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Good doctors don’t trash-talk their patients

“Bounce-back.”

That was the term I used to describe a patient to the team one morning on rounds. I was a medical student, and was delivering a summary of the patient’s care to the small crowd of fellow students, residents and one attending physician clumped there in the hallway. I could not now tell you a single thing about him, other than that he had been recently discharged and later readmitted for the same condition. Hence “bounce-back,” the piece of medical slang I employed to sum that fact up.

I hadn’t really meant it pejoratively, merely descriptively. Medical communication is all about efficiency, after all, and “bounce-back” quickly conveyed something about the patient. Like its cousin term “frequent flier,” used for patients who were often admitted over and over, it wasn’t entirely respectful, but I hadn’t meant it to be insulting, either.

My attending physician was not in the mood for leniency about such things. There in front of everybody he explained to me quite pointedly that using dehumanizing terms to describe patients was unacceptable, and not something he would tolerate. My ears were a deep shade of crimson when it was over.

I never called a patient a bounce-back again.

However, compared to another piece of medical slang, “bounce-back” and “frequent flier” are practically “beautiful darling.” In a rather startling article for Slate, Dr. Anne Skomorowsky introduces the non-medical world to “SHPOS,” short for “sub-human piece of shit.”

Truth be told, I can’t remember ever actually hearing a doctor call one of his or her patients a SHPOS in real life. I’ve only heard it referred to, never used. In her book “What Doctors Feel,” Dr. Danielle Ofri renders it “shpoz,” and describes it as a term of contempt medical providers use for patients they feel are less deserving of compassion — the drug addicted, the alcoholic, the morbidly obese. When I came across that passage not long ago, it took me a few moments to parse the term before I dredged up its meaning from some dusty corner of my memory.

But Dr. Skomorowsky, a Columbia psychiatrist, goes a little bit further. Not only does she indicate that use of the term is commonplace amongst doctors, an insinuation I would vehemently dispute, but she further implies that some patients kind of have it coming.

“Not surprisingly,” she writes, “the SHPOS is often alone in the world. He may have just been released from jail, or his loved ones may have refused to take him in. He may have been fired from his job or banned from seeing his children. On top of that, now he is ill. The SHPOS comes to the hospital in a state of social despair, isolated and unhelpable, and the only person left to absorb his rage is the health care worker who must care for him, no matter how hateful he is.”

She goes on to describe certain things as “SHPOS behavior.” While she concludes with a rather tepid declaration that “no one is proud” to call another subhuman, apparently in some cases the shoe just fits. Doctors simply call it like it is, in her apparent estimation.

I reject that attitude outright.

Make no mistake, medical providers often see people at the utter, utter worst. I was once one of about ten emergency department personnel literally kneeling atop an extremely violent patient who had taken some bad PCP, attempting valiantly to restrain him as we waited for the whopping dose of sedatives to calm his combativeness. (He was also a spitter.) During residency a mother accused me of stealing a bracelet from her toddler, and when she later found it in his bed didn’t apologize but claimed I had planted it there. In my current practice, it is all too common for bitterly divorced parents to spare no opportunity to lacerate each other, using their child’s medical care are yet one more battlefield in their endless war of attrition.

People can be awful. Patients can be horrible. But it’s not because they’re subhuman, even at their worst. It’s because they’re human.

If one cannot deal with this immutable fact, that we often find ourselves taking care of human beings at their most desperate and vulnerable and wretched, then medicine is not the right profession. If being made to care for people who are ungrateful, rude, mean or otherwise horrible allows one to justify calling them pieces of shit, then one needs to reexamine what one is doing try to care for them in the first place.

Doctors are human, too, and we will naturally respond negatively when people lash out at us, try to manipulate us for their own ends, or are otherwise baldly nasty. Protecting ourselves from the toll this can take is difficult, and none of us do it perfectly. But finding a way to hold onto our own integrity while treating people as we find them, rather than how we want them to be, is a necessary skill. It’s part of the deal going in.

What we don’t get to do is start telling ourselves that the most unpleasant people are beneath our care. We don’t get to call them subhuman or try to rationalize our own nastiness. They aren’t pieces of shit. They’re our patients.

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23 thoughts on “Good doctors don’t trash-talk their patients

  1. First, good to see you, Doc!

    Second, it does not surprise me that Slate engaged in this sort of hyperbole.

    Third, my profession (teaching) has some in it who similarly use disrespectful language when discussing students. In bothers me to no end. Just this morning, I had to sit in a meeting where a teacher talked about two 3-year-olds — 3-year-olds! — as if the difficulties they presented were an inconvenience for her. It took all my energy to not say, “Actually, the difficulties they present are the reason you are here! Your job is to support them through the difficult moments and arm them with the learning or skills to manage their difficulties!” Students and patients are not and should not be seen as an impediment to the work of teachers and doctors but rather as the people we are charged with supporting no matter what. I’m glad to hear that the language discussed in the Slate article is not as pervasive as they try to make it seem. And while the phenomenon I describe in education is real, it is similarly not the norm.

    Now, talking shit about parents, on the other hand… well, that’s what gets us through the day.

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    • I am completely unperturbed by these nicknames, or even darker ones. I think it’s a natural inclination of any subculture to have its own cynical language of affiliation–it’s a encoded way of bonding and commiserating. And other subcultures have far more disturbing dismissals of the other humans they encounter. The LAPD refers to civilians as “assholes,” and many military dismiss their targets as “Charlies,” “haji”, “camel jockey”, or “skins.”

      The slang of the physicians seems to me as a way of creating a little psychic distance between themselves and a job that can sometimes seem futile.

      By the way: I was gratified to see that you haven’t given up on us yet. I’m hoping that your blogging time has been consumed by completely-satisfying family time, but still–What about us??? It’s good to see you back.

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      • Thanks, guys. Writing on deadline elsewhere plus demands from family life and my day job have sucked up a lot of my writing time here, to my chagrin. The demand for freelance stuff at one of my other outlets is tapering off, which may end up freeing up some time.

        It’s always so nice to be here.

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  2. Once again, I am struck by the parallels and divergences between our respective professions. Law, and in particular litigation, is very much about understanding and communicating what makes people do the things they do, the kinds of actual behaviors we might expect from people.

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    • Press the wrong button too fast. To continue…

      If I were to see a defendant in an eviction case whose name I recognized from a previous eviction, I would call this defendant a “repeat customer.” My client, the plaintiff in the second case, will typically find this amusing. Granted, the characterization is just a little bit cruel. At the same time, it provides a measure of psychological respite for my client. Many of my clients have expressed confusion about their tenants’ failure to pay rent. A pithy description often helps them understand the situation, and let them realize that they personally are not being insulted by their tenant. (Yes, many of them come into the process feeling personally insulted.) it isn’t about them, it’s about the tenant.

      Of course, some of them get more confused. “You mean, they didn’t pay their previous landlord, either? What kind of a person does that?”

      In response to this, I have a wide range of things I might say. A very nuanced description of the situation might refer to the fact that some people lack significant economic opportunities owing to a wide variety of sociological factors which are the legacy of a painful and unfair history, a problem that is the fault of no one living, but nevertheless which creates fallout that must be dealt with on a daily basis. Further, the people on the receiving end of these disadvantages develop psychological coping skills which include responses to short-term economic incentives, anddefenses and deflecting moral justification for doing what they believe is necessary to survive notwithstanding a broader normative sense perhaps those decisions are not altogether morally or legally justified. Perhaps they find a way to rank moral imperatives such that while they are not doing the morally best thing imaginable, from their perspective, they are doing the morally least bad thing available, and the landlord’s contractual due comes out lower than their own well-being in that calculus.

      Or, I could say, “What kind of person does that? A thief.”

      Is it entirely fair to call someone who has not paid rent to two or more landlords for more than a year “a thief?” My more nuanced description is indeed more nuanced. But it’s not what the confused and upset plaintiff in the courthouse hallway needs to hear.

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      • I read an interesting article on bounty hunters a few years back that noted that the most successful ones were the really friendly ones who were nice to the people they chased down and polite to the families in the process. Why? Because they get a lot of business from repeat customers. They often have to track down the same people over and over, so it pays to be able to just give the mother a friendly call and say, “Hey, is he hiding out at the usual spot? Can you let him know I’m coming to pick him up?”

        I bet that most professions that deal with their customers’ self-inflicted wounds tend to get a lot of repeat business.

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  3. I’ve actually heard a lot more derisive talk about patients from health-care professionals who are not doctors then from doctors; but I think perhaps the non-doctors have to deal with a lot more of the challenges that difficult, socially-inept patients present to health care workers after a hospitalization, too; and of course, my experience is anecdotal. But I think nurses, technicians, etc. get a lot of abuse from difficult patients, and while I expect them to act professionally, I think the harm they cause by venting this is (somewhat) balanced by the importance of expressing the stress it causes.

    A really good friend of mine, a neonatologist, tried to save Scott and Laci Peterson’s baby; and while Peterson was an outlier (and outright lier), it was really important for the staff that dealt with him to process what happened. Less significant events may not seem as crucial; but I think they aggregate, rather like cat-calling and internet misogyny aggregate in women’s psyches. I don’t know if this is an issue strong enough to suggest better mental-health support for medical professionals (and teachers and cops and retail workers and . . . ) but I do think the drain of difficult people, and the way it taints our ability to see people as human, merits consideration from the perspective of the burden that might trigger dehumanizing in the first place.

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  4. Wonderful piece, Doc! Good to see you ’round here still with all of your interests and children to fend off!

    I’m kind of wondering what the point of the Slate article was – there’d be an interesting and informative piece there if it had just stuck to describing abusive patients and the effect they have on doctors and how doctors put up with them. That some doctors have less than kind lingo for such patients is also not surprising, but what is the point of proudly telling the world what that lingo is and making that lingo the point of such a piece – it’d be one thing if it was a piece on a medical listserv, where its purpose would presumably just be to provide a place to vent, but why write such a piece for public consumption? I just don’t see the point, especially if the lingo isn’t merely an aside but the entire focus of the piece.

    What makes the piece particularly appalling, though, is that it’s written by a psychiatrist. Had it been written by a regular ER doc, then you could perhaps understand the lack of empathy and the scorn involved even if you couldn’t excuse it; at worst, such a doctor would still be stepping into the role of a veterinarian treating a cat.

    But a psychiatrist willing to heap such scorn on abusive patients with obvious mental illnesses? To refer to them as “subhuman pieces of shit” is to effectively deny the patients have a mental illness at all, but instead say that are simply not human and are incapable of receiving psychiatric treatment. It is to sit in judgment of the patient, to define that patient by a bout or bouts of abusive behavior, when the entire point of psychiatry is so often to show the patient that their mental illness shouldn’t and doesn’t define them, to treat them as people who “have” a mental illness rather than as people who “are” mentally ill.

    The equivalent would be treating patients suffering from leprosy as lepers. Viewing such people as persons suffering from a disease is to express a willingness to treat them regardless of whether the disease is curable. A doctor who views them as lepers defined by their illness is a doctor who believes they should just be removed from society and left to die in a colony. A psychiatrist who calls his most difficult patients “subhuman pieces of shit” is a psychiatrist who would have no qualms just locking them in a rubber room for the rest of their lives and then walking away from them.

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  5. I’m totally 100% behind this. As you said Russel, they aren’t sub human, they are human. That, however, does not aren’t a total POS. But neither does that absolve anyone in the medical profession from dealing with a POS in a professional manner. This is also why I’m not in any field where I deal with these types of people. :) Kudos to those that do.

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  6. I wonder to what degree you *can* be an effective care provider for people you think are SHPOS. It’s hard for me to imagine that no matter how stoic you thought you were, it would have to creep in there somewhere.

    And I have to say, I kind of wonder that about a psychiatrist especially.

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  7. As I mentioned on Twitter, my wife has never heard of the term. I tested her by asking what it stood for, and she had no idea. She was aware of another acronym that she’s seen once, that basically means the same thing, but that was all she could come up with.

    “Frequent flier” and “bounce back”, though, are terms I do hear a fair amount.

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  8. I have heard that sports journalists do what they can to out-Herod Herod in the newsroom because investigative journalists tease that sports journalists don’t have to engage in journalism. Sports journalists just say that the Lightning got X points, the Thunder got Y points, and come up with a handy narrative of X and Y using the videotape. This results in some serious “I’m a Journalist!” posturing on the part of the sports guys.

    (Aside: I’ve written a handful of articles talking about the various Professional Wrestling house shows I’ve been to reporting who fought who, who won, and what the finish was. The hard part was reading notes a few hours later that I wrote in the dark.)

    All that to say: it wouldn’t surprise me to hear that there is a plurality of psychiatrists out there that have some serious real medical doctor envy.

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  9. I remember hearing SHPOS on “e.r.” back in the day. (“Couple of shpoes”. “What?” “You know, sub human piece of–” “I know what it means, Carter. Why are you saying it?”)

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  10. If being made to care for people who are ungrateful, rude, mean or otherwise horrible allows one to justify calling them pieces of shit, then one needs to reexamine what one is doing try to care for them in the first place.

    One is trying to earn a living.

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  11. From the long sit in the waiting room onward, it’s such an uphill battle to try to get respect as a patient.

    Thank heaven for a few good doctors. Because the system is set up to make you feel small.

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