AMA Journal of Ethics^®

Abstract

Members of communities of color have long experienced structural marginalization and biases that have measurable health consequences. When a group of medical students choreograph and perform Kuchipudi and Bharatanatyam forms of Indian classical dance, they illuminate a collaborative, narrative approach to interrogating ethnic and racial biases in clinical jargon. In these video recordings of “Bagalamukhi’s Words,” performers interpret a patient’s embodied, visceral responses to language-induced dehumanization during a clinical encounter. The accompanying commentary helps viewers consider how traditional dance, such as classical Indian dance, is useful as a narrative approach to ethics in health care documentation and communication practices.

Racial Bias in Clinical Jargon

Lingua medica, the language practices of health care, can be experienced by patients as depersonalizing (ie, feeling that one’s unique identity is erased in the course of communication) or as a source of negative bias (ie, feeling that one’s unique identity is supplanted by negative stereotypes in the course of communication).¹Negative stereotypes are a hallmark of racist communication, and racism is widely regarded as a key health determinant in communities of people whose identities have been racialized.² Members of these communities routinely receive substandard care and feel more dissatisfied with care that is influenced by clinicians’ implicit and explicit biases than White patients.^3,4

One major, yet neglected, source of negative bias is jargon clinicians use to verbally represent patients’ stories to one another on teaching rounds and when documenting key data, events, and changes in patients’ health records.¹ Physicians, for example, often convert patients’ narratives of their illness or injury experiences into subjective, objective, assessment, plan notes (commonly abbreviated and referred to as SOAP notes), complete with patients’ chief complaints, histories, and physical examination findings that are often also referred to by various clinical colloquialisms.¹ Health care is full of acronyms (eg, SOAP) or terms of art (eg, chief complaint) that “shape as well as reflect the thought, the talk, and the actions of trainees and their teachers”¹ and influence how clinical encounters play out. Although some clinical jargon is necessary for clinicians to communicate effectively enough to motivate decision sharing, overuse of clinical jargon or overlexicalization of information that could be conveyed more plainly can unnecessarily complicate important clinician-patient or clinician-clinician exchanges or obfuscate critical information, which, if not clarified, could exacerbate racial and ethnic health inequity or lead to iatrogenic harm.

Narrative approaches to thinking about how we reason, clinically and ethically, draw attention to humanism in clinicians’ use of language during clinical encounters. 

Descriptions of patients’ adherence to clinicians’ intervention recommendations often differ based on race; Black patients’ health behaviors, for example, are more frequently characterized as less adherent than White patients’ health behaviors.^5,6,7 But language use in clinical encounters is not always overtly racist. Overly medicalized or academized language is not only clinically but also ethically troubling because it can result in patients’ feeling that their agency has been diminished, that their perspectives have been erased or pathologized, or that they are being objectified and dehumanized.^1,5,8,9 Although jargon can be used by clinicians with the intention of being clinically accurate and specific about a diagnosis or intervention, if it’s interpreted or experienced by patients as alienating or undermining, it can damage the patient-clinician relationship, possibly irreparably. Moreover, clinicians’ depersonalizing communication can lessen their sense of professional responsibility for that patient’s care and welfare.⁸ Rampant health inequity makes depersonalizing communication during clinical encounters particularly damaging to clinicians’ relationships with patients of color.^1,9

Narrative Thinking

Narrative medicine is an arts-based field that seeks to improve patient-clinician communication by encouraging clinicians to integrate into their representations of patients’ stories patients’ own perspectives and the language they use to describe their illness and injury experiences. Narrative approaches to ethics and caregiving are used in health professions education to help trainees reflect on how their habits of perception and their personal biases shape their clinical reasoning.^10,11 Narrative approaches to thinking about how we reason, clinically and ethically, draw attention to humanism in clinicians’ use of language during clinical encounters. Narrative strategies can help motivate racial and ethnic health equity—perhaps most efficaciously, by helping clinicians be more thoughtful and intentional about how their language use defines and is defined by their roles in hierarchical structures of health care education and work environments; by common practices of diagnosis, intervention, and documentation; and by the predominance of English language in health care spaces. Narrative approaches to caregiving prompt clinicians’ deliberation about their use of language that can help them represent others’ experiences and stories—and their own—more accurately and justly.

Healing Words as Fighting Words

Words are not the only things people use to tell stories, however. Gestures and other movements are also linguistic, culturally situated, and used to convey and interpret culturally nuanced stories to achieve social equity. In fact, bodies tell stories unexpressed—stories hidden from the conscious mind—in a phenomenon known as embodiment.¹² As described by Nancy Krieger, the body puts narrated evidence in physical context.¹² This notion of embodiment is particularly helpful when considering the cumulative, negative health effects of racism and supports Indian classical dance as a useful tool for interrogating jargon’s roles in exacerbating racial and ethnic health inequity.

Kuchipudi and Bharatanatyam Indian classical dancing are drawn upon in the accompanying videos to demonstrate a performance-based exploration of language biases in health care settings and cultures.¹³ First, understanding of these key terms—natya (storytelling), nritta (rhythmic footwork), and nrithya (natya and nritta combined)—will facilitate viewers’ experience of “Bagalamukhi’s Words” in 2 choreographed performances. Second, key background information is that Indian classical dances are age-old art forms that often focus on Hindu mythology and open with an exaltation of a Hindu goddess or god. Bagalamukhi is the demi-goddess of words; she uses words to heal and also to fight. Metaphors of healing and fighting are familiar ones in medicine, especially in cases in which fighting disease capably requires weaponization of interventions—pharmaceutical agents, for example—as a key feature of what it might mean to heal a patient.

In the video 1, the performance features an unnamed, faceless patient reacting as a physician presents her case. The physician refers to her age, social habits, chief complaint, history, and initial presentation—but not to her as an individual person. The patient appears to express and embody confusion commonly experienced by patients, particularly patients of color, as a result of depersonalizing clinical communication.^4,14,15

Video 1. Bagalamukhi’s Case Presentation

In video 2, Bagalamukhi’s story blends with the patient’s story. We see that the patient’s story is more complex and relevant than depicted in her physician’s case presentation; we learn that her name, identity, and roles were inaccurately represented and unjustly oversimplified. The patient resists the physician’s misrepresentation of herself, of her story. She reanimates her own humanity beautifully in her own words, as a poem.

Video 2. Bagalamukhi’s Words as Resistance