Ophthalmology Medical Internship Reflection #2

The Effect of Words in the Medical Field

Over our radio, on our television, in our newspapers. Language, and its effects, are grabbing more and more headlines as people begin to understand the power of words. Arguments arise over the historical vs. current implications of racially-named sports teams (ex. Redskins); mainstream media devotes full articles to the implications of college students wanting safe spaces and inclusive language. Politically, words have become statements, lines in the sand to showcase your positions. Do you say ISIS or ISIL? Are you pro-life or anti-abortion? In the light of words’ power, I decided to look at the various effects of word choice in the medical field.

One intriguing factor I noticed the use of traditionally business-associated terms in the clinics. Throughout this week, especially in Dr. X’s* clinic, I heard various business-like concepts, such as patients being referred to as “clientele” and decisions being motivated by “reducing overhead costs.” Dr. X prides himself on “efficiency” and “streamlining the process.” He asserts that his lack of technician is due to his attempt to “keep costs down” and mentioned that one of his dislikes about  patients cancelling late because they can’t fill up that spot with another patient, which he comments is a loss of revenue, especially as they don’t charge a no-show fee. He had an appointment with a patient who was also a doctor, and interestingly, their conversation (about another practice) revolved largely around the cost of service. When describing the establishment, they would mention cost first, and care second (ex. “It’s definitely on the higher end price-wise, but you really get what you pay for”). They used phrases like “getting your bang for your buck” and emphasized “free advertising.”

The proliferation and use of business-associated terms can influence the thinking/practices of medicine and lead to the creation of healthcare as business, which I would argue, is detrimental to healthcare overall. This is not to say, however, that business models do not have important and replicable values that the health system could benefit from. The efficiency and stream-lined process prized in business, and focused on by Dr. X, should be strived for in healthcare, so that patients can receive quick and accurate diagnoses and treatments. Likewise, the concept of good customer service can cause doctors to be cognizant of their patient interaction.

The issue with this mentality, however, is that it was designed with companies in mind, which operate on a system that puts revenue first. A mentality great for capitalism, but unfitting for health. When medicine is treated like a business and profit comes before patients, various pitfalls appear. For example, appointments may be rushed in order to fit in as many paying customers as possible, leading to lower quality visits and misdiagnoses. Doctors can also feel the need to prescribe unneeded drugs/prescriptions in order to satisfy the client and ensure repeat visits. For example, I also shadowed ophthalmologist Dr. Y this week, who saw a case of blepharitis. This clears up on its own, but can also be assisted with manual means like warm compresses. Instead of suggesting these treatments to the patient, however, she prescribed a set of steroidal drops and antibiotics. When asked, she responded that one of the reasons she did so is because “people just want a drop,” showing how doctors can, and do, change their treatments plans to satisfy the client, despite knowing that other, less costly, options exist, and that the problem will resolve itself without intervention.

The effects of the business model of medicine also have political and public health effects. Many doctors are refusing to accept Medicaid because they feel that the revenue is not enough for their services, leading to problems in healthcare access for those on government assistance. Drug companies practice “price gouging,” which can lead to individuals going without needed medication. A high-profile example would Martin Shkreli, a CEO of a pharmaceutical company, skyrocketing the price on an HIV/AIDs drug price by 5000% ($13.50-$750). The prescribing of unneeded antibiotics contributes to the creation of more resistant disease strains. In terms, politics affects healthcare as well. Congress has barred Medicare from negotiating with drug companies, depriving many of its members the ability gain their drugs for a fair price. Budget cuts in federal spending and in hospitals can lead medical personnel to increase focus on the bottom line, leading to the uprise of business terms in medicine. This contributes back to the adoption of the business model, leading to a cycle of action creating language, which creates action again.

Intriguing, the “business model” focus in language was heard most prevalently in the Optometry rotation. Dr. X also seemed hyper-aware of this situation, prefacing many of his comments with “it sounds like I’m talking about money . . .”One technician I spoke to specifically pinpointed towards this specialization as having issues, quoting that she “didn’t like the direction that field was going in,” and “didn’t like the high-pressure-to-sell environment where it disregarded what was best for the patient.” Following discussion at Journal Club, I discovered that there is often a rift between optometrists and opthalmologists based on these different models. So perhaps this specialization particularly lends itself to such practices but, as seen above, the effects of the business model can be felt throughout the health field.

The other point that jumped out at me was the use of language in the doctors’ medical notes. When denoting information about the appointment, examination, etc., the inclusion of race was sporadic—sometimes noted, sometimes absent. After watching appointment after appointment, I found the pattern–race was only included when the patient was non-white. When I asked the doctor how they decided whether or not to include this, the answer was usually some variation of risk factor. Different races may have different incident rates of a disease, and thus, the doctor would note the race to coincide with this information. (For example, African-Americans may have a 8% incidence rate, Caucasians 4%, Asians 6%, etc.).

At first, this method seems completely logical, useful and efficient. Yet, I still felt dissatisfied with this system and, after some time, discovered why. First of all, the ethnicity of the patient is already in each record, next to name, gender, age, etc., so any repetition is technically unnecessary. Secondly, the inconsistency of information creates ambiguity. When the information is absent, is it because the patient is Caucasian, or because the doctor forgot? But, lastly, while risk/incidence factor is a perfectly valid reason for calling attention to this information, risk factors come with other markers besides race. Age and sex also create different incidence rates, and in every record I saw, the doctors recorded both in their notes. We do not only mention gender if the patient is female/male. We do not only mention age if the patient is out of a certain range. So why only mention race if the patient is non-white? This creates a situation where “white” is considered the default, where minorities are singled out, marked, or set aside as “other.” In a world where racial bias is still prevalent, where some doctors still hold the belief that different races have different pain thresholds, leading to differences in pain medication and treatment, only harm can come creating “default races” and deeper distinctions between majority and minority.

Words are, technically, just words. Collections of sounds, arrangements of letters that we assign meaning to in order to communicate. But that assignment of meaning tells all and gives words, not only power, but political clout. Language has the ability to affect the reality around us. Denoting race in patient records only when it is not Caucasian perpetuates a system that places “white” as default, which engenders troublesome situations and complications. Adopting the language used in business can influence healthcare into adopting a similar model, which comes with benefits, but also negatives that we must be aware of. The creation of the business-model style is further supported through budget cuts, which also foster business-like language, creating a cycle that feeds into itself.

*All names have been changed for privacy purposes

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