous sexual history. Yet Jesus looked past the surface issues and reached her heart.

Sadly, healthcare workers often have negative attitudes toward people with excess weight. This includes physicians, mid-level providers, nurses, dietitians and psychologists. The quality of the care provided suffers, leading to:

  • Fewer preventive health services and exams
  • Less access to cancer screening tests, such as pelvic exams and mammograms
  • More frequent cancellations or delays of appointments
  • Less time spent with the healthcare professional
  • Less extensive differential diagnosis—that is, a tendency to blame all of a patient’s symptoms on the excess weight, rather than considering other causes or diagnoses

As their BMI increases, patients report that their caregivers have less patience, less of a desire to help them and more scorn. As a Christian, I don’t want this tendency to be true with me. I want to communicate respect for my patients as human beings made in the image of God. And it all starts with the words I use to describe my patients in my thoughts, deep inside my mind.

I remember reading House of God by Samuel Shem during the preclinical years of medical school. House of God is celebrating its 40th anniversary this year, but it was a newish book when I read it. Shem was a pseudonym for Stephen Bergman, who had recently completed his internship and decided to fictionalize his experience. He and his fellow physicians-in-training delivered care with little sleep, constant stress and a pervasive feeling of powerlessness. How did they respond? By depersonalizing their patients and becoming cynical.

House of God is satire—a negative example, as it were, and that is how I took it. It galvanized me. I determined to fight the tendency to see patients as mere cases, and not people. The book opened my eyes to how the downward spiral into depersonalization could happen, and I didn’t want to fall into that trap.

The book is caustic and raunchy, so I generally don’t recommend it, but both my fellow family-physician husband and I thought it would benefit our daughter, Martha Grace, as she entered medical training. She decided to delay reading it until the end of her intern year.

“I found it cathartic,” Martha Grace said, “because it validated my experience of internship being very hard. Sadly, some people still talk the way they do in the book—though, system-wide, changes have been made. Residents don’t work 120 hours a week, and we’re not verbally abused. If I’d read it earlier, it would have been off-putting. Some loss of wide-eyed optimism is inevitable in the medical training process, but reading it earlier would have accelerated that for me. I admit, though, that I do sometimes say things like, ‘Room 235 is the cellulitis.’ I try to use person-first language, but when I’m just trying to get through rounds quickly, it’s easy to slip up.”

Martha Grace’s family medicine residency hosts Balint groups, which are groups of six to 10 residents with a facilitator, meeting to discuss “difficult patients” and their responses to them. These are not medically-oriented discussions, but rather a forum for discussing the struggles of caring for patients who, as she says, “take 90 percent of our energy and are the least grateful.” Balint groups were first formed in the late 1950s by Michael Balint, a British psychoanalyst to “improve physicians’ abilities to actively process and deliver relationship-centered care through a deeper understanding of how they are touched by the emotional content of caring for certain patients.” Martha Grace’s residency hopes they will help forestall cynicism and prevent burnout.

In the medical literature, patient-centered language has increased over the decades, recognizing that patients are unique, complex individuals and participants in the research process: “Whereas medical language previously emphasized treatments and disease processes, the trend during the last 40 years has been to separate patients from their disease and to emphasize the patient rather than characterize patients by their disease.” So you will no longer find in the major medical journals a reference to “the diabetic patient” or “the diabetic,” but rather “the patient with diabetes.”

Nowhere is it more important to use patient-centered language than in documenting mental health issues. In the electronic medical record, it is best to use objective words that describe behavior, and replace words with negative connotations with less charged words. How we use language either reinforces biases or promotes strengths.

So in our documentation, in our conversations with other healthcare professionals, in our encounters with patients, and—most fundamentally—in our thoughts, it is important to choose our words carefully. Are they reflecting what we know to be true, that God made each and every person in His image, for His glory? Words, I say again, are important. Words can harm, and words can heal.

David Stevens, MD, MA (Ethics)

About David Stevens, MD, MA (Ethics)

Dr. David Stevens, author of Jesus, MD, Beyond Medicine and co-author of Leadership Proverbs and Servant Leadership and serves as CEO Emeritus of the Christian Medical & Dental Associations, a national organization of Christian healthcare professionals that seeks to change hearts in healthcare. Founded in 1931, CMDA promotes positions and addresses policies on healthcare issues; conducts overseas and domestic mission projects; coordinates a network of Christian healthcare professionals for fellowship and professional growth; sponsors student ministries in medical and dental schools; distributes educational and inspirational resources; holds marriage and family conferences; provides missionary healthcare professionals with continuing education resources and conducts academic exchange programs overseas. At CMDA, Dr. Stevens has helped develop an evangelism training program that teaches thousands of healthcare professionals how to share their faith in a healthcare setting. He was a catalyst for starting the Global Missions Healthcare Conference, trains new healthcare missionaries three times a year and annually leads a summit for executives of mission organization doing healthcare ministry. He has also helped launch a nationwide network of community-based ministries that provide on-site discipleship, fellowship and outreach opportunities for local healthcare professionals and students. As a leading spokesman for Christian healthcare professionals, Dr. Stevens has conducted thousands of media interviews, including NBC's Today Show, NBC Nightly News, BBC-World Television, Newsweek, JAMA, USA Today, CNN Sunday Morning, CNN News Site and National Public Radio. He has also appeared on FOX Family Channel, PAX-Television, Tech TV, The Odyssey Channel, America's Health Network and many other national outlets. He has written many book chapters and magazine articles. Prior to becoming a Zondervan author, he wrote a regular health column for the Promise Keepers' New Man magazine and served on the editorial board of Christian Single magazine. Dr. Stevens is also heard as host of the CMDA Healthwise Public Service Announcements, which address general health and bioethical issues and airs on radio stations nationwide. CMDA members hear him as the host of the popular Christian Doctor’s Digest audio magazine, which has featured national leaders such as Luis Lugo, Jim Cymbala, Newt Gingrich, John Stonestreet and Kay Arthur. Prior to his service with CMDA, Dr. Stevens served as director of World Medical Mission. In Somalia, Dr. Stevens led an emergency medical mission that treated 45,000 suffering Somalis in the midst of war. In the Sudan, medical teams under his leadership treated more than 25,000 villagers to stop the spread of an epidemic. Dr. Stevens has seen firsthand how meeting the physical needs of patients provides opportunities to meet their spiritual needs—by introducing them to God’s love through a relationship with Jesus Christ. From 1981 to 1991, Dr. Stevens was a missionary doctor at Tenwek Hospital in Bomet, Kenya where he served as Medical Superintendent and then Exeuctive Officer. He helped to develop Tenwek from a bush hospital to one of the most outstanding mission facilities in the world. At Tenwek, he directed a $4 million development plan, secured the installation of an $850,000 hydroelectric plant, oversaw the start of a nursing school and doubled the size of the hospital. The community healthcare and development programs he designed at Tenwek are currently reaching more than one million Kenyans and serve as an example of what medical outreach in the developing world can accomplish. Dr. Stevens’ experiences provide rich illustrations for inspirational and educational presentations at seminars, conferences and churches. His topics include missions and evangelism, spiritual commitment and growth, bioethics and other medically and spiritually related subjects. Dr. Stevens holds degrees from Asbury University and is an AOA graduate of University of Louisville School of Medicine and is board certified in family medicine. He earned a master’s degree in bioethics from Trinity International University in 2002 and served on the boards of World Gospel Mission and Asbury University. He has regularly taught at the Christian Medical & Dental Associations' educational seminars for missionary physicians and dentists in Kenya, Malaysia and other forums. He is a Fellow of the Biotechnology Policy Council of the Wilberforce Forum and helped found the National Embryo Donation Center. Dr. Stevens and his wife Jody have a son, Jason, and two daughters, Jessica and Stacy, and nine grandchildren, all of who are involved in domestic or international healthcare ministry.

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