September 09, 2018

"Plain English" in medicine

Writing about web page https://www.bbc.co.uk/news/health-45394620

I was suspicious this week when the BBC and other British media ran stories that doctors were being told to "use plain English" when communicating with patients. Like a lot of descriptions of language, Plain English seems intuitively straightforward, but actually isn't. There is no objective way to say that some ways of talking or some sets of words are "plain" and others are--I don't know--"elevated."

The closest we could come, I think, would be to say that we should avoid jargon, which is a specialized vocabulary used by a group of people engaged in a common activity, usually associated with a profession. But if plain English were really being used in this way, then it would cover football commentators when they describe a strike as a header and plumbers when they describe a pipe banging as being caused by air hammer. And no one complains that football commentators and plumbers need to use "plain English." So challenges to plain English aren't straightforwardly a demand that people avoid jargon, or use words in a constrained, common-parlance sort of way. Plain English is instead at least partly based on the people who use particular linguistic features as much as it is based on the actual linguistic features being used. Plain English is, in other words, ideological.

My initial suspicion was piqued by the reports that patients were having trouble understanding doctors. For instance:

The Royal College of GPs is also on board. Vice-chair Prof Kamila Hawthorne said: "I have seen a number of patients who have asked me to 'translate' the letter they have received from the hospital, which has been little more than a medical summary."

Prof Hawthorne is referring specifically to written communication. That detail was not clear in TV reports I saw, which (to me) suggested that patients were complaining about not being able to understand doctors in face-to-face communication. Writing is different from speaking, so I take no issue with Prof Hawthorne's observation. I remain suspicious, though, about the more general communicative frame presented in the media (that patients can't understand what doctors are saying) and the ideologies that might have led to this particular story being picked up by British media. My suspicion is bolstered by the appearance of the word translate in the Hawthorne quote.

Specifically, I am suspicious that demanding that British doctors use plain English encodes an objection to British doctors speaking using foreign-accented English. A report to Parliament in February 2018 noted that 12.5% of NHS staff "say that their nationality is not British." The largest proportion of non-British staff are Indian. And these non-British staff are disproportionately doctors; the report shows that 12% of NHS doctors are Asian (mostly Indian and Pakistani) and that 20% of NHS doctors received their qualification in Asia. In total, only 74% of NHS doctors are British and only 64% were educated in Britain.

So, many NHS medical encounters will take place between a British-born patient and a doctor who speaks a non-British-sounding English. I suspect that, if patients are truly complaining about the English being used by NHS doctors, at some level they are complaining about English not sounding sufficiently British.

Again, this is only a suspicion. It should be developed into a hypothesis, and then tested. It could be tested, e.g., by patient satisfaction surveys that track the degree to which patients feel they understand their doctors and the national origin of those doctors.

Nevertheless, the Academy of Medical Royal Colleges would do well to remember that there is no such thing as objectively plain English. When they advocate for doctors to use plain English, they are advocating something on behalf of ideology rather than fact (which seems like a patently-non-medical thing to do).

The non-objective nature of the advice to use plain English is highlighted by the advice given under the "Keep it suitable" section of the BBC story about the advice. For instance, the article suggests:

They should think about softening the impact of potentially sensitive information by using a more non-committal style, as with: "During the examination, the tremor and stiffness in your right arm suggest that you have Parkinson's disease."

But softening information and using a non-committal style is, in a sense, the opposite of plain English. It obscures diagnoses. A patient's natural response to the exemplary sentence is "Do I have Parkinson's or not?" (!?!?!!?!).

The word-focused guidance isn't helpful either. For instance, I think it's fair to accept that oedema is not part of general vocabulary. But surely seizure is, and surely seizure is more medically accurate than fit?

These contradictory linguistic prescriptions reflect competing communicative goals, which include being precise, being empathetic, being kind, being brief, and being understood. These goals are much more complex than simply using plain English.

It's crucial that doctors and patients work together to communicate medical information in ways that are indeed precise, empathetic, kind, brief, and understood. It's laudable that the Academy of Medical Royal Colleges advocates for the achievement of these goals. But a call for doctors to use plain English is unlikely to provide much practical guidance, and may reinforce problematic ideological biases.


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