By Suzanne Gordon
“The patient failed” this or that therapy.
I first heard medicine’s 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—an earnest man devoted to his patients—was talking about a man who was dying of cancer. “Well,” he said with grim resignation, “he failed six rounds of chemotherapy and there’s nothing else we can do.”
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-Barré syndrome. As the resident was presenting the case, he reported that the patient “had failed” several rounds of antibiotics and was now completely paralyzed. People in the room nodded sagely. No one but me—who thinks of herself as a potential patient or sometime patient—seemed to think there was anything wrong with this formulation.
And why would they? The F word is everywhere in medicine. It’s 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:
Oncology attending to resident– “I put the patient on Taxol and Adriamycin and the patient failed Taxol/Adria.”
ER physician to hospitalist, “Mr 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.”
An attendant in the neonatal intensive-care unit (NICU) talking to a NICU nurse—“The baby has a congenital diaphragmatic hernia and has pulmonary hypoplasia. We started nitric oxide and the baby failed the nitric oxide therapy course.”
With variations, notes in charts use the same language, as do reports in research journals.
Many healthcare professionals with whom I’ve spoken about the F word think it is purely descriptive—almost neutral in its content and connotations. They don’t recognize that the verb to “fail,” used with the noun “patient” as a subject always implies blame.
Here, for example is how, Ask Dictionary.com defines the word fail:
“to be or become deficient or lacking; be insufficient or absent; fall short:
to fall short of success or achievement in something expected, attempted, desired, or approved”:
Failure is always an act that is accomplished by an agent. When you fail at something—particularly in competitive Western cultures—you 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—to follow the dictionary definition—setting 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—not the disease process, the limitations of contemporary treatments, or of the state of current scientific knowledge—is responsible for his or her own suffering, deterioration, or demise. Unless the patient actively compromised their own treatment, using the term “the patient failed,” 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’s almost as if nothing is patient-centered except the patient’s failures.”
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