Emergency physician Malika Fair, MD, MPH, bristles when she is told “you have a ‘sickler’ today.”
That derogatory term describes a person with sickle cell disease. It also suggests that the patient may have come to the emergency department because of a substance-use disorder rather than for relief from their overwhelming pain or receive treatment for a critical illness.
The use of such dehumanizing terms “changes the way you think about a patient and that can lead you down a pretty bad pathway,” said Dr. Fair, senior director of equity and social accountability at the Association of American Medical Colleges (AAMC). “Being careful about your language changes how you take care of patients.”
Dr. Fair contributed to a new document, “Advancing Health Equity: A Guide to Language, Narrative and Concepts.” The document—one of the most comprehensive health equity communication guides to support physicians’ conversations with patients—promotes a deeper understanding of equity-focused, first-person language and why it matters. The guide was developed by the AMA and the AAMC Center for Health Justice.
The goal is to speak to patients “without reinforcing labels, objectification, stigmatization and marginalization,” says the communications guide.
AMA President Gerald E. Harmon, MD, noted the importance of using the right words.
“Physicians instinctively know the power of our words,” Dr. Harmon wrote in a Leadership Viewpoints column. “They must be clear but also precise; they must convey empathy but also understanding.
“Above all, our words must demonstrate our competence and our confidence when counselling our patients or their families about a difficult diagnosis,” the column adds. “Our words matter because trust is foundational in the patient-physician relationship.”
The move toward equity-focused language is not about being politically correct, Dr. Fair said.
“Using this language changes the way you think, and it can save someone’s life.”
Learn more about the AMA Center for Health Equity and the AMA’s strategic plan to embed racial justice and advance health equity.
7 terms to change medicine’s approach
Below are seven equity-focused alternatives to some terms that are commonly used in health care, as outlined in the guide. In total, the guide offers definitions for more than 140 key terms, and explores principles for inclusive communication reinforcing new guidelines from the Centers for Disease Control and Prevention.
Cultural humility
This is an alternative to “cultural competence.” Health care cultural competence is described in a 2002 Commonwealth Fund report as “the ability of systems to provide care to patients with diverse values, beliefs and behaviors, including tailoring delivery to meet patients’ social, cultural, and linguistic needs.”
The “cultural competence” term implies that, with enough training and education, a physician can become “savvy enough to engage with any culture,” Dr. Fair said. Substituting “competence” with “humility” more accurately describes the process as a continuing journey.
“It's a slight shift, but it's an important shift,” she added. “We have to continue to evolve.”
Groups experiencing disadvantages
This formulation, which should be the first part of a sentence that details the nature of the health-related disadvantages, serves as an alternative to terms that such as “disadvantaged,” “under-resourced” and “underserved” that have been used for decades but which many now find pejorative.
“Under-resourced” and “underserved” are used to describe the historical disinvestment experienced by some communities. Equity-focused alternatives include “historically and intentionally excluded” and “disinvested.”
Formerly incarcerated
This term for people who have spent time in jail, prison, juvenile detention or another form of incarceration follows the guide’s general principle of describing people “as having a condition, not being a condition.” Other options include “returning citizen” or “persons with a history of incarceration.”
“Ex-con” and “felon,” by contrast, are dehumanizing.
“If, tomorrow, everyone stopped using the term ‘ex-con’ or other examples of dehumanizing language, I still don't think that's success—success is when individuals understand why the language has changed,” Dr. Fair said. “It's less about language, and it's more about perspective.”
Undocumented immigrants
There are structural issues that actively deny immigrants the ability to become “documented.” This is an alternative to the dehumanizing term “illegal immigrant.”
“No human being is illegal,” the guide says.
Native Peoples
This term is an alternative to “Indians.” Other equity-focused options include “Indigenous Peoples” or “American Indian and Alaska Native.” Native people prefer to be identified by their specific tribal name.
“When referring to Native groups, use the terminology the members of the community use to describe themselves,” the guide adds.
Historically marginalized
This is an alternative to “minority” or “underrepresented minority,” the latter a term often used in discussions of physician workforce diversity. “Minoritized” is another option to consider.
“Minority” can be inferred to mean “less than” and is now considered pejorative, as minoritization is associated with a loss of power, the guide says, adding that marginalization and minoritization happen with gender identities as well as with racial or ethnic identities.
The recommendation is not that terms such as “underrepresented” should never be used, said Dr. Fair, but context matters.
“If you're producing a study that shows Black, Latinx, some Asian groups and Indigenous groups are underrepresented in medicine, that is a fact—but you can't stop there,” she explained. “You have to say the reason they have been historically excluded. It's not just—they're not there. They weren't allowed to be there.”
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Nonadherence
Whether patients can follow, or adhere to, physician advice can be limited by structural, cost and insurance barriers, the guide notes. “Nonadherence” is an equity-focused alternative to “noncompliance,” which can be seen as placing blame for treatment failure solely on patients.
“In recognizing the power in our words, it is our hope that this guide will stimulate conversation and understanding about language, narrative, and concepts—helping us to identify harmful phrases and terms while also providing alternatives that move us closer to racial justice and health equity,” Dr. Harmon says in his column. “If this helps to improve the health of our patients—and our nation—it is a conversation worth having.”
Just as science and medicine evolve over time, so does language. The communications guide is not meant to be a definitive and all-encompassing instruction manual. Instead, it offers a fresh perspective about the language physicians and others in health care commonly use, and it enables them to recognize the harmful effects of dominant narratives in medicine.
Learn more with Philip Alberti, PhD, founding director of the AAMC Center for Health Justice, about why language matters when talking about racial and health justice in medicine.
Dr. Fair said the effort to make medicine’s language more inclusive should be seen as “part of quality improvement,” noting that hand-hygiene initiatives, for example, required education and a change in professional norms to take hold.
“There was a time when handwashing was not universal,” she said.
“The space of diversity, equity and inclusion is not a destination—it’s a journey,” Dr. Fair added. “If we think that there's a right answer or there's a perfect way that we can communicate, then we've already lost.”
