A recent article in the Washington Post entitled “Twelve Things the World Should Toss Out”1 caught my eye as I read the Sunday paper. It was a collection of short essays by different guest authors—some whimsical, some serious—on the theme of spring cleaning, which asked the question, “What about a little spring cleaning for your brain, your country, your world?” The authors proposed different things that they thought we would all be better off without.
For example, economist James K. Galbraith nominated “The Congressional Budget Office”; Karl Rove said “exit polls”; and Ed Begley, Jr. proposed “lawns” (you have to read the article to understand that one).
It got me thinking that, as an oncologist, if I had to come up with something that our field should get rid of, it would be our language, or more specifically, the often imprecise, obscure, and baffling word choices that permeate our consultation notes and other communications. Now, I realize that if the genie granted me one wish for the field of oncology, I shouldn't waste it on my personal linguistic obsessions, so my answer should be something like “cancer,” or “patient noncompliance,” or “HMOs,” or the “sustainable growth rate formula.”
It is not new information that we physicians often do not use language very effectively, tending toward jargon, imprecise word choices, and those repetitive inscrutable idioms embedded in our culture. Some of this language has gotten so engrained in our psyche that we probably don't even recognize that our meaning is lost on our audience of colleagues, referring physicians, or patients, or even worse, that our words may alienate or offend.
Below are eight words, phrases, or themes that I propose we banish as part of our own spring—or summer—cleaning. And let me be the first to admit that I can find examples of all of these in my own writings!
* “Aggressive.” Yes, a 4 cm, Grade III, node-positive, triple-negative breast cancer is an aggressive tumor, but we sometimes forget that when patients read our dictations, that word is very frightening. Might we not convey that there is a high risk of relapse without an adjective that unnecessarily anthropomorphizes the tumor?“Aggressive” is also a poor word choice when applied to a physician. Some oncologists get labeled as aggressive (some I know cultivate this), which presumably means that they are more willing to recommend chemotherapy compared with others. This implies that more must be better, and we all know that is only rarely true. It must follow, then, that a non-aggressive oncologist is someone who is less willing to treat, and perhaps someone who suggests palliative care or hospice more readily, hardly an undesirable trait. Let's limit the use of this word.
* “OK?” I call this the Great Word of Medical Coercion, most often heard being used by housestaff or fellows on rounds and spoken in pseudo-interrogatory form (usually at the end of a sentence) when trying to convince a reluctant patient to undergo a particularly unpleasant test or treatment. Regrettably, this dialogue sometimes passes as informed consent. Have you ever heard this (one-way) conversation: “Next we are going to do a bone marrow biopsy and aspirate to see if your lymphoma has spread there, ok? Then we will send you to Radiology where they will draw out some spinal fluid to see if there are any lymphoma cells, ok? Then we will have another radiologist put a device in your chest to draw blood and give you the chemo, ok? Then we will start you on Hyper-CVAD chemo, ok?” Usually not ok.
* The overuse of double negatives and the underuse of positive forms. Most guides to style and composition recommend limiting the use of the double negative, but we oncologists just love our double negatives and our “not” phrases. The tumor is not small; the regimen is not without certain side effects; we would not object to the use of post-mastectomy radiation; and my least favorite phrase, “it is not unreasonable.” So does that mean it is reasonable? Often, yes, so let's not be afraid to commit when we want to recommend something.
* “Well-developed, well-nourished.” Enough said.
* “Well tolerated.” Why is it that so many cancer treatments are “well tolerated?” In a decidedly unscientific review, I randomly selected 12 issues of a major oncology journal, and in more than 50% of the reported therapeutic trials, the treatment was described as being well tolerated, whether it was chemotherapy, a tyrosine kinase inhibitor, or even high-dose therapy. Well tolerated--really? This type of inexplicable language is common: “The therapy was well tolerated, except for the known toxicities.” Or this direct quote, disguised to avoid incriminating the guilty: “The [combination] was well tolerated by…patients, even when [adverse events] were taken into account.” Except when formal quality of life assessments prove otherwise, it seems that we shouldn't be calling so many of our therapies “well tolerated” when most patients on the receiving end of these “well tolerated” toxicities might tend to disagree.
* “Suggests” and “…is consistent with.” We all recognize that experiments and clinical trials do not often produce definitive conclusions. However, the use of “suggests” as a transitive verb has gotten way out of hand. Oncologists seem increasingly reluctant to acknowledge causation, so we always seem to say that something is “suggested,” or we qualify our assessments by saying that the findings are [only] “consistent with” x. I heard a presentation recently where the speaker said that the addition of trastuzumab to chemotherapy in N9831 “suggested” that there was a decrease in first events in the trastuzumab arm. Come on now, the hazard ratio was 0.48 with p<0.0001! That's a little more than “suggested.” Granted, in oncology it is often very difficult to prove an association let alone causation, but let's not be afraid to use “is” when something really “is.”
* The military metaphor. It is well known that many patients, who would prefer that we call their illness anything other than a battle or a war, detest this.2 However, it can be challenging to find alternative expressions. I was composing a condolence note to a spouse recently, and I struggled to characterize my patient's recent death to metastatic breast cancer with some other idiom or phrase. I welcome suggestions.
* “If you had to get cancer, then [Hodgkin's lymphoma, testicular cancer, dysgerminoma, etc.] is a good one to get.” Hopefully, only a few among us would land ourselves in the Insensitivity Hall of Fame with a beaut like this, but I will say that over the years, I have heard a few variations on this one. (Clarification: This one did NOT appear in anything I wrote or said. Honest.)
Spring is now over, summer is here, and so are the grammar and language police. Clean it up!