{"id":35768,"date":"2015-12-07T12:53:54","date_gmt":"2015-12-07T11:53:54","guid":{"rendered":"https:\/\/blogs.bmj.com\/bmj\/?p=35768"},"modified":"2015-12-07T12:53:54","modified_gmt":"2015-12-07T11:53:54","slug":"suzanne-gordon-medicines-f-word-fail","status":"publish","type":"post","link":"https:\/\/blogs.bmj.com\/bmj\/2015\/12\/07\/suzanne-gordon-medicines-f-word-fail\/","title":{"rendered":"Suzanne Gordon: Medicine’s F Word\u2014Fail"},"content":{"rendered":"

\"suzanne_gordon\"<\/a>\u201cThe patient failed<\/span>\u201d this or that therapy.<\/em><\/p>\n

I first heard medicine\u2019s F word almost 30 years ago when I was having a casual conversation with an oncologist in a break room on the hematology\/oncology unit. The oncologist\u2014an earnest man devoted to his patients\u2014was talking about a man who was dying of cancer. \u201cWell,\u201d he said with grim resignation, \u201che failed six rounds of chemotherapy and there\u2019s nothing else we can do.\u201d<\/p>\n

The last time I heard the F word was at a morbidity and mortality round. A group of physicians were discussing a case that had gone badly. The patient had contracted Guillain-Barr\u00e9 syndrome. As the resident was presenting the case, he reported that the patient \u201chad failed\u201d several rounds of antibiotics and was now completely paralyzed. People in the room nodded sagely. No one but me\u2014who thinks of herself as a potential patient or sometime patient\u2014seemed to think there was anything wrong with this formulation.<\/p>\n

And why would they? The F word is everywhere in medicine. It\u2019s used when professionals are talking about patients who are in trouble or are dying, when they describe a treatment that has not worked, or when a patient has experienced a set back. Consider the following examples:<\/p>\n

Oncology attending to resident\u2013 \u201cI put the patient on Taxol and Adriamycin and the patient failed Taxol\/Adria.\u201d<\/p>\n

ER physician to hospitalist, \u201cMr Y is a morbidly obese patient with a terrible infection on his left leg. He failed oral antibiotics and needs to be admitted for IV antibiotics.\u201d<\/p>\n

An attendant in the neonatal intensive-care unit (NICU) talking\u00a0to a NICU nurse\u2014\u201cThe baby has a congenital diaphragmatic hernia and has pulmonary hypoplasia. We started nitric oxide and the baby failed the nitric oxide therapy course.\u201d<\/p>\n

With variations, notes in charts use the same language, as do reports in research journals.
\nMany healthcare professionals with whom I\u2019ve spoken about the F word think it is purely descriptive\u2014almost neutral in its content and connotations. They don\u2019t recognize that the verb to \u201cfail,\u201d used with the noun “patient” as a subject always implies blame.<\/p>\n

Here, for example is how, Ask Dictionary.com defines the word fail<\/a>:<\/p>\n

\u201cto be or become deficient or lacking; be insufficient or absent; fall short:
\nto fall short of success or achievement in something expected, attempted, desired, or approved”:<\/p>\n

Failure is always an act that is accomplished by an agent. When you fail at something\u2014particularly in competitive Western cultures\u2014you have done something wrong. You have not studied hard enough so you failed the test. You did not run fast enough, so you failed to win the race. When one says that a patient failed a therapy, the patient is, by definition, not doing something right or efficient. They are lacking, absent, falling short or\u2014to follow the dictionary definition\u2014setting him or herself up for the medical equivalent of bankruptcy. When a patient is said to have failed something, the unavoidable implication is that the patient\u2014not the disease process, the limitations of contemporary treatments, or of the state of current scientific knowledge\u2014is responsible for his or her own suffering, deterioration, or demise. Unless the patient actively compromised their own treatment, using the term \u201cthe patient failed,\u201d ascribes agency or action to someone who, in most cases had very little ability to influence the outcome. When clinicians use these terms, they are infecting the patient experience with the same burden of shame and blame that they so often shoulder. Only this time, they are transferring part of that burden to suffering patients. As Mardge Cohen, an internist and HIV-AIDS specialist puts it, “It\u2019s almost as if nothing is patient-centered except the patient\u2019s failures.\u201d<\/p>\n

When I\u2019ve talked about this phenomenon to different healthcare providers, many respond that this terminology is only used when physicians or other healthcare professionals communicate with each other\u2014either verbally or in their charting. They insist that they would never, ever tell a patient\u2014to their face, that they had \u201cfailed a therapy\u201d and were about to suffer the consequences. They wouldn\u2019t be so callous as to sit down with the patient\u00a0and inform him that he\u2019s dying because he failed his treatment.<\/p>\n

They somehow believe that we, as patients don\u2019t know that they, as providers, consistently refer to our setbacks in language that makes it seem like they think we are responsible for any poor outcomes we experience. \u201cI always tell my residents that if we use the term the patient failed in our case meetings, this language may slip out of our mouths when we are in front of patients,\u201d says Glenn Bubley, chief of Genitourinary Oncology at the Beth Israel Deaconess Medical Center.<\/p>\n

Bubley is right. The F word slips out when physicians-in-training fan out around a patient\u2019s bed and inform their attending doctors that Mr\u00a0X\u00a0has \u201cfailed four rounds of chemo.\u201d Or when a parent sitting next to their desperately ill child on a NICU overhears rounding physicians tell one another about that poor baby who failed the course of nitric oxide.<\/p>\n

I myself was told that my bladder failed when it somehow acquired\u2014all on its own\u2014a urinary retention injury after surgery. After having heard these comments over and over again for the past thirty years, it is hardly reassuring to think that the people caring for me will consider that I may have failed in some therapeutic enterprise and blame me for the poor outcome of my medical journey.<\/p>\n

If healthcare is to be truly patient centered, then those who care for the sick cannot continue to use language that ascribes blame to suffering human beings\u2014whether in conversation, through notes in the chart, or discussions in the scientific literature. Medicine, nursing, and all other healthcare disciplines have perfectly good options when discussing poor patient or treatment outcomes. Consider some of the following:<\/p>\n