-Department of English-
Health Humanities Undergraduate Research
Valuing the Patient-Physician Lexicon
Purpose
The patient-physician relationship determines patient outcomes. It’s an aspect of medicine that has been highly studied and patient-focused healthcare strategies have risen over the last few decades. Effective communication between a patient and a doctor will decide a patient’s quality of care. Howbeit, throughout my studies, literature on doctor lexicons highlight medical terminology or speech patterns rather than causal language. The actual words spoken are neglected. I moved my research goal from performing lexical analyses on dialogues I’ve gathered to justifying the need for examining word choice because of the sparsity of information on the topic. My research investigates how important vocabulary—each and every word spoken to a patient—may be to improving communication.
Approach
I had strict criteria for the literature I selected. As any linguist would agree, if studying word-choice, the language from which terms are selected from must also be defined. Including languages other than English—already somewhat incorporated as English is a bit a bully language, beating other dialectics up in alleyways—would require separate etymological studies and extensive research about culture and sociology from the nations most associated with said languages. That was beyond the scale of my current abilities, especially within a single semester.
Furthermore, variants of English weren’t included for similar reasons. That unfortunately eliminated many interesting papers from my preliminary dataset. Additionally, I insisted on only studying the doctor-patient relationship because of stark differences in how doctors are trained versus other highly skilled medical workers. Doctors also have a unique social status in the U.S., which would affect the relationship between them and their patients, thus impacting the way the two groups speak to each other again.
Early in the research, I “banned” any sources without at least a few direct quotes from doctors in conversation with patient as I intended to perform my analyses this semester. Once I shifted my goals, I incorporated material that directly referenced on that type of dialogue and/or would build a case for the importance of lexical research in medicine. Researchers dealing with jargon were excluded because I was interested in how conversation went. I found that most words in dialogues largely excluded technical terminology, even more so following decades of patient-centered practices advising clarity.
My approach made finding information about medical language in relation to word-choice difficult. I ended up looking primarily for guides before moving onto books and published papers. My common search terms included but are not limited to: “patient outcomes doctor patient relationship,” “patient-doctor dialogues,” “physician-patient dialogues studies,” and “lexical analyses doctor patient.” Below, I have collected and recorded 39 sources. All are listed in the archives with respective hyperlinks.
Main Texts
The four books below were the primary sources in research. Each contains at least one strong association with my source evaluation criteria and are mentioned in relation to each other as well as other relevant literature.
Sarah Manguso: The Two Kinds of Decay
Manguso’s experience with medicine is painful, like many other patients. That makes her story, the honesty she’s barred to the world—to medical professionals willing to listen—important. After collapsing on her Harvard campus, Manguso was diagnosed with a rare autoimmune disorder that dissipated her cells, threatening to not only kill her but the person she wanted to become.
Her book details how long-term patients view medicine and their memorable relationships with physicians. Manguso remembers years of inaccurate diagnoses before one neurologist landed on Idiopathic demyelinating polyradiculoneuropathy, a rare form of Guillian-Barre syndrome.
She remembers her first central line, “My hematologist might have thought I’d wanted my parents there to help me feel less fearful, but I didn’t know enough about the procedure to feel fearful” (37). Her doctor informed her about the science behind the procedure but not that “some would be standing over me, massaging my collarbone, while I lay blindfolded…the doctor flubbed the procedure…he tried again and again to jam the tube into my vein… At one point I thought I felt a jet of blood spurt into my chest cavity, and that’s when I lost my composure. Months later, after his hair had gone from steel gray to white, my father told me it had looked like a horror movie” (37-8).
Manguso’s trauma largely centers around the doctors around her, who seem unable to relate to her. The poor communication from the doctors ricochets onto Manguso until she’s able to take control over her treatments. The Two Kinds of Decay explains that chronic patients don’t simply desire control. They need control to survive the medical complex—not just their illnesses.
Though the only long-form patient narrative included in my research, I found Sarah Manguso’s memoir essential to shaping any further exploration into doctor-patient communication. She gives a sharp reminder that the lasting impressions doctors form with patients are too often devastating. These interactions destroy a patient’s confidence in the medical system at large and are often compounded experiences. Many medical professionals in these cases do not wish the harm they cause, but the difference between a positive and negative impact can be a single word or action.
Two Kinds of Decay solidifies word-choice’s importance in the medical field. Doctors’ empathy is often incomprehensible to patients. They don’t know the doctor outside their professional relationship, and not everyone is accustomed to others’ caring for them. Furthermore, neurodivergent patients struggle with reading neurotypical social cues, which may increase their stress. Manguso details one such troublesome, empathetic doctor.
“My primary care doctor visited me and said I’d already endured something much worse than most people have to endure in an entire regular-length life. His voice shook. He was forcing tears either forward or back… I refused to let him in my hospital room again…I felt no antipathy, just a certainty that his pity would accrue to me and would grow in me like the sea of antibodies with which I was already invisibly killing myself, and that I couldn’t take in any additional poison” (84).
Eric J. Cassell: Talking with Patients Volume 1: Theory of Doctor Patient Communication
Dr. Cassell’s series was the constitution this research abides by. It was difficult to purchase, and I had invested more than intended on both books. Buying them was also the best decision I made during my study.
In the first volume, which had been purchased after the second due to a shipping mix-up, Cassell discusses all parts of speech, personality, and psychology when dissecting patient dialogue. He also introduces paralanguage “(or paralinguistic) …the music of language: those nonword phenomena, such as pause, pitch, speech rate, and intonation” (10). Using dozens of recorded patient conversations, Cassell identifies pitfalls in communication and demonstrates how to understand patients.
In one example, Cassell returns to an earlier statement, “words always stand for something (6). He describes a story an anthropologist told him. A group member was hysterical after a snake bite that they all assumed was poisonous. Once the doctor said “‘that snake is not poisonous,’ the ‘patient,’ when finally convinced, recovered rapidly” (56). As Cassell points out, language can and will change perspectives. Therefore, words alter reality.
“Remember you are already dealing with two translators in any conversation: the patient’s understanding of your meaning, and your understanding of his or hers” (55). Fittingly, the book’s final chapter includes a complete list of descriptors for doctors to use when thinking about patients, including a separate adjective checklist.
Eric J. Cassell: Talking with Patients Volume 2: Clinical Techniques
The second volume is no less important than the first. Cassell writes from the opposite perspective of my research. He examines how doctors should speak to patients’ by looking at the side of patient-physician dialogue. Everything the doctor says should be a response to a patient’s needs, therefore interpretating patients’ statements is critical to formulating a treatment plan.
Cassell is unique as he involves language and mental health in his research. Much of what is said about communication aligns with another source author, Alan Alda, experience at a dentist office. “Physicians have a special responsibility to heed what the patient says about the past because, despite their misgivings, most patients do what they are told” (Cassell 123).
There’s a nuance in how Cassell prioritizes listening because he takes on an intersectional approach. Cassell proves that there is little difference between practicing medicine, communicating well, and as Alda says, acting. Likely because medicine is an intersection for all aspects of life. Heading back to etymological research, Cassell raises the importance of word choice when describing his approach when taking histories, “Close is not enough for history taking. Thus, to get at the real story of patients’ illnesses, it is not sufficient to peel the experiences away from the patients’ assignments of meanings, we must be doubly careful to keep our own meanings out of the story” (39).
Cassell further expands on this, stating, “Thinking about symptoms, attaching meanings to them, searching for explanations, are as much a part of the illness as are its physical expressions” (125). He even performs his own close readings, something that helped me contextual physician’s thinking processes and how they wish to use their words. “…if you change the wording of a question, you may change the response… Whenever I change a question or introduce a new one, I think about it and work on the wording for quite a while” (89-90). The factors Cassell brings up in both volumes must be preserved when attempting to optimize word choice.
“When we say that a woman has carcinoma of the breast, three years after mastectomy, the present tense is warranted because it conveys our understanding of the prognosis and what it requires of her physicians today… ‘She has Parrot’s disease’… does not even necessarily imply that the female is human” (149).
Alan Alda: If I Understood You, Would I Have This Look on My Face?: My Adventures in the Art and Science of Relating and Communication
Life experience rules the stories Alan Alda tells, all stemming from one encounter with his dentist. When told he’d experience tethering in his mouth, Alda, “well over the age of fifty, and certainly old enough to ask him to put the knife down and answer a few questions,” saw the dentist in his “priestly surgeon’s gown…impatient” and accepted the procedure, not realizing it would destroy his frenum—impacting his career, as he no longer smiled properly, and his relationship with his doctor (9).
Above all, Alda recalls the doctors’ language. “I told you there were two steps to the procedure. I haven’t done the second step yet,” followed by a cold, unapologetic letter advising against a lawsuit (10). Ironically, medicine, with or without intent, sometimes causes all the pain it wishes to heal—just like with Manguso. Proper word choice utilized alongside improved patient-empathy would given both the dentist and Alda the tools to navigate this experience better. Alda thought so as well.
Following this experience, he reflects, “I wanted the feeling that I was actually being seen by him….[The dentist] was speaking into the vague mist of interpersonal nothingness…[it was] disengagement from the person we hope will understand us” (10). Alda synthesized his acting talent with an honest captivation for the human experience in a manner that has changed the development of science communication.
His book details the origins of those alterations, including the foundation of the Center for Communicating Science at Stony Brook University. Alda drew from his understanding of relating, “real conversation can’t happen if listening is just my waiting for you to finish talking” (18).
He writes about the focus groups and research studies he’s been involved with, testing anything from Viola Spolin’s improvisation activities to relational studies that transferred emotion through sporadic string ensemble music. “the shock for me—and it was a happy shock—was that almost all the kids seemed to be playing the music with more freedom, even more joy” (79).
Alda includes an entire chapter that focuses on training doctors to be more empathetic, summarizing the work of psychiatrist Helen Riess, who researches empathy after an experience hooked up to a skin conductance machine with a patient. “‘I realized that with this careful attention I had learned to be more empathetic’” (50). She explains that empathetic intelligence, cognitive empathy (valuing patient intelligence within the relationship), and affective resonance (feeling of connectedness) are essential to building proper communication channels.
Much of this research connects well with Cassell’s second volume, where he details how a patient “swamped by hopelessness” transferred that emotion to a student who “felt hopeless because the patient felt hopeless. The student was entirely unaware of the origin of his feeling of hopelessness,” (Cassell 3).
This is relating at its peak, defined by Alda as, “It’s being so aware of the other person that, even if you have your back to them, you’re observing them. It’s letting everything about them affect you; not just their words, but also their tone of voice, their body language, even subtle things like where they’re standing in the room or how they occupy a chair. Relating is letting all that seep into you and have an effect on how you respond to the other person.” (18).
In terms of my research, Alda’s book was a blessing. Word-choice assessments weren’t isolated to the accuracy of dictionary or even social definitions of words. I had to include the quality of whatever meaning a sentence communicates. Reiterated, word-choice is tied with good communication because relationships are built off the “power of commonality” (152). Specifying the role of individual words in conversations is important because language is the peck of human socialization. It builds a people together, building the similarity Alda mentions. “For the best communication to take place, it may be that we can’t just be alike; we may have to be aware we’re alike” (150).
Word choice is not only easily malleable when looking at the fundamentals of communication; it’s also a subset of that awareness.
Highlighted Papers and Noted Sources
Outside the four main texts I read, my research encompassed several different books, papers, and articles. As my research expanded, I introduced literature that broadened my “Patient-Communication” section beyond dialogues and included theories or other relevant work on how doctors should speak to patients. The “Radiologist Series” is sectioned away from the other sources due to the specialized hypothesizes those researchers pursued. “Linguistic Focus” draws back to my original research question and will include content that has strong evidence for future analyzes. Those may have otherwise been sectioned into “Patient-Communication.” Lastly, “Natural Language Processing” delves into machine learning systems that recreate create dialogue from physicians.
Patient Communication
Stanford Medicine: "GET SMART: How to Talk to Your Patients About Antibiotics"
Stanford Medicine: "Serious Illness Conversation Guide"
This infographic focuses on increasing patients’ comfort with antibiotics, presenting a guide for medical professionals to aid concerned patients. The “GET SMART” strategy emphasizes several steps like gaining trust, explaining the reasoning behind prescriptions, and clearly defining future expectations regarding the medication’s effects. The advice is solid with a clear emphasis on clarifying each statement a physician makes for the patient’s benefit.
Unfortunately, this resource fails to identify vocabulary to use and doesn’t suggest that physicians explore reasons why patients have anxiety about medications, which could range from addiction concerns to financial strain. This isn’t uncommon for doctor-patient conversation guidelines. Though the short format of the document restricts the amount of information, “effective communication strategies” aren’t complete without including the language those strategies are employed with.
GET SMART is an example of how critical language choices are undervalued in current medical education. Word choice matters and guides that advise on speaking with patients should include tested—studied—phrases that will yield clarity to patients and provide better foundations for ongoing communication between both parties.
AMA STEPS Forward: "Choosing Wisely: Promote Patient-Physician Conversations to Improve Patient Engagement and Choose Appropriate Care"
AMA provides a program centered on bettering physicians’ interactions with minority populations and building trust with patients called STEPS Forward. Their miniguide presents several questions for physicians to consider when broaching conversation. STEPS Forward also addresses doctor’s top concerns like “Time Constraints,” “Overcoming Patient Preferences/Value,” and “Fear of Patients’ Dissatisfaction,” by reflecting on the average patient’s actual beliefs.
In terms of dissatisfaction, the document notes that many patients want appropriate care, not necessarily long visits, medications, or numerous health plans. This source contributed to my overall understanding of how physicians are taught to communicate with patients. Similar to the GET SMART infographic, no word choices are included. Despite referencing patient’s thoughts on doctor’s concerns, the document also contains no sources with direct patient quotes.
AMA STEPS Forward: “Empathetic Listening: Honor the Patient Experience During Crisis”
Unlike the 4-in-one script source, this is a direct module from the STEPS Forward program. The “Empathetic Listening” module revolves around increasing empathy—a central topic in Alan Alda’s book. It presents the five “STEPS” of empathetic listening: “Connect with Empathy by Honoring the First ‘Golden Moments,’” “Listen for Underlying Feelings, Needs, or Values,” “Remain Present When You Are Listening,” “Look for Cues to Speak Versus Listen,” and “Reflect on Your Experience.”
As a research source, the module aligned with the importance of implementing the right vocabulary with a patient and highlighted listening over speaking. Given that doctors are more accustomed to playing the role of a “speaker,” the module is an essential resource when restructuring one’s approach to patient-dialogue. Yet, I found some fault in how their advice was presented.
Alda mentions that empathetic listening is only hard and challenging when unbalanced. Though difficult, there are ways to slowly incorporate better communication tactics. “The problem is that some of these tips can have the opposite effect if you’re not aware of what’s going on in the other person’s head—or in your own. Or if you’re not aware of how your own feelings are affecting your tone of voice. Active listening can easily morph into veiled hostility” (73).
The “Empathetic Listening” module reads like a textbook and here I think it falls short. The STEPS module may not be effective in continued use. I did find their shorter guideline documents in line with Alda’s writing. They highlight actions and give brief examples before identifying group activities to practice skills, such as overcoming deflective listening.
Also, Dr. Cassell’s approach is visible in sample questions like “Is the patient feeling [this emotion] because they have this particular [value or need]?” emphasize the “Interior World of Language” (Cassell 45).
The conversation guide selects key statements that are attributed to different parts of patient conversation. Key words in sentences are bolded, which are noted for future research on word-choice, such as “goals,” “fears and worries,” and “hope.” These words are powerful because they identify the reason a doctor would ask a certain question for a listening patient.
The key words also provide a frame for other words in the sentence. For example, “I want to share with you my of where things are with your illness.” “Understanding” indicates that doctor communicates that they are knowingly giving information (on their perspective) to the patient.
“Where things are” suggests an unconscious unease with directly referencing current problems the patient’s illness may cause, but also promises to define the situation or illness at hand. This source was specific to severe illnesses, biasing the word usage in the phrases and perhaps making it inapplicable to other conversational settings.
AMA STEPS Forward: "Scripts to Help Your Practice Collect Patient Payment at the Time of Service"
Most medical organizations value the dispersal of short scripts and infographics, likely because the materials are easily circulated and require less effort to produce or follow while standardizing the pinnacle of “quality care.” This source contains 4 scripts to help professionals approach payment conversations with patients. “Show kindness, yet expect to be paid.” There are a few lines in each that address difficulties in communicating payments, including checking out and possible patient reactions. An example: “And when do you anticipate paying the balance of today’s visit?” (3).
Each script included a statement identifying the “frame” of the health provider’s words. The line above attempts to confirm a date of payment as well as formalizing the patient’s agreement to pay the provider. In my research, I originally disregarded scripted that weren’t centered around clinic conversation or diagnosis. However, all the conversations one has with a patient are essential to maintaining a proper relationship and ensuring that both parties are heard. This script also yields itself to future research I will perform as it contained direct lines, and therefore direct words, for me to analyze.
Though the writer clearly explains that the script should emphasize patient commitment, I wonder what research was done to make sure these statements are the most effective? In my conversations with medical students, as mentioned in the introduction, many instructors pulled from their own life experiences. While a reliable, if not the best, data source for medical providers, the experience of each doctor is nuanced, region-specific, and it’s nearly impossible to test objectively because it relies on an individual’s personal understanding of how their words are arranged.
James E. Groves: "Taking Care of the Hateful Patient"
Grove’s article deals less with the imagined “devil” patient and more how trauma and unmet needs manifests in doctors’ most begrudged. He identified clingers, demanders, help-rejecters, and self-destructive deniers as unpleasant patient archetypes—but Groves explores these patients scare medical professionals, “admitted or not, the fact remains that a few patients kindle aversion, fear, despair or even downright malice in their doctors” (883).
I found value in the psychology behind his research. It adds another layer of nuance to language that can be addressed once word-choice assessments are performed. Perhaps by structuring word banks against the extremes of patient needs and the doctor’s meaning, then working up from there. Groves identifies the emotions’ these archetypes cause as a form of countertransference, liking in Freudian psychology reworked by psychoanalyst D.W. Winnicott.
This article approaches the patients with empathy while providing physicians with broad guidance on working against these brewing, poor relational dynamics. He describes the clingers as “naïve about their effect on the physician…what is common to them as a group is their self-perception of bottomless need and their perception of the physician as inexhaustible” (884). He explains that their clinginess requires careful boundaries set from the moment early signs (extreme gratitude and “the doctor’s feelings of power and specialness to the patient…puppy love”), such as avoiding psych referrals and telling them that “the physician has not only human limits to knowledge and skill but also limitations to time and stamina” (885).
Grove approaches other patient types in this manner as well. Though his article gives much to learn regarding tailoring word selections to patient needs, I think the paper stands as a good example of a long-form way to communicate word-choice findings to medical providers. He threads in genuine humor along with situational examples, granting fellow physicians’ understanding and respite from their own feelings of inadequacy with certain patients.
Alt Text: "Hateful" Patients
BMJ Publishing Group Ltd.: "Patient Semi-Structured Interview Questions"
I found a series of patient-interview questions from the British Medical Journal. It has no source attached to it, but I did like the number of statements there and the information influenced search terms: “patient-interview dialogues” and “clinician patient interviews studies.” It appears to come from a study on physician-communication done at “Townsville Hospital,” so I will follow up and discover the actual article detailing the experimenters and research goals. However, unless the researchers are from the U.S., I will disregard this study in word analyses as British English varies from American English.
The American College of Obstetricians and Gynecologists (ACOG): “Effective Patient-Physician Communication”
The ACOG’s reaffirmed committee opinion number was another confirmation of how current medical approaches to patient communication are taught. Not only in that they tend to lack word-assessment and follow mnemonics, (and at this point, I had speculated and confirmed that the tendency to use mnemonics was residue from medical school) but also that the current guidelines would be critical to making optimal word choices easily applicable on the field.
Though their research contained little to no dialogue, they combined the nationally recognized “RESPECT” Model (rapport, empathy, support, partnership, explanations, cultural competence, and trust) with the Five Step Patient-Centered Interview checklist. For word-choice to be utilized, it shouldn’t be a laundry list of terms and extensive definitions, but small word banks sectioned off using current strategies.
At no point do I suggest that decades of research and reliable experience be cast aside. Rather, word-choice assessments sharpen what exactly is being said, making sure each word is used within the proper context, with the proper meaning, to eliminate a particular area of miscommunication.
Donald A. Schon: The Reflective Practitioner
The search for actual textbooks that included patient-dialogues and well-taught example statements lead me to find Donald A. Schon’s . The book is not centered around medical professionals, but there is heavy attention to communication across different work fields. The chapter “The Patient as a Universe of One,” delves into the relationship of psychiatrist within the medical world throughout history before examining the dynamic between a supervisor and a psych resident.
Schon notes that the supervisor has an “instruction [consisting of] demonstrating and advocating a kind of therapeutic reflection-in-actin, but it is also an approach of mystery and mastery…he keeps the sources of his performance mysterious. The Resident has complementary approach to learning. It is one of mystery and passivity. He withholds his feelings of dissatisfaction and frustration…he does not ask for what he wants to learn” (126).
Though this was not a choice I explored in this research, I am fascinated by this dynamic—it demonstrates that doctors’ personal experiences are, at times, inaccessible to their students. Furthermore, in conversations with patients, how much is missed because of assumptions? If word-choice assessments were used this vagueness may not be solved, but it could reduce other confusion factors or passively improve how medical professionals generally communicate.
Schon’s book is then a great resource for identifying these types of communication fractures in both patient-dialogue but instruction. I intend on returning to at least this chapter to clarify how word-choice assessments should be taught.
Mack Lipkin: “Teaching Medical Interviewing: The Lipkin Model”
The Lipkin Method, an approach to teaching patient-interviews to medical students and residents, is discussed in chapter 36 of Mack Lipkin, Jr.’s “The Medical Interview.” He explains “his approach integrates principles of learner-centered (or self-directed) learning with core human values, such as unconditional positive regard for others and attention to affect” (422).
Formulated after his experience in a problem-solving graduate lab, Dr. Lipkin wanted to reproduce the high-level student-learning rates he saw. His implementation of the method in medical school courses at the University of Rochester and later residency trainings serves as a possible parallel to integrating word-choice assessments into doctors’ training. Dr. Lipkin altered his course to accommodate participants’ time constraints, meeting weekly or learning contracts that are later turned into 10–15-minute presentations. “
The major barrier to using learner-centered approachs during inpatient months is the overwhelming patient care responsibility faced by the house staff team” (434). They are often won over by accomplishing their goals during his program, “Lipkin asked each resident beginning the elective to define goals and objectives… encouraged that their work together be based on real experiences” (433).
I hope that future research leads to methods that support physician education in this manner, making patient communication stronger without burdening already overwhelmed medical professionals.
Vidant Health: “Conversation Scripts for Providers”
I include the Vidant Health conversation script because it contained words for assessment, and I realized that a full discussion on physician’s word choices is inept without some mention of all possible influences to a doctor’s language. Insurance companies do insist that doctors they employ or otherwise work with follow certain instructions in conversation.
Vidant also served as a case study: What messages do insurance companies want to send? How do their messages dictate doctor’s speech? Vidant’s dialogues encompassed the entire visit, unlike others that gave more leeway with a few statements.
Ultimately, I found several scripts from insurance companies that were disregarded because they didn’t fit into my research methods. As mentioned in the introduction, I had maintained a narrow definition of what fit into assessable words for my original research plan. Many insurance company scripts were written, or edited, by lawyers, which didn’t fit the more organic word-flow I wanted to investigate.
Furthermore, many insurance company scripts were either too specific or including medical professionals other than doctors. I had wanted my study to only examine doctors’ lexicons because other professionals like nurses, physician assistants, etc. were trained differently.
They also maintained different historical and current social statuses and alternative relationships with patients. While their vocabularies are no less important or fascinating, it would have broadened the research scope too much.
PC: Noted Sources
Karen Knops and Sangeeta Lamba: Clinical Application of ASCEND: A Pathway to Higher Ground for Communication
Sneha Baxi Srivastava: The Patient Interview
Maysel Kemp White and Vaughn F. Keller: “Difficult Clinician-Patient Communication”
J Cutan Aesthet Surg: « Patient Satisfaction »
Charles Casassa: “Just Go with It: My First Patient Interview"
Timothy Gillian: “Patient-Clinician Communication: American Society of Clinical Oncology Consensus Guideline”
Mark N. Ozer: The Interactive Assessment: A Means for Enhancing Development
Ann Kind and Ruth B. Hoppe: “‘Best Practice’ for Patient-Centered Communication: A Narrative Review”
M. Jawad Hashim: “Patient-Centered Communication: Basic Skills”
Radiologist Series
Andrew B. Rosenkrantz: “Differences in Perceptions Among Radiologists, Referring Physicians, and Patients Regarding Language for Incidental Findings Reporting”
Rosenkrantz’s study was instrumental in defining my word choice key. His research provided samples on condensing word choice analysis in the medical context alongside the report “Examining the Linguistic Needs of Internationally Educated Nurses: A Corpus-based Study of Lexico-Grammatical features in nurse-patient Interactions.”
I found his work early on in my research, and it was backed up by two other studies related to how radiologists, other physicians, and patients can have different interpretations based on the slightest change in words. Rosenkrantz documented how those three groups viewed common terminology applied to liver lesions. He studied phrases like “benign cyst” vs “cyst” vs “tumor considered unlikely,” addressing how “terms used to characterize the level of uncertainty may themselves be a source of further uncertainty.”
There is enough change in how these groups interpret terms such as these that it affected patient treatment. “However, a referrer's likelihood of ordering follow-up imaging varied markedly according to the expression used to describe the lesion, ranging from 22% to 88% when the lesion was reported as anything other than a “benign cyst.” There are real consequences to miscommunication beyond patient dissatisfaction—medicine is a life-saving practice and thus anything detrimental to patient care will cause death. Word-choice analyses is understudied in medicine but may save lives with little research costs or trouble in implementation, as the Lipkin Method models.
Rosenkrantz concludes, “referring physicians and, to an even larger extent, patients had greater perceived concern than did radiologists regarding numerous expressions used in radiology reports to describe an incidental finding.”
Marian I. Mityul and Brian Gilcrease-Garcia: “Interpretive Differences Between Patients and Radiologists Regarding the Diagnostic Confidence Associated with Commonly Used Phrases in the Radiology Report”
This source, along with the other two radiologist studies mentioned in greater detail, studied interpretations based on different word choices in patient scans. The researchers compared patient and radiologist interpretations on patients’ likelihood of cancer. Terms assessed: “likely represents,” “compatible with,” “consistent with,” “concerning for,” “may represent,” “suspicious for,” “cannot exclude,” “diagnostic for,” “probably,” and “represents.”
David M. Panicek and Hedvig Hricak: “How Sure Are You, Doctors? A Standardized Lexicon to Describe the Radiologist’s Level of Certainty”
Yet another lexical study, Panicek and Hricak’s research remains consistent with the data from Rosenkrantz. They made a small list of “certainty terms in standardized departmental lexicon, with associated numeric estimate of radiologist’s certainty”: consistent with, suspicious for/probable/probably, possible/possibly, less likely, unlikely. They also define how each phrase should be employed.
Their terms were already in use at Memorial Sloan Kettering Cancer Center, where the radiologists were located. The researchers only arranged those terms, noting that they don’t intent the list to be optimal but rather an attempt to “share our experience with the hope of stimulating others to develop and adopt standardized terminology for this critical aspect of radiology reporting.” The lexicon was casually introduced and grew to “nearly universal” acceptance with compliance up to 98%.
This is exactly what I wish to do after applying an etymological lens to each word. The quality of the radiologist research series convinced me to open my source evaluation terms, including short chart notes when advisable. Though there is a difference between written and spoken words, the way the researchers’ spoke about the lexicon implied that it was spoken about at Memorial Sloan. Hence, small phrases which are easily recalled would be included when talking to fellow doctors and thus to patients (these are not overly complex medical terms).
Linguistic Focus
Alt Text: Future Research guide for word-choice assessments
Herbert H. Clark: “On the Use and Meaning of Prepositions”
Prepositions were a special focus I keyed in on when I first begun my research. Partly because I personally love using them in my own writing and was curious about their unique speech functions, but mainly because prepositions were prevalent in the few scripts I found.
Clark’s research investigates thirty-three prepositions’ meanings and similarities, centering on “their meanings as a system of relations” (421). With the help of 110 middle school students, some undergraduate students, and different grouping systems, Clark arranged the prepositions according to their similarities based on “Intersection Coefficient, a measure of the similarity of two distributions of words” (423).
Other methods were used to factor in possible preposition substitutions and free association—how easily related one word is to another in the mind. Within 528 pairings for the thirty-three prepositions, Clark discovered that “sentence composition, free associations, and semantic judgments were expected to be closely related, and they were found to be so…the main finding is that two prepositions are treated as semantically related when they are interchangeable in discourse” (427).
His work is relevant to analyzing doctor’s word choice and provides an additional research method for understanding the connotations physicians apply to their words. Cross-studying that with patients could identify gaps that encompass word choice but may also extend into other semantic features.
“[The way humans process words] implies that free associations originate in underlying cognitive units and not directly in sentences that [we] might produce” (430).
NOTE: Dr. Clark is also known for his “common ground theory” that highlights shared knowledge as the standard for meaningful conversation. Link to that work: https://web.stanford.edu/~clark/
Shelley Staples: “Examining the Linguistic Needs of Internationally Educated Nurses: A Corpus-based Study of Lexico-Grammatical Features in Nurse-Patient Interactions”
Staples’ research failed to apply to two areas of my source evaluation standards. It focuses on non-physicians and including analyses on non-English languages. However, I briefly include it in my research sources because of the study’s structure. The lexico-grammatical features studied are specific to the provider-patient interaction.
“Research has revealed two main grammatical features that seem to serve these purposes: expressions of grammatical stance (e.g., sort of, probably, only) (Malthus et al., 2005, Prince et al., 1982, Skelton and Hobbs, 1999a, Skelton and Hobbs, 1999b, Skelton et al., 1999), and conditionals (e.g., if you are in pain in the morning, see Dr. Carl or whoever) (Adolphs et al., 2004, Ferguson, 2001, Holmes and Major, 2002). The use of personal pronouns by doctors and nurses (e.g., I and you) has also been shown to reflect the patient-centeredness of the interaction (Adolphs et al., 2004, Holmes and Major, 2002, Rees and Monrouxe, 2008, Thomas and Wilson, 1996).”
It was one of the few studies that had an explicit center on causal medical dialogue between a medical professional and a patient. The study also included real-time dialogue rather than case notes, which is preferrable. I will likely refer to this source when structuring future resource. It breaks down the sentence components in more detail, including the assumed purpose of the part of speech (verb vs. “mental verb” to describe “feel” or “think”).
Steven A. Cole and Julian Bird: The Medical Interview: The Three Function Approach
This source was discovered late into the research process, after I’d made the switch from strictly studying words in patient-physician dialogues to justifying the importance of word-choice analyses.
As a result, only Units 1-3 are represented in the actual body of literature since those are dedicated to physician statements. Numerous sentence examples are offered and will be included in word assessments as they fit into all established source evaluation criteria. Bird and Cole’s Three Function Approach adjusts another guideline, Function Three, and aims to develop medical students’ skills when fostering bonds with patients.
“The three functions address three core objectives of the clinician-patient communication process: (1) build the relationship; (2) assess and understand the patient’s problems; and (3) collaborate for management of these problems” (xii).
Information is sectioned into distinct categories like Partnership or Personal Support. “Statements of personal support enhance rapport. The physician should make explicit efforts to reassure the patient that he or she is there and wants to help” (19). The dialogues are sometimes equipped with the oh-so beloved mnemonics and statement goal explanations. Breaking the units into chapters and sectioning conversation goals/topics prevented the book from reading like a textbook, reducing some of the strain Alan Alda warns of.
In an introduction written by Dr. Mack Lipkin, another author in the research literature, stresses that the normal physician performs 250,000 interviews during their career. “It is the responsibility of each diligent clinician or future clinician to know at least the main points of this literature, and this book represents one useful starting point” (viii). I believe that the current literature alongside the lack of studies deeply involved with doctor’s lexicons (outside of jargon) represents a similar responsibility with word-choice.
M.D. Anderson: “The Complete Guide to Communication Skills in Clinical Practice”
Dr. Anderson’s “pocket guide” includes a mnemonics like “CLASS” Protocol (context, listening skills, acknowledge, strategy, summary), which covers some of the same concepts Dr. Cassell does, including the ever-resourceful open-ended question and clarifying statements like “Tell me more about that.”
The “HEY BUSTER” section about “Challenging Emotional Conversations with Patients and Families” has structured “Wish statements” like Dr. Cassell’s series of tested clinical responses. “That wonderful all-purpose question, ‘What do you mean by that?’—will do the job,” (121 vol 2).
These similarly emphasize “put[ting] your own agenda aside until the other person is finished” (Anderson 21). I found that the pocket guide had several helpful dialogue lines for future word-choice analysis alongside those mnemonics. His guide was compact without density issues, but still had an aspect of “story” to it, as if the different mnemonic protocols were novella chapters.
While I still believe word-choice assessments are important for fine-tuning communication between doctors and patients, and thus the doctor-patient relationship, Dr. Anderson seemed aware that the pocket guide wasn’t all encompassing. It’s structured around quick tactics to pick and improve on, which also increases the guide’s adaptability to new information. I think this should be included as a standard of transferrable research into patient communication.
LF: Noted Sources
Debra Roter and Richard Frankel: “Quantitative and Qualitative Approaches to the Evaluation of the Medical Dialogue”
Natural Language Processing (NLP)
Timothy Bickmore and Toi Giorgino: “Health Dialog Systems for Patients and Consumers”
Giorgino and Bickmore address the growing industry for computer systems capable of interviewing patients based on natural speech patterns. They report on existing natural language processing systems (NLPs) that use data from physicians to formulate set vocabularies that later are programmed into these systems beyond following a script.
The paper mentions that sentence structures (sounds, phonemes, words, syntactic structures, etc.) that are analyzed at different linguistic levels (syntactic, pragmatic, lexical) are generally used in most dialogue systems. NLPs intersect computation linguistics and medical informatics in ways that benefit patients, providing fast quality care and reducing fear of stigmatization.
Bickmore and Giorgino give examples of evaluation programs that control dialogue quality too “PARADISE uses a decision-theoretic frame-work to combine evaluations of system accuracy (success rate at achieving desired conversational outcomes) with the ‘‘costs’’ of using a system—comprised of quantitative efficiency measures (number of dialog turns, conversation, time, etc.) and qualitative measures (e.g., number of repair utterances)—to yield a single quality measure for a given interaction” (12).
My concern with the use of NLPs falls under the inauthentic of their speech patterns and the near impossibility to keep up with ever evolving human vocabularies alongside their accepted misuses. Meaning that language constantly changing, and people often do not speak “properly” or make errors that another human can easily interpret.
These systems are also AIs, as seen with the Apache sources, and thus are prone to racism. Non-native English speakers and speakers of dialectics like African American Vernacular English or Chicano English may be similarly discriminated against. For my research purposes, I do see value in these systems as different methods for parallel studies meant for human use.
NLP: Noted Sources
Mike Miliard: “How Mercy is Using NLP with Its Epic EHR to Improve Analytics for Cardiac Care”
Mike Miliard: “EHR Natural Language Processing Isn’t Perfect, But It’s Really Useful”
Maruti TechLabs: “Top 14 Use Cases of Natural Language Processing in Healthcare”
Xavier Amatriain: NLP & Healthcare: “Understanding the Language of Medicine”
The Apache Software Foundation: “Open NLP Documentation”
The Apache Software Foundation: “cTAKES Apache cTAKES”
