Of Labels and Language

Regular readers may be aware that 278.00 stands for the ICD-9 classification “Obesity: not otherwise specified”.

A thoughtful essay by Elizabeth Toll from Brown University, Providence, Rhode Island, in JAMA, warns about how even the “appropriate” use of such diagnostic labels could affect patient-client relationships.

This is specially true in an era, where patients may have full and access to their records, often with no explanation or context. (I recently heard a story about a patient complaining that their doc had referred to them as SOB (common medical jargon for ‘Shortness-of-Breath’)).

But, irrespective of who has access to what information, the point that Toll rightly makes is that the use of such diagnostic labels and jargon, only serve to further “dehumanise” medicine:

“We need to remember that people skills directly affect clinical outcomes. Human qualities like intuition, warmth, and emotional intelligence are profoundly important to effective communication and successful care. It behooves us to ally with our patients in order to speak out against the pervasive labels and numbers that lull administrators and legislators into a false sense that they can evaluate and track true quality and success using such limited parameters…..The focus should remain on knowing our patients and their problems in the full context of daily living rather than pigeonholing them into drop-down phrases and diagnostic codes like 278.00 Obesity, Not Otherwise Specified.”

While I agree that communication skills and sensitivity should be an essential part of medical practice and that medical diagnoses and jargon can be shocking and hurtful to patients (irrespective of whether or not these are accurate or misunderstood), I do recognise that diagnostic labels (whether numbers or otherwise) serve an important function in medical communication and record keeping.

So while the label “obese” does not describe all (or even the most relevant) aspects of my patients, neither do the labels “diabetic”, “hypertensive”, or “arthritic” but I’d me amiss to not note them in my records.

I have previously written on the importance that there is a big difference between having something and being something. The implications of being “obese’ are different from those of having “obesity”. This is why I try to avoid using the words overweight or obesity as nouns (as in “the obese”) or even as adjectives (as in “obese patient”) – I personally prefer to speak of the patient as someone having obesity.

I agree with the author that it would be nice to,

“Imagine a diagnostic system built on composite knowledge of a patient’s unique clinical situation, including information about age, experience, responsibilities, motivation, and previous health challenges and successes.”

This, however, will never be described in numbers or labels but only in thoughtful narratives.

In the context of obesity, this is exactly why we introduced the Edmonton Obesity Staging system, because it describes so much more about the patient (mental, physical and functional health) than BMI alone.

AMS
Edmonton, AB
Toll E (2013). A piece of my mind: 278.00 Obesity, not otherwise specified. JAMA : the journal of the American Medical Association, 309 (11), 1123-4 PMID: 23512059

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