Jarring Unprofessionalism: Argot Revisited

The dark side of medicine, involving examples of physicians ridiculing unconscious, anesthetized patients, has recently been exposed in medical journals and in the lay press.^1,2 In 1 instance, an anesthesiologist was the perpetrator and, in the other, the anesthesiologist was the “hero” who insisted that the repugnant behavior cease. When discussing these circumstances with our anesthesiology residents, I was dismayed and puzzled by a lack of universal agreement that this egregiously disrespectful behavior is unacceptable. I then engaged in considerable soul-searching to “explain” our trainees' ambivalent, and profoundly disappointing, reaction.

When I first read the satirical novel The House of God by Samuel Shem (aka Stephen Bergman, MD, PhD) in the late 1970s, I was chronologically young and emotionally immature. I thought the terminology used by the residents to describe many of their challenging patients was hilariously clever and eminently “cool.” Indeed, I recall laughing raucously at several bawdy and outrageous passages. Perhaps some of my unrestrained glee was in reaction to my own demanding residency at the Peter Bent Brigham (now, Brigham and Women's) Hospital in Boston, where the Chief of Anesthesia, Dr Leroy Vandam, presided over a program that was intellectually rigorous, physically arduous (residents worked more than 100 hours per week then), and emotionally exhausting.

Although I admired “the Chief” enormously, he was a martinet who did not suffer fools gladly. His standards were exacting and his code of conduct was strict to the point of being inflexible. Our attire was continuously scrutinized, lest there be the slightest departure from professional appearance. Even—or perhaps, especially—our vocabulary was monitored. Using expressions such as “bagging” or “tubing” to refer to procedural interventions was verboten and guaranteed to elicit Dr Vandam's wrath. With the passage of time, I came to appreciate that Dr Vandam led by example and that, at his core, had a deep and abiding respect for patients and their caregivers. He could not, and would not, countenance behavior that detracted from the dignity of patients or physicians.

Even though decades ago I reveled in the mordant humor of The House of God, today I cringe if I hear an intern or resident use derogatory slang when referring to a patient. Terminology that is amusing to read in a novel can be hurtful and degrading when applied to real people; fiction is not life, with all its vagaries and pain. I think it is important to express unequivocally the opinion that labeling patients with derisive or demeaning terms is inherently disrespectful and robs them of their human dignity. It also undermines the profession of medicine and its practitioners. Patients who are obese, elderly, or demented are especially vulnerable to this type of abhorrent behavior.

Who among us has not heard the terms “gomer” “Q-sign,” “beached whale,” or “frequent flyer” to describe these individuals? Given the expanding patient population who fall into these categories, demeaning behavior could become more prevalent, if unaddressed.

The formal name for this type of slang is argot, which is defined by Webster's New World Dictionary as “the specialized vocabulary of those in the same work.” The word argot probably harkens back to the 17th century and derives from the term les argotiers, a name given to a group of thieves at that time. Victor Hugo described argot in his 1862 novel Les Misérables as the language of the dark, saying “What is argot properly speaking? Argot is the language of misery.” Arguably, it serves a “purpose” by forging a bond between users, affording those who use it an opportunity to vent, and creating some emotional distance between the speaker and a high-stress or unpleasant situation. Clearly, argot is intended to prevent outsiders from understanding the insiders' conversation. Perhaps what most disturbs me about this type of discourse is that it weakens, if not severs, the physician-patient bond. True to its etymological origin, argot robs patients of their intrinsic worthiness. It is particularly destructive and exploitative because patients enter into a covenant with the physician to whom they entrust their health and, in many cases, their lives. The speaker appears to be suggesting that he or she belongs to a superior class, entirely distinct from the flawed, beleaguered patient. This offensive jargon lacks acknowledgment of our common humanity.

In an attempt to excuse unacceptable behavior, we can hypothesize about reasons why physicians—especially neophytes—resort to argot. Certainly, caring for a demented patient is difficult, especially since most of us entered medicine to improve the condition of our patients. This goal is virtually impossible when confronted with dementia. Correspondingly, obese patients present their own challenges to clinicians: difficulties with vascular access and airway management, as well as propensities to development of thromboembolism and postoperative infection, to name but a few. Moreover, the young physician may consider morbid obesity to be a self-induced condition that reflects gluttony, laziness, and lack of discipline. Resentment and frustration fester, ultimately becoming manifest in degrading and unprofessional language.

One could also argue that modern technology has acted as an accelerant to this slippery descent into unprofessionalism. Who among us has not observed the coarse, unfiltered, personal comments that appear regularly in social media promulgated throughout the Internet? Perhaps we have become desensitized to offensive language and ideas unworthy of purportedly educated, sentient human beings.

While we can understand the pathophysiology of argot, we should not condone such inappropriate behavior. We took an oath to be patient advocates, not patient deprecators. Moreover, this issue is not merely a superficial or comparatively trifling matter of manners or decorum, although we would do well to remember that etiquette is the diminutive of ethics, as in une petite éthique. This is about basic human dignity and the respect that every individual deserves, especially one who is suffering.

When I applied to medical school, my father, also a physician, urged me to read Tolstoy's The Death of Ivan Ilyich, hoping that this masterpiece would help me to see “cases” as “people.” But it was only after reading another Russian artist, the physician-writer Dr Anton Chekhov, that I came to understand that we are all suffering human beings, worthy of sympathy, empathy, compassion, and respect. Chekhov, who died in his early forties from tuberculosis, knew that physicians are often patients, vulnerable to the same physical, emotional, and moral infirmities as others. A dose of Dr Chekhov is an effective antidote to the fourth “Law” of The House of God: “The patient is the one with the disease.”

As educators striving to shape the next generation of physicians, we need to do more than suggest a reading list in the humanities. In our words and in our deeds, we must make it eminently clear that all our patients deserve unmitigated respect and compassion. We must care for, and be present to, each and every patient regardless of circumstances. As physicians, we must reflect on the values and behaviors that animate our lives, affirm our humanity, and nourish our existence. Personal connections with our patients often begin with quiet moments and small gestures, such as a reassuring glance or a gentle smile. Once that connection is established, it would be unconscionable to defile the relationship with unworthy remarks that not only undermine, but also deny, our common humanity.