The banned list

Does language always reveal underlying attitudes? Do lazy words confirm lazy thinking?

These questions were asked when, some time ago, I entered into an ultimately fractious debate with an ED doctor who had ‘banned’ certain words and phrases in the department where he worked. I reacted to the list, as I thought it was overly proscriptive and borderline repressive. It was advertised with such emphasis, such absolutism, I worried that a young doctor heard using one of these words (‘acopia’, ‘off legs’) would be intimidated by the reaction. This led me to wonder, does the use of phrases that we ‘grew up with’ really mean we think like this? For instance ‘off legs’ is said to discourage further efforts to find out what led the patient to fall over or take to their bed. And take acopia, a short hand way of saying the patient (usually elderly and frail) has stopped being able to cope with everyday activities. The doctor who writes it down as a diagnosis is not going far enough. People don’t stop coping for no reason. There must be something wrong, an infection, heart failure… something. Look harder…

But there is more. Short phrases or words, although useful as a code – a quick way of communicating information between colleagues who are inducted to the same cryptic language – do carry visual and pejorative moods or feelings. Say acopia to me, and I immediately visualise a frail, thin person sitting in a chair in a dark room trying but failing to stand with their Zimmer frame or progress across the kitchen to fill a kettle. Say ‘failed discharge’, and I imagine a man being delivered his lounge by an ambulance crew who wave him goodbye and leave, only for the patient to find that his breathlessness is still so bad he can’t even make it to bed, and spends the next ten hours in the same chair until the first visit from the new, inadequate ‘package of care’. Code is useful for rapid communication, but it is also overly simplistic in complex scenarios.

The doctor who wrote the list insists that failed discharge (i.e. rapid readmission) is referred to as a ‘relapse’. I don’t agree with this entirely, as I disagree that discharge arrangements fail because the underlying disease worsens. But I do agree with the subtle change of emphasis between the two terms. ‘Failure’ suggests the patient is weak, that they failed, whereas relapse suggests that the pathology was not completely controlled – a failure of medical management, if you like. It changes the flavour of the presentation from ‘social’ to ‘medical’, and will therefore demand a higher level of engagement from whichever doctor sees the patient in the ED.

Similarly, labelling a patient with ‘mechanical fall’ could immediately switch the doctor into a lower gear, as what diagnostic magic can be required to work out why someone tripped on a table leg? It’s all about awareness, not turning off the brain, looking deeper.

So I appear to agree with the list…

Mmmm. What I objected to was the idea of controlling another’s language. The imposition of one person’s preferences – however sound the thinking behind them – on others. It is an attempt to educate yes, but it feels borderline coercive. ‘Don’t talk like that in my department…’ This has happened before. I remember being corrected by an endocrinologist when I used the word ‘diabetic’. ‘No,’ he said, ‘It’s a person with diabetes.’ I rolled my eyes. But were they right? I was defining a person by their condition. This brief re-education didn’t work, as I still use the term, along with epileptic, colitic, cirrhotic and alcoholic. It’s my way of talking. Yet… I correct people too. If a trainee refers a patient to me with ‘acute liver failure’ and then describes someone with ascites and a bit of jaundice, I subject them to a fifteen-minute lecture/tutorial/harangue on the difference between cirrhotic decompensation and ‘true’ acute liver failure. I am probably as patronising and as full of medical self-righteousness as any other consultant with strong opinions and specialist knowledge. We all do it. Those who work with us risk being bounced all day between acceptable and unacceptable words. Each of thinks we are gradually improving attitudes, knowledge and patient care.

As doctors we have opinions, and if we care about our area, we proselytise. That’s what the ‘banned list’ was – a kind of proselytism. You might call it part of clinical leadership, continuing (re)education, improvement. Nothing really wrong with that, as long as it doesn’t lead to those who aren’t quite up to date with being criticised, just nudged. Culture changes gradually, or else people are left behind.


See also David Oliver in the BMJ ‘Minding our language around care for older people and why it matters’ 

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