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Views And Reviews Primary Colour

Helen Salisbury: A chronic problem with language

BMJ 2019; 367 doi: https://doi.org/10.1136/bmj.l6437 (Published 20 November 2019) Cite this as: BMJ 2019;367:l6437
  1. Helen Salisbury, GP
  1. Oxford
  1. helen.salisbury{at}phc.ox.ac.uk
    Follow Helen on Twitter: @HelenRSalisbury

When I was instructed some years ago that the term “chronic disease” had been replaced by “long term condition,” I sighed, inwardly muttering the equivalent of “snowflakes.” But I changed my mind after a little thought and some data gathering among my non-medical friends. To them, “chronic” meant bad or severe. “Acute” also meant severe. I also asked another friend recently, a learned professor in a different field of science, who gave the same answers.

So, if “chronic” means bad, a chronic disease must be a bad one that’s likely to harm or kill you, whereas a “long term condition” sounds like something you live with rather than die from. Doctors know what they mean by acute and chronic—but, if we’re copying letters to patients and giving them access to their notes, shouldn’t we tailor the language we use?

Since 2006, GPs have been incentivised through the Quality and Outcomes Framework to keep a register of patients with impaired renal function, doing blood tests and measuring blood pressure yearly. Unfortunately, this has meant that many older people, whose decline in renal function is unlikely to cause a problem in their remaining life, are coded as having chronic kidney disease.

At its most benign, this just means a few minutes’ conversation at the time of diagnosis, explaining why they don’t need to worry. Even when it’s discussed thoroughly, the impact of acquiring the label “chronic kidney disease” may have negative effects on the mental health of some patients. At worst, communication is missing or forgotten, and distress and panic can arise when a patient sees the condition mentioned on an invitation for review or a discharge letter. Many people associate kidney disease with dialysis and death: it’s not a diagnosis that you’d want to stumble on by accident.

We can’t abandon technical language, as we need its precision. It’s useful to know that my patient has multiple atrial ectopics rather than “atrial fibrillation,” and lay terms such as “irregular heartbeat” are insufficient in doctor-to-doctor communication. Copying clinic letters to patients is good practice1: even if patients struggle to understand some of the terms, at least they have a record of the consultation and a chance to clarify the decisions made. However, sometimes we could align medical language more closely with lay terms and reduce confusion. Some medical terms are woefully imprecise and can be scary, such as “heart failure.”23 And sometimes the lay and medical meanings just don’t match, as in the frequently heard utterance “My arm’s not broken, just fractured.”

There are many ways we could make our communication clearer and less frightening. It’s a huge task, but outlawing the term “chronic disease” would be a good start.

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