As modern practitioners, we all know that the patient should be the central focus of the consultation, and the days of patriarchal medicine are long over. Or at least, so we thought. In recent years, people living with conditions such as diabetes or obesity – conditions where they are responsible for their day-to-day care choices – have explained that the language we use in our interactions with them can be patronising, reduce confidence and ultimately affect both short and long term health outcomes.

Language matters in patient interactions

Our language (spoken and written) is a key way in which we reflect our attitudes and opinions to others. Used positively it can motivate and inspire; used negatively it can discourage and dispirit. As professionals we often feel compelled to instruct and advise our patients on how to improve their health-related behaviours, but often this is perceived to be critical or unhelpful, and rarely do we find we make a difference.

In their daily lives, people living with diabetes or obesity are bombarded with unhelpful stereotypes and judgements from others in society which may colour their clinical encounters. In a 2017 study, 76% of people with type 1 and 52% of people with type 2 diabetes reported that they experienced diabetes-related stigma (1). Regardless of type, respondents felt blamed for causing their condition e.g. reporting accusations of laziness and poor diet.

There is also a wealth of literature around the negative biases experienced by people living with obesity – sometimes described as the ‘last acceptable form of discrimination’. A view seems to pervade that ‘thinness’ is a moral choice and a demonstration of self-control, and therefore obesity results from lack of control – entirely ignoring the complex genetic, neuroendocrine, physical, psychological, social and environmental factors at play. Repeated exposure to these stigmatising attitudes can result in feelings of shame, low confidence, and societal exclusion.

Biases affect the language we use

Sadly, whilst healthcare professionals have an important role in challenging harmful and inaccurate stereotypes, we are not immune from exhibiting these biases ourselves and this spills over into the language used – phrases such as “poorly controlled diabetic” or “non-compliant” are frequently applied and carry inherent judgement. We should remember that diabetes is a 24/7 condition with no respite, and spending time on daily management may not be top priority at that time in a person’s life. Even studies of obesity specialists have revealed strong hidden negative biases. A person living with obesity recounts:

“Visiting my GP with chest pains, to be told to ‘go home and look in the mirror, as that was what was wrong with me’ “ – Obesity UK (2)

People with diabetes who reported experiencing the highest levels of stigma also had higher levels of Hba1c, which may reflect resultant difficulties in staying motivated for the many daily tasks of self-management, and in maintaining engagement with healthcare services.

About the Language Matters movement

The ‘Language Matters’ movement began with a publication from Diabetes Australia in 2011 to highlight – particularly to healthcare professionals and relatives of people with diabetes – how commonly used words and phrases can perpetuate unhelpful and even harmful messages about diabetes (3). Its great reception not only prompted further releases from diabetes associations across the world, but also extension to other agencies such as Obesity UK, The Network of Alcohol and other Drugs Agencies (NADA) and National Institute on Drug Abuse (NIDA), supporting people with obesity, addiction and other stigmatised conditions.

The focus of ‘Language Matters’ is to move away from using negative or judgemental phrases, and towards those that are positive and encouraging. This does not mean colluding or avoiding any discussion about difficulties, but simply taking time to consider how your message comes across. Rather than talking about blood “tests” being “good” or “bad”, try using objective descriptions e.g. “levels at/below/above target”. Choose “person-centred” language, e.g. “person with diabetes” or “person living with diabetes” rather than “diabetic”. Giving primacy to a person’s diagnosis or an aspect of their appearance or behaviour when you address them ignores the individual living alongside and beyond their condition.

Top 5 areas for change

There are helpful suggested words and phrases in all of the ‘Language Matters’ publications. In the consensus statement from Diabetes Canada, five key areas were identified as priorities for change. The examples are for diabetes, but can be extrapolated to many other conditions (4):

1. ACCURACY – for instance when referring to interventions that may prevent type 2 diabetes in the media it is important to be specific around the type of diabetes being discussed – helping to improve general public understanding about the multiple types and causes of diabetes.
2. POWER – using inclusive, easy to understand language helps promote a collaborative relationship, rather than one in which the professional has the knowledge and authority.
3. LABELLING – choosing person-centred language and avoiding negative labels such as “non-compliant” can lead to exploration of important aspects of life and lifestyle that can affect daily management.
4. STEREOTYPING/SHAME/STIGMA/BLAME – always avoid blaming the patient for their condition, or associated conditions. This could include being non-judgemental about body weight, and avoiding future use of insulin as a “threat” for patients with type 2 diabetes currently using other therapies.
5. FRAMING – for instance framing diabetes as “disease” and the person as a “sufferer” may negatively colour their attitude towards life living with their long term condition. It is also preferable to talk about aiming for a “target glucose range” rather than “control of diabetes” which implies a “pass or fail” judgement

Most importantly, as highlighted by Fox and Kilvert in a special ‘Language Matters’ edition of the journal Diabetic Medicine (5), the language we use should feel genuine and reflect our real feelings of respect, empathy and openness in the consultation. So much of our communication is non-verbal that stock words and phrases may otherwise seem overly twee, fake or ‘politically correct’.

Language does matter, particularly to the people experiencing negativity and stigma across society. We all have a role to play in examining our attitudes and language when interacting with our patients: challenging negativity when we see it and considering what it really means to be “patient-centred”.