The Secret Language of Doctors

by Brian Goldman

  Lingo such as FLK, which once signified a “funny-looking kid,” code for an infant or child born with the visible facial characteristics of a genetic or congenital anomaly such as Trisomy 21, or Down syndrome. Kussin said he recalls being admonished by the chairman of the department of pediatrics at Mount Sinai School of Medicine never to write the letters FLK in a child’s hospital chart because the term was insulting and pejorative. What Kussin remembers most about that lecture was that he and his young colleagues ignored it.

  “No one was going to pay attention to that,” said Kussin. “Our notes, our handovers, our communication—the way we talked to each other—were replete with slang. It was totally politically incorrect—culturally and socioeconomically insensitive—and it was beautiful.”

  What made it beautiful, he said, was the way slang could tightly pack a lot of telling information about a patient. “It was an era when it was more important to communicate precisely,” said Kussin. “When we talked about handoffs, there was nothing better than a handoff done in concise medical slang. There’s nothing better than to refer to an obese patient with liver cirrhosis as a Yellow Submarine. They require huge amounts of work and the team has to keep on top of so many things. When you stand in the elevator with one of your buddies and say, ‘Yeah, I got this Yellow Submarine,’ the person automatically knows what you’re talking about, what the problems are and what your mood is because of that.”

  What Rutherford taught me and what Kussin has taught many others is something called the hidden curriculum of medicine. The phrase hidden curriculum comes from a 1968 book by Philip Jackson, Life in Classrooms. Jackson observed the behaviour of students in grade-school classrooms. He found that students learned and processed not just academic information in class but social concepts such as co-operating, showing allegiance to both classmates and teachers, and being courteous—and that these traits were essential to getting through school.

  Later, in 1970, Benson Snyder, at the time the dean of Institute Relations at the Massachusetts Institute of Technology in Cambridge, Massachusetts, wrote a book titled The Hidden Curriculum. In it, Snyder elaborated on a complex array of unstated or hidden academic and social norms and expectations that lead to student anxiety and frustrate students’ attempts to think independently. He labelled these items as hidden because they were not set down in course manuals and textbooks, yet were widely known by students to be essential to passing a course and succeeding on campus.

  Simply put, the hidden curriculum is the gap between what teachers teach and what students learn. When it comes to studying to be a physician, it turns out there’s a lot of curriculum that’s hidden.

  Dr. Frederic Hafferty, director of the Program in Professionalism and Ethics at the Mayo Clinic in Rochester, Minnesota, is credited as the first academic to identify the hidden curriculum of medicine. In a book chapter titled “The Hidden Curriculum, Structural Disconnects, and the Socialization of New Professionals,” Hafferty and co-author Janet Hafler write that the hidden curriculum in medicine “refers to cultural mores that are transmitted, but not openly acknowledged, through formal and informal educational practices.”

  An outsider with a background in medical sociology and behavioural sciences, Hafferty has spent his entire career studying how medical students and residents learn to be physicians. He began his career in the 1980s, just as medical schools started teaching students about the emerging field of medical ethics. One day, he went to a conference in which speaker after speaker went up to the podium to demand more ethics training for students.

  “I just sat in the audience and I thought that this is crazy,” Hafferty recalls. “You can give them eighteen courses but there’s all kinds of other stuff going on in the environment in medical education that says this stuff is really not all that important compared to all this other stuff you’ve got to know.”

  Stuff like knowing where doctors fit in the pecking order of health professionals.

  “There are no courses that I know of at medical schools that teach formally that MDs are the best, and everybody else is stupid,” says Hafferty. “I can’t go into any course catalogue that says MDs are the smartest of the bunch.” But physicians learn to think they are.

  There also is no course that teaches specialists that they’re smarter than family doctors. There’s no seminar that trains internists to think surgeons are all do and no think, just as there’s no book that teaches surgeons to believe the exact opposite of internists.

  The very notion of one group of doctors dissing another may seem odd or even disconcerting to you but, as you’ll learn in The Secret Language of Doctors, it’s woven into the fabric of medicine’s culture.

  If you want to learn about the ruthlessly competitive streak possessed by many physicians, then mastering the secret language of doctors is essential, says Hafferty: “There’s all kinds of stuff that nobody would ever dare put on the books. If you put it on the books, there’d be outrage. So how do you teach it when you can’t formally announce that you’re teaching it? One of the ways is argot.”

  A medical textbook or a page on the official website of a hospital might tell me that the orthopedic ward is where patients go to have their hips and knees replaced. But it won’t tell me—as some residents have—that the orthopedic ward is sometimes ruefully referred to as being “where patients with diabetes go to die.” The acronym FOOBA says basically the same thing—only quicker and more efficiently.

  Is that information worth knowing? If, as Hafferty argues, terms such as FOOBA are accurate, they are invaluable to medical practitioners. If you’re an internist or resident on call, FOOBA tells you not to walk but to run when you get a call from the orthopedic floor to see a patient in distress. And maybe, if you’re a patient or a patient’s loved one, knowing about FOOBA tells you to find another hospital.

  In a 1998 article titled “Beyond Curriculum Reform: Confronting Medicine’s Hidden Curriculum,” Hafferty wrote that the hidden curriculum is passed from student to student and from resident to resident not in the classroom but “outside formally identified learning environments: in the elevator, the corridor, the lounge, the cafeteria, or the on-call room.”

  The Bunker is a compelling way to describe the place where medical students, residents and their attending physicians meet to discuss their patients. Dr. Abraham Verghese is a noted physician and author of the novel Cutting for Stone, the New York Times medical bestseller set in pre-revolutionary Ethiopia and in a poorly funded New York City hospital. In a 2008 New England Journal of Medicine article, “Culture Shock—Patient as Icon, Icon as Patient,” Verghese referred to the team room as “a snug bunker filled with glowing monitors.” In his article, he encouraged his young charges to abandon the Bunker and spend more time at bedside.

  The Bunker also has a much darker meaning. As a twentieth-century cultural reference, the phrase invokes the memory of the Führerbunker, a subterranean air-raid shelter near the Reich Chancellery in Berlin that served as the final headquarters of the Third Reich. The Bunker is also the title of a 1981 CBS television movie about the last days of the Third Reich, starring Anthony Hopkins, who won an Emmy for his portrayal of Adolf Hitler. In this context, a bunker is a refuge under siege. It may or may not be an accident that bunker rhymes with hunker, as in “to hunker down.”

  In the world of hospital medicine, the Bunker is a place where physicians gather strength and find respite amidst a siege of patients and their families. It suggests that physicians—especially young ones—are on a war footing. To extend the analogy, during the Second World War, the Nazis used the Enigma machine to encrypt and decrypt secret messages. Similarly, residents encode their “messages” to keep them from the prying ears of laypeople.

  “The Bunker is something I hate,” says Dr. Peter Kussin. “I also call it the ‘nuclear plant control room.’ The Bunker is the place where the residents retreat to avoid going to the bedside. To me it is the
place where residents go to avoid nurses, avoid patient contact and avoid hearing bad news. So to me, it is a pejorative.”

  Dr. Nathan Stall, a first-year resident in internal medicine, budding geriatrician and one of the most thoughtful young minds you’ll encounter in the world of medicine, says there is a huge disconnect between what goes on behind the closed doors of the Bunker and what happens when staff interact with patients and their families. “There is that dynamic of what gets talked about in there, the language and the jokes that go on behind the patients’ backs.”

  Being discharged up—as opposed to being discharged from hospital—is a casual and flip way of saying a patient has died. Stall remembers the first time he heard it. “I was a naive medical student,” he recalls. “I didn’t even really know what handover or morning report was. The resident kind of chuckled and said, ‘You know, we discharged one up tonight and we’re going to discharge two home today.’ I turned to the guy and I said, ‘What’s discharged up?’ And he pointed up at the sky.”

  Discharged up is just one of many euphemisms for death. Discharged to heaven, admitted to the seventeenth floor (of a hospital with only sixteen floors) and referred to the outpatient pathology clinic (pathology being where autopsies are done) are just three other examples. Medical personnel love to craft jests on dark subjects. It’s not uncommon for one doctor to tell another that a patient who is dying is “in the departure lounge.” We also love puns on common acronyms. Most laypeople know that ICU stands for intensive care unit. In hospital corridors, it’s not uncommon to hear about a patient who died on the wards being transferred to the ECU, which is slang for “eternal care unit.”

  “There was something sort of funny in a dark way about it,” says Stall. “You know, there are a lot of laughs and there are often a lot of inappropriate comments made about patients. I don’t want to damn the whole profession of internal medicine, but it touches on what really bothers me so much about team medicine and internal medicine.”

  Stall may be young and idealistic, but he’s also right. There is something dark and quite disturbing about the culture of modern medicine that is reflected in the slang used both by young and up-and-coming healers and by their mentors. We’re not talking about callous or immoral people. With more than thirty years of practising medicine in my rear-view mirror, I’m still convinced that doctors and other health professionals are among the most ethically grounded people on the planet.

  Still, why would young men and women in a caring profession invent and use such language? I put that question to a remarkable group of residents taking postgraduate training at McMaster University’s famed Michael G. DeGroote School of Medicine in Hamilton, Ontario. McMaster is one of the most humanistic medical schools on the planet. And yet, even there, young doctors learn and master medical slang.

  Dr. Nooreen Popat, a fifth-year resident at McMaster who is training to become a respirologist, told me on White Coat, Black Art, the show that I host on CBC Radio One, that getting doctors to admit that they use medical slang is “like admitting to a guilty secret. We all admit that these are terms we’re familiar with. None of us really thinks that all of them are appropriate and yet we use them all.”

  Clarissa Burke, who was finishing a residency in family medicine at McMaster University when I spoke to her on White Coat, Black Art, says that “when we use these terms among colleagues, it’s one way of really expressing how we feel about a case. You’ll have almost instant commiseration from your colleagues because we’ve almost all been in these situations before. With our colleagues, we understand instantly what it is that they’re feeling. There’s this instant sort of camaraderie about using terms like that because we all recognize what that person is expressing.”

  Camaraderie is definitely one reason doctors learn medical slang; it helps us share and process the human tragedies that we witness each and every day we work. Take, for instance, the phrase peek-and-shriek, used by surgeons to refer to an operation in which they open up the patient’s belly, find it’s riddled with cancer and promptly close it up. The slangy rhyme helps fortify them for the long, lonely walk down the hall to the surgical waiting area, where they’ll break the worst of all possible news to loved ones gathered to hear something hopeful.

  Residents also use slang to complain to their peers about the brutal hours they face as postgraduate trainees. In the past, residents in some specialties (neurosurgery, for example) were expected to work as many as 100 hours a week and as many as thirty-six hours in a row. Concerns about medical errors committed by sleep- deprived residents have led to cutbacks in residents’ work schedules. Authorities call the process of giving residents more sleep time “duty hours”—jargon that instantly inspired residents to invent a derisive slang term.

  “The one that they came up with was so classic: DOMA—‘day off, my ass,’” says Kussin. “They get these days off that really aren’t days off because they can’t leave the hospital until noon and then they have to be back the next day, so they get like five hours off.”

  Sometimes, the purpose of slang is to provide a friendly warning to colleagues about a patient. A surgery resident told me that when he’s operating on a patient with HIV, it’s polite to give everyone in the OR a heads-up so that they can take appropriate precautions to prevent being exposed to the virus—within easy earshot of a patient who may be groggy but still awake. “When I’ve scrubbed and gone into the operating room, I walk in saying ‘double glove’ or ‘high five,’” says the resident.

  Putting on two pairs of gloves is a precaution surgeons take to prevent accidental exposure when they operate on patients with HIV. “High five” is a clever bit of slang that stands for HIV, as in hi-V.

  Peter Kussin loves medical argot for another reason: it brings his love of words and letters into the world of clinical medicine. Yellow Submarine, for instance, is “very rich and linguistic,” says Kussin with a big grin. “It’s under the water and it’s sort of sinking. It’s also a reference to The Beatles’ song. It has wit.”

  But times have changed. The polite reasons that I’ve listed do not explain why medical slang flourishes nowadays. Other, more sinister factors are at play. Much of today’s slang is directed at the growing array of patients that health-care professionals greet with undisguised contempt: the elderly, especially those with dementia; people who refuse to sign a Do Not Resuscitate form when we think it’s futile to do CPR; people who are morbidly obese; people with mental health and substance abuse problems; people who are acutely anxious about their health or that of a loved one; and those who come from the economic and social margins of society. Doctors have invented pejorative slang terms for each and every one of these types of patients. Old patients are referred to as FTDs, which stands for “failure to die.” Obese patients are called whales. People with borderline personality disorder are called swallowers because sometimes they swallow object like kitchen utensils and nails. People who come often to the ER because they have no other place to receive care are called frequent flyers.

  The argot you’ll read about in The Secret Language of Doctors reduces patients who are ill and in distress to mean-spirited stereotypes. Despite the growing ranks of these patients, the best medical schools in North America continue to crank out class after class of physicians who describe such patients using slang that reveals the utter contempt with which doctors regard them.

  We don’t like these patients very much—and we like each other even less. Much of the venom spewed in the Bunker is reserved for colleagues. We’re supposed to be a team of health professionals, yet we act like a bunch of rabidly competitive and sometimes even bitter rivals.

  “Medical training is highly competitive and has historically focused on individual excellence and not necessarily on team building. For many physicians it has been an every-man-for-himself-type workplace,” says Dr. Katherine Grichnik, professor of anesthesiology and critical-care medicine in the department of an
esthesiology at Duke University Medical Center in Durham, North Carolina. As associate dean for continuing medical education at the Duke School of Medicine, Grichnik is a thought leader in the evolution of professionalism among physicians.

  “We’re all Type A personalities,” she says. “We have fought all our lives to get where we’re going. It’s always been one test after another, one achievement after another. Then, all of sudden you’re at wherever you’ve achieved or whatever you’ve thought you were achieving. Once you’re in a job or a specialty or a practice, how do you continue to achieve? Well, it’s not on test scores anymore. It tends to be more on how can I make myself better? This may be defined differently by different physicians. Luckily for most, the core issue relates to continuing to improve patient care and striving for better outcomes than one’s peers.

  “Certainly, political and remuneration factors can also come in to play. Clearly, there are appropriate ways to better oneself. And, there are inappropriate ways.”

  Grichnik is giving her colleagues the benefit of the doubt. From where I sit, a quiet seething goes on inside hospital corridors, a simmering frustration felt by doctors about their work, their patients and each other. It’s a low-pitched rumble just below the hearing threshold—enough to irritate and bother my colleagues, even if they don’t know why. And the secret language of doctors is flourishing despite the best efforts of medical schools and residency programs to teach young doctors that medical slang is unprofessional and should be eradicated. Like a guilty pleasure, it lives on.

  If you or a loved one have entered or are about to enter hospital, The Secret Language of Doctors pulls back the curtain to reveal some of medicine’s darkest modern secrets. Does your overweight mother’s orthopedic surgeon have respect for patients who are obese? Does your heart specialist respect your GP or does she think he is incompetent? Is your dad being transferred to a teaching hospital to help him live or to help him die? This book will give you insight into these and other important questions that you might be reluctant to put into words—let alone ask anyone—insights that are important both for your well-being and for that of the doctors and other health professionals who look after you.