Words matter. What we write about our patients in our medical notes to a great degree reflects how we feel about them. Our words also mold our future relationship with our patients. One good example cited by Jayshil Patel, MD in a recent JAMA editorial (found here) is the common phrase “the patient was a poor historian.” There may be many reasons why a patient is not able to answer our questions well, such as dementia, delirium or psychosis. In fact, the inability to present a cogent narrative usually is an important symptom of an underlying condition. “Poor historian” does not reflect this fact. To the contrary, “poor historian” implies that the patient is at fault for my poor documentation, not me! “Poor historian” leaves out that there are other ways for me to get a medical history (medical records, talking to family, etc). “Poor historian” also implies that the patient was deliberately not cooperative—even though perhaps I spent maybe two minutes attempting to get a history.
Many other common medical phrases also subtly disparage patients. Two good examples are the words “denies” and “admits” as in: “The patient denies drinking” or “the patient admits to IV heroin use.” The implication of these words is that we are engaged in something akin to a hostile cross examination where I forced the patient to “admit” (against their will) to drinking and I really don’t believe the patient who “denies drug use.” Words guide how we think about our patients, even if on a subconscious basis. When I use these words, I am saying that my patient and I are not on the same team.
In corrections, perhaps the single best example of a word that negatively influences our relationship with our patients is “inmate.”
I have reviewed hundreds of correctional patient charts and I can confidently say that “inmate” (or the abbreviation “I/M”) is used more than “patient” or the person’s name in correctional medical records. Now I understand that in corrections, our patients are, indeed, inmates. They are incarcerated in a jail or prison and so, by definition, are inmates. I also understand that we learn to use “inmate” in our medical documentation by example and it becomes habitual. No malice is usually intended!
However, “inmate” is usually inappropriate in correctional medical documentation (in my opinion). When inmates are in our medical clinics, they are primarily patients. Yes, they are also inmates, but the fact that they are inmates is irrelevant.
Consider the example of people committed to a psychiatric facility. They are also inmates (by definition) but the medical professionals in state psychiatric facilities do not use the word “inmate” in their documentation. They say “patient” or use the patient’s name. So why do we?
The answer, I think, is that we picked up the term “inmate” (or its prison equivalent “offender”) from our security colleagues. Security is an ever-present concern in jails and prisons in a way that it is not in a psychiatric hospital. We have to go through security to get in and wait to be buzzed through clanging metal doors. We have correctional officers or deputies always about—and we rely on them. They are our friends. The Deputies say “inmate” so we historically have used the term “inmate” until it became habitual.
But our relationship with the inmates in a jail is very different than the relationship that deputies have. When inmates are in our medical clinic, they have become our patients. Using the term “inmate” in our medical documentation misidentifies our relationship. When I used to work both in the ER and the county jail, I commonly would see the same patients in both locales.
“When did you get out of jail?” I’d say at the ER. “Yesterday.”
“When did you get re-arrested?” I’d say to the same person at my next jail clinic. “Yesterday.”
My relationship with that person is the same in both circumstances. They are not an “inmate” in one setting and a “patient” in another. In both places, I am their doctor and they are my patient.
I should finally say that “inmate” is fine in appropriate non-medical contexts. “The inmates just finished rec,” for example, or “How many inmates are in Dorm C?”
But in our medical documentation, let’s please get rid of the term “inmate” and “I/M.” Let’s instead use their name (Mr. Jones) or the general term “patient.”
As always, what I have written here is my opinion based on my experience, training and research. I could be wrong! If you think I am wrong, please say why in comments!
How do you refer to the people in your correctional medical clinic? Please comment!