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[cough] [jeoff bull]uh, so hi everybody. uh, i'm jeoff bulland, uh, not even checking my notes, i can say that i am a teacher in the general an arts and science- general arts and sciences stream of the schoolof liberal arts and sciences here at humber college,and it's my honour to be the host today of our talkand to thank you for coming to our fifthof six presentations this year

in the president's lecture series, where todaywe'll have the great pleasure of hearing doctor brian goldman,emergency room physician and host of white coat, black art on cbc radio, speaking to us about"the secret language of doctors – cracking the code of hospital culture." now, as it's often, uh, done before we start these talks, i'd like to, uh, givesome thanks to people who've helped usbring this lecture

and our whole lecture seriesthrough the years, and in the future we hope,uh, to you. so, first to my fellow president's lecture series committee members – angela aujla, melanie chaparian,chandra hodgson and our chair,ian gerrie. i'd also like to say thanksto media services at humber who do such a spectacular job every time, especiallythe excellent technicians here

who've helped us set up today. say thank you to the president'sexecutive assistant, deborah green, and, of course,to our president, chris whitaker, who we'd like to thankfor his continuing support of this lecture series. as mentioned, this is our fifthof six lectures this year, and i just wanna go over some of the other ones we've had, so you're f- you're aware if you didn't get to see them of what we did.

last fall we heard from nora young, another cbc host,this time of spark, who talked about"seeing the forest and the trees – surviving and thriving in the coming data boom." we also heardfrom lawyer steven wise who spoke on "the struggle of non- for nonhuman rights a- and legal personhoodof nonhuman animals" by the human rights project. and near the end of the year, uh, term,

we heard from jennifer hollett,political pundit, who describedto the lakeshore audience what happens when digital gets political. just last month, paula todd,formerly of tvo, spoke at the lakeshore about"extreme mean – trolls, bullies, predators, and you online." and the reason i mention all of theseis because they are all available on our video archive,which you can get to if you followthe president's lecture series link

on the school of arts and sciences' website, and doctor goldman's, uh, lecture will be going up there shortly. in fact, we have,uh, lectures going back at least ten years in this series, uh, that are available for peoplein the humber community to download and, uh, learn from. in fact, i'd say these are a great research and lecturing tool, so why not have a pokearound in there and see if there's something that you might be able to use.

we have one more lecture,as i said, this term, that'll be on thursday,march the twenty-sixth at 1:30 in this room,seventh semester. we'll hear from doctor ward struthers, who's from york university's department of psychology, and he'll be talking about"understanding the power of apology in decisions to seek revenge, harbour a grudge, and forgive." let me give you a reminder toothat notice of this talk and all president's lecture series talkscan be found

on the humber communiquã©,on humber tv, on hsf bulletin boards, as well as, uh, at our linkson facebook, google plus, and if you like to tweet, uh,on twitter at @humberpls. now, the pls,or president's lecture series, aims to connect all of humber with ideas and thinkers of note. so we're really pleased to seethat so many, uh, different members of the community are here today, not just professorsand support staff but administrators and, most wonderfully, students.

thank you for coming.welcome. welcome tooto everybody else who's tuning in through our livecast link to the lakeshore and orangeville campuses. and i've been asked in particularto offer a special welcome to the nursingand sociology of health students who have come here,uh, thanks to the efforts of constantine belegris and alexander shvarts. now, i'm not sure if doctor goldman's material will be on your exam,

but i am surethat he will help unveil some of the mysteries related to your areas of study, so it's good that you're here. now, we get to the- my favorite part of being the moderator, which i where i get to tell everyone to turn off their cell phones. because i don't have a cell phone, and i find them a little strangeand perplexing and so maybe in my evil wayi like this feeling that i've done something that seems to bother a lot of people,

asking them to turn off their cell phones. but, but i want you to know it's for a good cause that you turn off your phone. no one wantsto hear your cray cray ringtone in the middle of doctor goldman's talk. so, shut 'er down. if you cannot last an hour or 90 minutes without texting someone, you're free to leave the roomand do that outside but just la- leave politelyand quietly

and don't turn on your phone until you're out the door. i'll remind you toothat we do have a question and answer session after the talk. so, if you think of somethingyou'd like to ask doctor goldman during his presentation,make note of it and feel free to, uh, ask the question after. we have microphones set up,you can see one over there. and we need you to ask the questioninto the microphone if you can because, uh, this q and a sessionis also livecast

and the people at other places wanna hear your questions. uh, if you cannot get to the microphonefor a particular reason i'm happy to run a microphone over to you if we have to, so just put up your hand and let me know, and we'll see to that. so, what i'm gonna do nowis turn things over to sarah delionof our nursing program who's going to introduce our guest lecturer today, doctor brian goldman.

[applause] [sarah delion] in the trenches for more than 20 years, doctor brian goldman is a graduateof the university of toronto and a respectedemergency room physician at mount sinai hospital. he is one of canada's most trusted voices in medicine – a doctor who thinks like patient. he has worked as a health reporter for cbc television's "the health show," as well as "the national,"its flagship news program.

he served as senior pro- production executive during the launch year of the discovery health channel, canada's only 24 hour channel devoted to health programming. his cbc radio show,"the house doctor," is syndicated in 20 markets across canada. you may also know himfrom cbc radio one's "white coat, black art,"where he takes listeners behind the scenes of medical offices to discuss a variety of health topics. in addition to all this,doctor goldman is the author

of two books – "the night shift – real life in the heart of the e.r." and "the secret language of doctors," themes from which he will speak about today. we are very happy to have him participate in our series. please join me in wi- welcomingdoctor brian goldman. [doctor brian goldman]thank you very much sarah for that kind introduction, and thanks to jeoff, i'm gonna rename you no bull. um, my, uh, daughter, uh, kaleyis turning 17 this year

and i've been looking very closely at this campus. do you think my daughter should come here? [audience]yes. [dr. goldman]you can do better than that, come on. alright, okay. alright, it's a great pleasure and a privilege to be here. i love speaking to students,uh, because i have a memory of being a student, um, uh, in fact, uh,one of the worst memories of my life was as a senior medical student at, uh, johns hopkins in baltimore.

and, uh, when i wasat johns hopkins, i was doing an elective in, uh, neurology, i had plans to become a neurologist, this was in my final year of medical school. electives, uh,are those free months when you get to try on for sizea potential residency and i went down to baltimore, uh, in order to score, uh,great letters of recommendation so i could get that, uh,

get that, uh, residency in the united states. uh, you know,it could have been johns hopkins, it could have been columbia – presbyterian, it could have been harvard,it could have been stanford, and the idea is that i would return to canada with my b.a. and if you're wondering what that means,b.a. stands for "been away." and once you have your been away,you know that thing, that self-loathing thingthat goes on in canada where we hate, we hate ourselves,we hate uppity performers,

then they go to the united states and become famous and then we love them. and how does that happen? anyway,i was gonna get my b.a. and, uh,i was a chronic insomniac, in fact,i was the professor of insomnia. i had this tendency to wake up early each and every morning, often four o'clock in the morning. and, uh, but there was one morning when i didn't wake up early, in fact, i slept in.

and that was the morning,unfortunately, that i was supposedto be presenting grand rounds in the department of neurology at johns hopkins. that was gonna be the morning when i was going to present a case, an interesting case, and some,and some literature search, and i was gonna impressthe hell out of them, and that was gonna seal the deal for my residency, and i slept in. i actually got up at four, went to the bathroom for a quick pee, went back to bed.

i didn't usually fall back to sleep but this morning i did. i happened to wake up at ten a.m.which was exactly the moment when i was supposed to be presenting rounds. and i remember runningacross north wolfe street after i had hastily, uh,dressed myself and up the s- the flights of stairs to the, uh, to the neurology floor, got to the back of the neurology conference room, very much- room very much like this one,maybe a little bit smaller, and there i was at the back of the room and my nemesis,

the senior resident in neurology who hated my guts, was sitting- was standing at the front delivering my rounds in my stead. and he took one look at me and, uh, you know, those of you- i guess your grandparents would know that, that way back in the stone agethere was a movie called the graduate,with dustin hoffman. and there's this delicious moment when,when dustin hoffman is at the back of the church and he's screaming to elaine – elaine's about to get married and this is the one-

this is his soulmate and, and she's about to get married to somebody else – and he's screaming,"elaine! elaine!" and i was kind of, i,i had that "elaine!" kind of face. and, uh, my senior residentcaught one look at me and smiled a really sadistic smile and said,"it's okay brian, you're too late," and everybody laughed. now, if you've ever had one of those performance anxiety dreams,

and i, i had a lot of those in my day, of, you know, slow motion to get to class the last day of, you know, and- because i'd missed all term in my dream, and... and i thoughtif i could just get there to catch the last hour,i might learn just enough to cram and pass the examand, of course, as soon as i arrive, the bell goes off, and the doors open,and i've missed the last class. so that was, i mean,this was a living nightmare for me.

it was the worst day of my life and after about six years of therapy... [audience laughter] why are you laughing? there's nothing funny about that at all. it was the best day of my lifebecause i wouldn't be standing here in front of,in front of you right now talking about what i'm about to talk about today, which is the culture of medicine as a kind of an embedded medical sociologist on the front lines,

if i didn't have that moment when,for whatever reason, call it a guardian angel if you're religious or spiritual, call it an id,call it just me finally giving myself the message saying, "goldman, you have no ther- you have no interest in becoming a neurologist." yes, it's interesting,although it got really boring once they invented the ct scan. really, no, really,you know, finding the lesion was,

was where it was at and then suddenly this picture's like, "what are we gonna do now?" you know, uh, anyway, uh,and then they invented mri, even worse. um, but the point is that, that, uh, you know,i... i got the message and then i startedto back track in my career and, uh, about a year lateri published my first article in the globe and mail,then another one and another one, and then i finally decided to duck out of residency, and i did.

and, uh, i found emergency medicine, uh, in a way that it's hard to find today. people, um,back then could moonlight, today it's not so easy to moonlight but a few of my friends- i was in my- i was doing a yearof internal medicine after a year of paediatrics, and, uh, a few of my, uh, fellow residents were starting were starting to do some shifts in the emergency department, and i did it and i liked it, and more important it liked me.

and it gave me- i- it was a perfect career, stimulating, um,you get to make a difference and it was part time enough that i had time to write, and that's how i started to put my writing career together. and, you know, i guess-i'm sure they'll be some of you who'll wanna know,how did you do it? i'll be happy to answer questions about that. uh, one article after another and then i started, you know, then i started to write some magazine articles,

i discovered you could travel and write about medicine in other countries. and then i,i sold my first radio documentary on prescription drug traffickers to a show called "sunday morning," which doesn't exist anymore,they called it "the sunday edition," but it's kind of a- that- that's kind of the son or the daughter of... of "sunday morning," which was oneof the top current affairs shows of the cbcin the mid to late 1980s,

and it had been around, i guess,for about 20 or 30 years at that point. uh, and, uh, then i,i had a little bit of time in televisionand then back to radio and, uh, about eight years ago, i came up with the idea for "white coat, black art," and really, for me,that was the career switch that kind of propelled me in a new direction, which was i- you know, i had been putting together the rudiments of it.

i had always been interested in the things that people sayin healthcare when they think that patientsand families aren't listening, and how they- their wordswould change instantly if a patient walked byor if they were talking to patients and, and i wanted to be ableto bring those voices to the public and, to my delight, i discovered that people wanted to hear it, an- and that's how i came to be here. so, what i'm gonna talkabout today

is a direct outgrowth of my workon "white coat, black art" and the two books that i've written,particularly, "the secret language of doctors." i want to talk to you about,about slang as a serious subject called argot, and i'm gonna define that, uh,in a little bit. uh, you know,we can call it slang but argot or argo is a, uh,is a, uh... a serious area of study, and i'll explain why.

uh, and then we'll getto the heart of the matter – to talk about whatthat slang reveals about various aspects of medical culture. and i'm gonna focus on, you know,situational slang in healthcare, situations that we,that we confront as health professionals that, uh, that are s- that, that evoke strong emotional reactions, for whatever reason. there is specific slang for aging patients,

patients who are bariatric,who are dangerously obese, and other marginalized populations – homeless, people who return to the hospital again and again. we also have some slang for colleagues and allied health professionals, and in particular at that point,i'm gonna focus on errors and the, the curious slang that we have for errors. uh, and then, and then we cometo the... the point when i ask what's the point, you know,what do you do with slang? do you stamp it out,do you encourage it

or do you find some kind of a middle ground? and... and hopefully i'll leave lots of time for questions with that. first of all, how did i come to write the "secret language of doctors?" well, um, you know, i wa- a very interesting thing and, and, you know, i can give you lots of lessons for life. one of the lessons for life that i'll give you is, is to... ti take rejection with a grain of salt. um, in fact, if i said to youthat every good thing i've ever done on this earth has come from a mistake or a setback,

would you believe me? please do. because if you are vigilantand learn lessons from the mistakes that you makeand the setbacks that you have, you'll learn far more from them than you'll ever learnfrom your successes because people aren't good at unpacking success. it's interesting, uh, how theyblame themselves for mistakes and... and attribute their successes to luck.

and, uh, and, uh, you know,if your ever... before a, a men- um... not a mentor but a director, a boss, if you ever attributed a mistake to,to bad luck, uh, they'd probably wanna talk to you about that. uh, anyway, interestingly i ha- "white coat, black art" started as a book proposalcalled "medical b.s." and, uh, that book proposal got an agent, shopped it around. he shopped it around to about 25 different publishers. uh, one or two sniffs,one or two editors sorta liked it,

but they rejected it,they all found it too negative. that was the- that seemedto be the common thread of the, of the criticisms that i received. i guess, you know,fortunately there was a cbc because it wasn't too negative for them. um, i, uh, shopped the- i, i reworked the proposal into a radio,potential radio series and, uh, they didn't say let's make a series, they said- in fact,i remember distinctly the words

that ramona dearing – who was on the program committee, she, uh, she's a producer, she's now the host of "radio noon"in, uh, st. johns – uh, she, uh, called me up and, uh, she gave me feedback on the proposal. she said, "we're not saying yes,"and my heart sank, and then she said,"but we're not saying no. why don't you get togetherwith a couple of producers and see if you can develop this more'cause we're not sure from this proposal

what the radio show's gonna sound like and that's kind of important." and so, uh, i metwith couple of producers and the, um,we kind of fleshed out what turned into"white coat, black art." and, and what's interestingis that one of the publishers that rejected "medical b.s."came back to me after the showwas an evident success and said- and asked my agent,"can brian write a book?" well, no,since you said no the first time,

you know,it'll be no forever. no, of course i wrote a book,and that became "the night shift." and that was an hour-by-hour, uh, c- it's, it's called literary nonfiction,all the patients are... are not real patients but they are- and that's what you have to doif you're gonna write in the world about,about what it's like. a- and that's kind of where all of uswho are involved in literary nonfiction who, who are basing our experiences on,

on life in the hospital are,are trying to accomplish. we're trying to create a sense of reality, uh, using patients that are not real. and, and i'm very good at doing that. one of the reasons why i'm goodat doing that is i've spent many years as a radio documentary producer and,and you learn to construct and deconstruct stories and,and you know, you have plot points, and you have climaxes,and you have denouements, and, and you have crisis for characters,

and they have to have high stakes, and it's not hard to, you know,if you've been exposed to that kind of experience in your,in your career, in your work,it's not hard to do that. so, that became"the night shift." "the night shift"was a modest enough success that harpercollins came back to me and said, "brian, can you write another book?" and i wentthrough the sophomore jinx

of about twoor three ideas for books. and, uh, that's very hard to write a second book. you know, the first one was kind of a memoir, an hour-by-hour accountof what it's like to work in the emergency department. then at one point my editor jim gifford said, "you know that book "how doctors think" by jerome groopman," which is a wonderful book. if you haven't read it,it was a new york times' bestseller.

it's basically-it takes cognitive errors, cognitive psychologyand the errors that we make when we see a patientwho is intoxicated and just see the- their intoxicated behaviour and miss the fact that they, that they have, uh, a subdural hematoma or they've got some- or they're having a heart attack. uh, and... and so, and... and what jerome groopman did was he took this, this wonderful scienceof cognitive psychology

and popularized it into a book and peppered it with his own cases, his own patients,where he had made mistakes, he came clean on his own mistakes. so, so jim gifford said to me, "how, how about you write a book called "how doctors talk?"" that was basically- that was the conceptual, the idea, the one-line expression for the book. and, and it's very interesting,um, you know, so i started to, to think about how i,how i was going to approach this.

and, you know,i think he thought i was gonna be spending hours explaining code blue. and, and, it's, you know,very interesting. code blue, you know, it,it was an obscure phrase. the idea behind code blue was that,was that you could say it in a hosp- over a hospital loudspeaker and nobody would understand,nobody would panic. if you heard code blueit sounded neutral. of course, you know,once it got popularized

on shows like grey's anatomyand scrubs it ceased to be,it ceased to be, uh, uh, jargon and it just got into the vernacular. and defibrillators,and clear, and all that kind of stuff is part of that, that lore. um, i realized very quickly that i'd get very bored, um, saying that dm2 is... is the short- is short for type two diabetes that- or acs is, you know,acute coronary syndrome, used to be called an miand, you know, unstable angina

and all that kind of stuff,it's like, that's pretty boring stuff if you think about it. it's just, you know,it's one dimensional. what's the purpose? well, i mean, there's- i'm sure there's- there a- you know, there's bragging rights, who gets to name the disease, there's- i guess that's mildly interesting, but a lot of it is just packinga ton of information into a short number of words.

far more interesting when you start to look at argot or argo. and, let's see if i can actually,ah, i gotta use this better. okay,so that's what i came up with. argot, an- and it's very interesting 'cause i, you know, i... i rememberedthat there was a book about slang which is a touchstone for me, and i'm gonna get into explaining that in a, in a couple of minutes. very, very important bookfrom the 1970s called "the house of god,"i'm gonna talk about that.

um, and... and so i rememberedthat was my introduction to slang and i'll, i'll talk about my,my first introduction to slang. um, but it- yeah, you know,i guess i could talk about it right now. uh, i was working on the cardiology floor 4a, 4b, at the hospital for sick children back in 1980, long time ago. that was a very,very stressful year in the life of the, uh,of the hospital for sick children because this was the year when there was- there appeared to be a series of unexplained baby deaths.

and, you may even remember, you may have heard of it,you may have read about it, that, that one of my nursing colleagues,susan nelles, was arrested and charged with murder. she was eventually, uh,uh, found not guilty. uh, and, and it turned out that, that the, the reason whythere was an excess number of deaths had more to do with a statistical anomaly of placement, where the patients were and where they weren't.

that they were dying on the floorwhen at another time in another place they would have died in the ten- in the intensive care unit. and- but it was the same number,if you added it up, it was still the same number of deaths. but for a long time they thought that these children had been killed with, with, uh, an overdose of,of digoxin, which is heart medication not,not used so much these days but was used a lot more back then. so, i was workingon the cardiology floor

at a time when they weresecond-guessing themselves and there was a lot stress going on. and, and on my first night on call,you know, i had, i had a senior resident who- he was my dude, his name was george rutherford the third. george rutherford the third,uh, came from stanford so his idea that he was going to workat the hospital for sick children and that was gonna be his b.a. and he was gonna go back to the states. i think he went to, uh, the, uh,london school of tropical disease

then went back to stanford and has had a long and storied career as a public health specialist and as an infectious disease consultant. but he was my cool dude. and he taught me some slang,a lot of slang, a lot of things that i'm not surethat i'd wanna repeat today because some of it was a little pejorative towards kids. but that night, uh, i had been on call,and i'd been up all night, and i was really,really tired that morning and i must have had a very forlorn look on my face.

well, george rutherford the third walked up to me, he wasn't on call that night, and put a big, reassuring hand on my shoulder and... and said to me, "well brian,how many did you box last night?" as in put into a coffin. and i was readyto throw up or faint and then his face broke out in a big grin. and that was george rutherford the thirdintroducing me to argot, to slang. and it- i, i can tell youthat honestly

i felt like i'd been welcomed to the club. you know, i was shocked, shocked at the... the coarseness of, of the language but,but at the same time i was pleased that i'd been introduced into the secret language. that was my introduction to the secret language of doctors. and, you know,at the time everybody was reading a book called "the house of god," which i'm going to talk about in a moment, and, and so one of the thingsi wanted to be able to do

was see how much slangwas being invented today because it seemed so important to usback in the late 1970s, early 1980s when "the house of god"was first published. and, and, you know i,i interviewed probably, you know, a couple hundred residents,and medical students, and attending physicians and surgeons. i had a research,i had a researcher, uh, uh, erin james-abra who was working with me. she's now an editor at encyclopaedia britannica.

she's a good writer in her own right. and... and we were collectingthese stories about slang and, you know, uh,we'd get some good stories and we'd go through dry spells where people would say, "ah, there is no slang." and then, i had a very important,uh, conversation, first of all an email exchange, somebody suggested to me that i,that i get in touch with renã©e fox. if you study medical sociology you know the name renã©e fox.

renã©e fox is the doyenne of,of medical sociologists. uh, her ph.d. thesis,"experiment perilous," uh, basically she... she wasan embedded sociologist on a ward at the peter bent brigham hospitalin boston at a very, very interesting and pivotal time in that ward, uh, in experimental,uh, clinical science, clinical research. this was at a timein the early 1950s when cortisone had firstcome into its own as a treatment for- as an anti- as a powerful anti-inflammatory drug

for rheumatoid arthritis and a lot of other conditions. this was the beginning of the dawn, like the dawn of the era of kidney transplants, and they were doing some crazy things on that floor. things like, like, um,doing adrenalectomies, taking the adrenal glands outto cure patients of hypertension,high blood pressure, and things that we don't do today. but she was embedded on the front linesand she was absorbing the dark humour

used by these scientists who realizedthat at the same time that they were pushingback the frontiers they were also killing patients. and the ambivalencethat they would feel about asking somebodywho was evidently obviously dying for another set of blood tests to try to push back those frontiers even more. she was the first personwhen i spoke to her on the phone she said- like,'cause there were moments

when i second-guessed myself about the book – should i,should i write this book? and she said,"oh, you must write this book, this is so important," and she started to talk about argot. it was the first time that slang had a formal term. argot or argo – it is a secret language used by various groups, including, but not limited to,thieves and other criminals. the purposeis to prevent outsiders from understanding their conversations,argot.

so i want you to,to just cogitate on, you know, that image of robbers and thieves. that's not like it,but certainly this, this is it. that you can go onto an elevator in a hospital and hear this sem- this semi-understandable language, perhaps being used in ways that you don't understand, and they can be talkingabout some patient on the twelfth floor or on the seventeenth floor. you know, they might be talking about a patient who,

who is being prepped for the ecu – the eternal care unit. it's a euphemism for they're dying. you know, the eternal care unitas opposed to the intensive care unit. the ecu, it sound like,eh, ecu must be real. or, or consult pathology. you know, an autopsy. you know, and, and there's a lotof that kind of language but that's... that's it,that you can be listening to it and have no clue unless you're,unless you are an insider.

um, i had a lot of criticism about,about the book initially, um, because, you know,it's a bit controversial and, and it was framed as, you won't believewhat p- doctors call you and other allied health professionals call you behind your back. um, which is kind of notwhat the book is about but we'll get into that. first thing i want to say about,about slang or argot is that it's normal.

it's normal in high pressure,high stress, high stakes,high intensity environments. so, uh, healthcare is one of them, but air traffic controllers,stock traders, people who were on, you know,currency traders, day traders, um, the military,uh, astronauts, uh, people who, uh, who work in various aspects of the airline industry, uh, and, uh, and, uh,the police, firefighters.

and, and each of them has their own slang, and this is just three examples of military slang. and, of course, i'm gonna have to be polite because this is being recorded for posterity. um, greeting- greetings to lakeshore and to orangeville. by the way, i didn't do that before and i should do that now. i'm watching you. you're watching me, i'm watching you, i just want you to know that. anyway, here are three and i'll,i'll have to clean up my language,

so- and this- these are acronymic,uh, examples, examples of acronymic slang. so, fubar,"fracked up beyond all repair," and then snafu,"situation normal all fracked up." uh, those two you've heard of. um, you may not have heard of bohica. bohica is another piece of military slang. it stands for "bend over,here it comes again." and... and you know,it's metaphorical sodomy.

and that is- i mean that's- we're among friends and i can, i can speak about controversial subjects, but this is clearly somebody'sor a- not somebody's, but a very commonly held view of military hierarchy. and, uh, you know, the,the other two, fubar and snafu, um, is- it tells you it... it speaksto a certain frustration with the fact that the best laid plans often, often go to waste. uh, that, that bad things happen with- even with the bestof preparation and plans

and, in fact,sometimes it happens all the time. the interesting thingabout all three bits of slang is that all three have been used in the corridors of medicine. fubar i've heard, you know, talking about a resuscitation that goes wrong. where everything that could go wrong does go wrong. um, snafu, um, that's-that might be a situation- that might be talking about, you know,what it's like to try to arrange for an outpatient ultrasound in a particular hospital. um, it's always goes this way or the, the record keeping,

the, the time when you really needthis record you're not gonna be able to get it. or, or, you know,you're waiting for a beta hcg, you're waiting for a pregnancy test,before you can do the imaging study. and... and murphy's law says that, that if that's the lab test you need the most desperately, that's the one that's gonna takefour hours to get back and then they'll say,"well, we never received the sample," and your rolling your eyes and saying,this has happened again and again.

it's like a living- it's like a recurring nightmare. bohica, you might think,hey, bohica? nah, in medicine? couldn't be. oh yes, yes. uh, i interviewed urologists and i interviewed people- anybody who trained in the veterinary,uh, not veterinary. veterinary administration system.[laughter] some of my best jokes are unconscious. the veterinary administration system.wow. wowee.

the veterans administration system,the va, which is the, which is the healthcare system for, for veterans. for, uh, peoplein the military and people who are retired from the military. they actually have bohica clinics,and that's the nickname. bohica clinic is a clinic in which menwith rather large prostates are invited to come to the clinicso that first year medical students can do the appropriate examination to feel an enlarged prostate. bohica clinic.

and, and so,so they actually- that's not metaphorical that's, that's literal. okay, so, so borrowed slang. um, british slang, um, you know,i- it's interesting, ca- i didn't have a chapter on british slang. um, the brits, uh, are- have some of the most caustic slang that's imaginable. and some of this, you know,i'm putting this up for your sociological analysis

not because i'm endorsing it. funny- flk, "funny looking kid,"horrible slang. it's interesting, i've ha- i've actually had older pediatricians who come up to me and say,"well, i still use it." but, but it is slang for, you know,you don't write this down in a chart, that's another interesting part about slang. it's slang that's used for a childwith facial appearance that appears to be consist- it's unknown, an unknown genetic syndrome

but it looks like it might be a genetic syndrome. that's actually, that was- that used to be written in charts, people don't write it anymore. others, uh, jlp,"just like papa." um, glm,"good looking mother." um, lbnh,"lights on but nobody home." there's a lot of slangin the british literature for, for people who, um, are somewhat intellectually challenged. pumpkin positive,you know,

my... my one of my kids asked me,"what does that, what does that mean?" well, when you hollow out the pumpkin and you- then you can put a candle in it and then the head lights up. so, if- you understand, you understand what i'm talking about there. um, prafto,i'm not going to- patient- i- somebody actually took the time to invent that acronym. uh, tube, "totally unnecessary breast examination." ubi, i didn't put that in,"unexplained beer injury." uh, sunday hangover patientswith black eyes

and swollen knees and no idea how they got them. and, and, you know, i- i'm just- i've been- these two guys didn't- steve coogan an- and john cleesedidn't invent the language, but, but i... i have to believe that the language comesfrom a culture with a very dry sense of humor and a very caustic sense of humor. now, i said i was gonna talk about "the house of god." "the house of god" was published,uh, in 1978 and it was an... a novelthat is, is- was very heavy

on semi-autobiography of that man, uh, stephen bergman. um, although he wasn't called stephen bergman back then, you'll notice his name was samuel shem. shem is, is hebrew for name, and so that was a bit of a joke on his part. he's also- it's alsoan even bigger joke because he's a practicing buddhist. um, stephen bergman did not want to be known, um, by his name 'cause he didn't want people-

he didn't want patients to be thinkingthat he was some kind of dude because he wrote a, a novel. anyway, he wrote a bookbased on his experiences at the beth israel hospital in boston. hence, "the house of god"was a euphemism, so it was kind of like primary colors for healthcare. um, this book, um, was in its day... you know, he sold 1,000,500, 50 copies at a time and then they did another print run –

it took him a long time to get a publisher. published in 1978. sold out the first run, second run,third run, fourth run. i don't know how many printings it's up to now, but it's continuouslyin print since 1978 and it has sold over two million copies. so, must be something. and i can tell youthat this was the book to read when- if you were, uh,in medical school, or in residency,

or early in your attending physicianor surgeon career back in the, uh, late, very late 1970s,uh, 1980s to the 90s. and, and the interesting thing about the book, uh, to me- i mean, there are many things,uh, you know, th- now we have more than 50 percent of the class, uh, of, of medical school classes and residency, um, consisting of women. and i've had many women say to me,"this book says- said nothing to me, and i got nothing to learn from this book." and, and i respect that and i, and i appreciate that.

it was a very sexist novel,but it was- it's dated. it was a book about its time and... but the, the thing that,that i remembered the most, was this very,very realistic slang. and those are some of the,some of the slang words that came directly from the book. gomers, lols in nad, that's little old ladiesin no apparent distress. now, that was a species of patientin, in a- admitted to hospital

by marginally competentattending physicians who were- who would justchurn them through the system to... to do lots of tests and put,put them on lots of therapies to try to raise their incomeand not do very much to help the, uh,to help the patient. um, turfing patients. um, and the, and the- all the slang had definitions. to turf a patientwas to admit them to your service and then find another reason,another medical or surgical problem,

in order to transfer them to another service, hence the turf. so, and, and this was a darkly humorous book, so they talked about-samuel shem his, his mentor, his dude,he didn't have a dude in real life, but his mentor, uh,was called the fat man. the fat man teaches him the,the eleven rules of the house of god. um, i'm gonna get into gomer in just a second. the o sign and the q sign. this is a visual, i don't know if you have to come in on a close up?

um, the o sign-and a lot of the slang was devoted to very elderly patients with dementia. and we'll get into what that's all about in... in just a moment. but the o sign was, uh,an elderly patient with dementia, lying in bedwith their mouth hanging open in the sign of an o. the q signis a variant of the o sign in which their tongue is hanging out to form the letter q. darkly humorous but also a very despairing kind of book.

but turf,so they talked about to turf a patient the... the dude or the, the, uh, the, the fat man would tell the hero of the book that if you wantedto turf a patient to orthopedics you would crank up the bedso that the patient would fall out of bed and break their hip. well that would be an automatic turf to orthopedics. and... and you know, like,like good satire it was a bitter pillwith a sugar coating

and, and there was a grain- there was not more- there... there was morethan a grain of truth to, to what he had to say. um, the purpose of that slangwas to help cope with the culture that exploited residents, and at the time they were working huge hours, and i want you to hear- let's hear a little bit of, of samuel shem talking about this. because if i was goingto do a book about slang,

i wanted to trace the history of slang,which meant i had to talk to this guy. and the first question i asked him was, um, "where did you get the slang from?who taught you the slang?" so there, so there wasn't a lot of terminology being used, you guys invented it. [stephen bergman] there wasn't a lot,no, in those days there wasn't. there were othersfrom other hospitals that we, we heard of a couplefrom other hospitals like sinai, i think,or ny- nyu is sinai, yeah.

uh, which didn't get much traction 'cause it was even worse than gomer. it's was- it's a shpoz.s-h-p-o-z, you know that? no, s-h-p-o-s. it seemed even too cruel for us but it was new york, you know. subhuman piece of shit.[laughter] that's what our reaction- we, we thought that was... because those were,those were about the, you know, the, the criminalsand drug addicts and, and, uh, gang guys that, that came in, uh, to bellevue.

we didn't use that. we... we thought that,we really thought that was too much. but there weren't too many terms,as i recall, no. [dr. goldman] so, so that was a cringeworthy, uh, word for you, shpos? [dr. bergman] that was cringeworthy. partly becausethe people it referred to, were, um, you know,people more our age who- i mean, you can get really angry,as you know, as an emergency room doc when an alcoholic or a drug addict,

for instance, one of them,comes in and is gonna die but you know how to save 'em and, especially with an alcoholic, a drug addictis a little easier sometimes 'cause you just give him some naltrexoneand he'll, you know, reverse. but an alcoholic, you knowit's gonna take a lot of work for you and you also think that he'll- you- you'll see him next week. and it makes you so angryat these people 'cause you- you've spent your whole lifegetting trained to save people and these people seemingly don't wanna save themselves.

[dr. goldman] so, you can begin to see... the thing that was wonderful,you know, i... so i visited, uh,stephen bergman at his, at his house in newton, massachusetts. he's recently retired as a psychiatrist, um, also works with a lot of people with substance use- substance abuse. uh, and, and you can seehe's very thoughtful and reflective on,on what the slang means. and, very interesting thing,there was an article

in which a new york psychiatrist,earlier- not earlier this year, i guess, late in 2014,wrote a book, wrote an article in slate about a shpos patient. and i fell off my chair. i could not believe that anybody- i had never heard the phrase shpos until he said it to me, and he said even back then it was outrageous, um, that...that anybody would use it, but clearly, there's a culture in new york that uses it.

what's interesting about thisis that there's been a backlash against the psychiatristwho wrote that article in which he used the word shpos. and... and a lot of it has been,you know, there- people can write articlesor cr- write criticisms or comments to say i disagree with you or that's a terrible bit of lang- language to use. it's rare to have p- criticstrying to disqualify it by saying, you know,"i've been practicing

for 30 years and i've never heard this word." so they actually questionwhether it was act- whether it was being used or not. but that shows you that there's a very strong reaction to it. what are we talking about here? we're talking about something called the hidden curriculum. and there's a hidden curriculum in... in every area of academic study. and you wouldn't be surprisedif i told you that there was a hidden curriculum in medicine.

and fred hafferty,who i interviewed for my book, is another medical sociologist who has written a boo- he's written many, many articles about the hidden curriculum of medicine. basically,the hidden curriculum is the gap between what you, uh, are, are- what you learn in lecturesand textbooks and what you need to know to survive in the system. you know, for instance, on the wards,you don't show up your senior resident. um, you... you know, you can be competitive,

but not cut throat about being competitive. um, you don't show up your,uh, your attending physician. and these are the kindsof things that, that you, that, that you learn to survive on the wards. and part of that hidden curriculum is slang. so, that's another- that was another person who legitimized slang in my eyes. so the premise hereis that gar- is that argot as, you know,as explained to me by renã©e fox,

is a symbolic language that unpacks attitudes and emotions. and if you develop an ear for hospital slang, you can learn a lot about our worldview of patients and healthcare, that means our worldview in healthcare, and, and about the culture of modern medicine. and this is some of the reaction to, not the book because they hadn't read the book, but to the publicity surrounding the book from last april. um, "i'm a surgeon at a busy hospital in montreal.

most of the terms exposed by goldman i've never heard of. his book paints too many of us in a bad light." i- i think that was because i- it wasn't the book, it was the coverage. um, "the morbid slang attributed to canadian mbs- mds in goldman's book is flip,insulting, and denigrating." that it is,i don't disagree with that. this is my favourite comment. "as a physician at vancouver general hospital,

i've never heard physicians or nurses using those pejorative terms. the most likely explanation is that the article originates from toronto." [audience] [laughter][dr. goldman] or new york, evidently. the reality is that i interviewed hundreds of health professionals, allied health professionals,then, and now, and since, and i asked them for slang,or stories, or both and, and they generously gave me both or either. and all of themhad either used slang

or heard it used by others in a contemporary fashion. and, and so, what i wanted to be able to do, using "the house of god" as a touchstone, i wanted to be able to... to contemporize it. um, and, and what i discovered is that there's three categories of slang or argot. situations that people in healthcare find distressing, annoying, or beneath us,et cetera, et cetera. things, things that they don't talk about in textbooks.

attitudes that we display that we- that they don't necessarily talk about in textbooks. um, there is slang, lots of slang for patient stereotypes, uh, that we pa- don't particularly,uh, care enjoying- enjoy caring for. and then, um, not surprising to me,but maybe a bit surprising to you – slang for colleagueswe don't like or, or respect,or sometimes worse. so, let's talk about situations first of all. um, you've heard of code blue.

which, um, i guess,could have been argot at one point. jargon, certainly jargon. uh, then it entered the vernacular, you know, wh- when shows like scrubs popularized it. so it's a cardiac arrest procedure, you drop everything and run to the scene. uh, code red, that's a, a fire, a fire emergency in the hospital. code orange, um, i- it, it- some of these vary,they aren't all universalized.

code orange, uh, may referto, um, a situation in which there are no bedsin the hospital, and it's kind of crisis management and what you have to do is, uh, tell amb- redirect ambulancesto other hospitals and... and begin to work on this- on... on early discharge of patients, go through the hospital and decide who can go home as quickly as possible. code black – disasters. so what do you think code brown stands for? a poop emergency, yes.

and, and, you know,there's a serious side to code brown and, i know, i don't wanna make you too queasy but, but i think a story here is in order. that's erin sullivan. erin sullivan was a registered nurseat one point and, uh, is now finishing up her residency, uh, at, uh, i- in family medicine,family and community medicine at the university of saskatchewan, and, uh, she and i talked about code brown stories.

and i want you to think about who has the code brown stories, who has the stories to tell, because that's really what this is about. who uses the phrase code brown more,doctors or nurses? [erin sullivan] definitely nurses.[laughter] they're the ones dealing with the code browns, in fairness. so, yeah. [dr. goldman] so, tell me the first timeyou heard code brown, you think you heardthe code brown used

or the most egregious code brown you can think of? [erin]i- well i can- i have a couple of egregious code browns that come to mind. i can't think of the worst- first on-the first time 'cause it was like- [dr. goldman] it doesn't matter.[erin] ...ten years ago. [erin] um, you want examples?[dr. goldman] oh, yes. [erin] oh, dear lord.okay. um, the a- i would say the worst one, uh, was a patientwho was morbidly obese

and, um, and very immobile – you know, couldn't move at all,even from side to side – um, and he just had, basically,a constant, constant diarrhea. i mean, i- it was unrelenting. and i was on- it was at nighttime, there was only one other nurse in the department, and so it was my job the entire twelve hour shift, basically, to just try and turn him as much as i could, pull the sheet out,put a new sheet down,

turn him on the other side,pull the old sheet out, pull the new one across and then it would just- the process would just start over again. [dr. goldman] so, you said he was,he was obese. how, how much did he weigh,can you estimate? i mean, nurses are really good at estimating weights. [erin] he was, uh,he was about 400 pounds. yep. he was morbidly obese,morbidly obese.

[dr. goldman]it was just you? [erin] it was just me, yes,and one other nurse who wasn't the most helpful rn on the planet, shall we say. [laughter] [dr. goldman] how the hell did you to do it? [erin] um, a lot of sweating and cussing mostly, to be honest. i mean, it was horrendous. it was one of those nightswhere i actually almost just quit my job and walked out of the department.

like i- you know,it was just like, what is happening here,this is just not on. [dr. goldman] and, you know, it's,uh, you know, i've certainly- um, there's a patient there and i've never met a patient who wants to be incontinent. so, it's importantto keep that in mind but, at the same time,it's not either or – patients allowed to have feelings and health professionals aren't supposed to have feelings.

i have a thing about that. i think you either put- you either stuff- you either talk about it or you stuff it, and if you stuff it, then you mightbe dealing with it by drinking alcohol or by having fights with your,uh, with your loved ones, um, because you've just got no place to put it. so i think i- i think there has to bea place for it but, but you might disagree. um, there's a lot of slang.

this is polite slang, it's called social injuries of the rectum. and, um, and, it's actually jargon because how do you talk about it? how do you talk about it? well, here's a guy who's willing to talk about it, mark burnstein, who's a colorectal surgeon at saint michael's hospital. [dr. marcus burnstein]there's an area that we refer to as social injuries of the rectum, and, uh, this includesforeign bodies

and other, uh, traumas to the anal-rectal region. it's certainly not our business to be judgmental, it's our business to,to help patients, but you could imaginethat sometimes we see some pretty unusual things in my specialty. [dr. goldman]like what? [dr. burnstein] gee, are,are you interested in a list? [dr. goldman] oh, uh, yeah,i think, uh, one or two. [dr. burnstein]well, you know, uh, uh, zucchini

and, uh, the, uh, cucumber are, uh, certainly, uh, on the hit list. um, we've seen everythingfrom, uh, deodorant spray bottles to, uh, vases,you know, similar objects. one of my favorite storiesin this to- area is when a young man had to have, uh, a zucchini removed from the rectum. my senior resident,i was a junior resident at the time, and my senior resident and i left the operating room, i think we were not expectingto run into the young man's mother, who we ran into in the loungeoutside the operating room,

and she said to my senior, um,"what was it?" and my senior resident said,"it was a bowel obstruction." not really prepared to give the whole story, he hadn't thought this through. he said,"it was a bowel obstruction," and she said,"i knew it was something he ate." [audience] [laughter] [dr. goldman] i don't know if they're laughing in orangeville. you're busted.you laughed.

so why do we laugh? we laugh because it permits us to express, indirectly,our own personal feelings, either at the patient's lifestyle or what we have to do to fix them. not so funnywhen it's not a zucchini and insteadit's a fluorescent light bulb that shatters. true story.surgeon had to fix it. it took eleven operations to,to fix that- to fix the patient.

and, and in addition to that,as part of the bond, it gives us a polite meansto share with others and it reinforces that bond. um, here's another kind of situation that we- about which we have a lot of slang. we have synonyms for patients who are dying – entering the drain,um, circling the drain. and so, the difference between the two – circling the drain, it's inevitable,entering the drain, they're teetering.

and, uh, you know, often- these are often patients in critical care, in the intensive care unit where, uh,you don't know how it's going- you have a, you know, your spidey sensetells you this may not go well but, uh, you know, it's gonna take a day or two to know for sure. and they have a saying in the intensive care unit, that if you're not getting better,by definition you're getting worse. you can't stay the same. if you stay the same,you're not getting better

and if you're not getting betterthen at some point it become inevitable that... that you're going to die. others, hanging crepe. you know, where do you hang crepe?at funerals. well, quaint custom but,but you understand what i mean. discharged up. discharged to heaven. pbad,pine box at door. pbad-lo,pine box at door, lid open.

croaked, meh.crumped, meh. um, transferred to pathology,the eternal care unit, um, admitted to the nineteenth floor of a hospital with eighteen floors. you know, there are cute and clever ways of dealing with it. and why do we have it? we have it because- well, first of all, in the case of code brown, nobody told usuntil it actually happened that we'd have to be cleaning this up.

and... and when you look around you, it, it's- sometimes your mentors are acting as if nothing happened, as if it's nothing,as if it has no, it has no instinctive gut feeling inside you. um, with death it's very similar. they- you know,there are weighty tomes about, about,you know, dealing with patients who are at or near the end of life, but very, very little is writtenabout the emotional impact

and, uh, until quite recently. and... and so, the language becomes a way of venting that feeling,reflecting upon it. circling the drain is a very interesting bit of language and, uh, and, you know,i had the privilege a few years back of hearing a number of residents, uh,rick mann, nooreen popat, clarissa burke, andrew burke and gaurav puri, talking about, about circling the drain and euphemisms for death and why they use it.

[man 1] what you described, i think, is what we all agreeand it's sort of understood and circling the drain is a way to say that in three words. you know,as we were talking about this, and this is somewhat on a tangent,but you asked about other euphemismsthat came up and the one that has always stuck with me, unfortunately for whatever reason,is a staff who colloquially used to say to patients or about patients,tell them not to buy any green bananas.

in the sense that they weren't gonna be around to see them go ripe. [dr. goldman] you're shaking your head. why? [woman 1] i just, i- it just seems a little bit, um, insensitive. [dr. goldman]who has a story of the first time that they recognized that a patient was circling the drain? [woman 2] the patient that comes to mind when you, when you said that was actuallymy first experience as a medical student with a patient who was dying. i think that maybea lot of us feel like

that very first patientis somebody who sticks with us because it's the first timethat we face ourselves as, you know,medical caregivers who aren't working towards fixing the problem, saving the life,fighting to the bitter end. i, i think it's the first timethat i had to take a step back and make a change towards thinkingabout how i could help that person come to their end in as dignified way as possible. it was, uh, a very nice lady

who had come in with breast cancer that had metastasized. she'd had probably a yearof back pain leading up to it and then came to the hospitalin an absolute crisis of pain. and that was the pointat which we made the diagnosis and, and had to tell herthat this was not something that we could cure,that we could treat, that would be, you know,gotten rid of. and that discussion,i participated in it and i was there, but i thinkthat as the patient was coming

to the understanding of what was happening, i think i was also coming to that understanding. and it was, i think,a very hard road to travel down. [dr. goldman] so you decide, you know, whether switching to comfort measures is a better way of putting it. i think circling the drainactually adds an emotional layer that actually speaks to what the pa- to what the healthpra- care providersare experiencing at that moment as they switch from,we're gonna try to save this person

to we've failed. how do you deal with that? and the language, i would submit to you,helps them to deal with that and, again,some people may disagree. there is slang about, uh, distressing situations- other kinds of distressing situations – horrendomas, horrendoplasties,horren-.... so, a horrendoma is a horrible situation. and notice, "oma", uh, is,is a suffix for a tumor, a mass,

so horrendous, ho- becomes horrendoma, that's a patient who has a horrible situation. a horrendoplasty is the surgical version. we go into the operating room and,and the fubar operation i... is sometimes called a horrendoplasty. then there's something called peek and shriek. peek and shriek is, is, um, slangthat's still used today for opening up the belly,you know, in the expectationthat you're gonna remove a tumor

and finding thatthe belly's riddled with cancer and you quietly close it up. and, and it speaks to f- a fru- a level of frustration, especially if you didn't know,if you're shocked an- and.... you know, i had a storyin "the secret language" uh, that was told to me by,by riaz moola, um, an ob/gyn, who remembered during his residency days, uh, taking a women- a team of physicians taking a woman in the third trimester of pregnancyto the operating room

because she hadthis vague abdominal pain and because she had a, you know,because she was pregnant you couldn't do a ct scan 'cause you'd irradiate the baby. and, uh, they opened up the belly, they did an ultrasound,it was equivocal, you know, they were able to,they were able to get some information. they finally just said, we'd bettertake her to the operating room and they did, and they found that she had metastatic cancer. and there was no emotional preparation for that moment when they...

because you think of pregnancy and, you know, this is the,this is the dawn of hope. you know, our hope for the world,our hopes and dreams are, are with the next generation, and here was a woman who was dying as she was carrying this... this baby, close to but not...not at the end of term. and, and so, this language helps physicians, surgeons, deals with the emotional impact of that kind of situation. and it's interesting because, you know,

you know, i- it speaksto the issue of what we're supposed to do with emotions, and i know there's a lot of students,uh, who are, uh, in the audience who are going to be healthcare providersan- and i can tell you that we are- that, that the original teachingfrom sir william osler was that we are supposed to exhibit something called detached concern. and, uh, you know, be concerned but be emotionally completely detached from what we see and that comes from an essay that osler wrote called "aequanimitas."

it was his farewell addressto the university of pennsylvania and this is a quote,"imperturbability means..." and that's what he- and that was a phrase that i, that i heard again and again in med school, that we should be imperturbable,that it "means coolness and presence of mind under all circumstances, calmness ans- amid storm, clearness of judgment in moments of grave peril, immobility, impassiveness..."

basically,never let 'em see you sweat. now fast forward to 2003,when a psychiatrist and philosopher named jodi halpernwrote this article in the journal of,of general internal medicine. that, "doctors strive for detachment to reliably care for all patients, regardless of their personal feelings. yet patients want genu- genuine empathy from doctors, and doctors wanna provide it." well, some do,not all of us do.

so, you can see the tension between, you know, the risk of getting too emotionally involved, but at same time,if you're so detached then, um, that, that you're ignoringthe suffering of... of the patients around you... well, i don't believe you can. i think what happensis that you bottle it up inside and, and it rages inside you. and that's why i think there's a lot of my colleagues, 40, 50 something,

who've got that lookof weariness on their face that they've never been able to vent their feelings. the delight's gone from their eyes. let's switch over from situations to slang for patients, um, that we find frustrating. frequent flyers. um, i've heard worse. cockroaches and crocks,which are awful terms, and... and in preparationfor the book,

i actually heard people tell me stories in which they used those terms. frequent flyer is neutral, um,but it's pejorative at the same time. and it's interesting because people said to me, you know, "i've been practicing for 30 years and i've never heard this slang," and i would come- my come backer would be, "well, have you heard the phrase frequent flyer?" and they'd say,"oh, yeah." you do realize that's slang? and it's ironic slang

because, you know,in the airline industry a frequent flyer is a beloved customer but in medicine, unh-uh. in a publicly funded system, you're wasting valuable resources or maybe you want booties,or maybe you want a free meal, or a, you know, a taxi chit or a ttc token, uh, and, uh, or you're trying to jump the queue, jump the system. you know, tha- that- there's a lot of that us and them. there is a hero and in every,and in every one of my chapters, and i had one called frequent flyers,i have a hero,

and jeff brenner is my hero. he doesn't call them frequent flyers,he calls them superutilizers. and, i don't know if i have a slide of him, no. um, he has... do i?no. ah, maybe i do. okay. uh, jeff brenner has made a study of people who utilize hospitals, who go back again and again, and his database comes from the city of camden, new jersey, one of the highest crime rates in the united states. and, he went looking for criminal hotspots

because he was very perturbedabout the death of a man named hiram ross,who was a young man who was accusedof being a drug dealer and just happened to be in the wrong place at the wrong time, was shot by police. uh, he was, in fact, at rut- a studentat rutgers on a scholarship and he was snuffed out. and this guy got- he was a physician,he was so frustrated, he went to the police lookingfor criminal hotspots

and what he found instead were medical hotspots. places, whole apartment buildings,that have superutilizers. people who- i- filledwith people who go to the emergency department or the hospital again and again. 300 times in a four year period,some outrageous number like that. well, you know,he's been able to, by... by finding where the superutilizers are, he's actually able to find outwhy they keep going back to the hospital again and again and fix the problem,

and if i have time at the end i'll tell you where- what he's doing about that. but what does it say about us that we would label a patient... um, you know, what does it sayabout the culture of medicine that we would label patients who return again and again for treatment? well, um, on a gut psychological level,healthcare professionals, if somebody keeps coming back,it means we must have failed them. and who likes to have failure confronted- confronting their failures again and again.

or, you know, maybe,maybe it's a frustration that i've tried my best with you and i can't- an- and i don't know what more i can offer. i, i don't know how to,how to rethink this problem. you know, they make the mistake of seeing return visit as a, as emblematic of failure. it may not be failure, it may be that they've got no other place to go, no better place to go to receive the care that they need. um, futility.

that if you keep coming back and i keep offering you the same treatment, that's futile. and we have a thing about futility in healthcare. some see superutilizers,as i said, looking for fail- for favours from the system, like booties, and taxi chits,and that kind of thing. um, but there's a problem with this whole, kind of, mal-analysis of frequent flyers. fact is, that, um,we could all be frequent flyers

because we are on the cusp of an epidemic of diabetes, and high blood pressure,and lung disease, and cancer, and kidney disease, and heart failure,and mental health issues, and musculoskeletal problems. and you add all of them up and they cost 75 percent, 75 cents out of every healthcare dollar that's spent. trouble is, we're all trainedto put in chest tubes and defibrillate hearts and... and take out cancers, which is all good,all important.

but increasingly,we're dealing with this. and we're not prepared for that at all. uh, and, and even worse, we think- uh, well, i- not we think, we know that there are three common denominatorsto most of those chronic diseases and they are –too much food, too much the wrong kind of food or not enough exercise, too much smoking,and too much alcohol and other drugs. and, and this is a very interesting thing, i'm going, i'm going a little bit off,off script for just a second

'cause i'm talking about the culture of medicine, but if there is one common denominator that i think is really intriguing, it comes from a studythat was, uh, paid for by the, uh, centers for disease control in the united states in atlanta. it's called the aces study,a-c-e-s, it's an acronym, but look it up, take a look at it because the common denominator, uh, if you see patients who eat too much, smoke too much, or drink too much,or a combination of all three, there's a good chancethat they have

one particular risk factor in common – early childhood trauma. physical, emotional, god forbid, sexual, or some combination. what we do with that information, i don't know yet, but it's a really important one to keep in the back of your mind. back to jeff brenner. jeff brenner, um, in camden, new jersey,went looking for crime hotspots and actually found apartment buildingswhere many of the residents show up again and again in the emergency department.

and, i don't think i have time to show you this, but, but this was the subject of a,of a frontline documentary that was hosted by atul gawande, who,who wrote the book, "being mortal." and, and it- it's worth keeping in mind that this is, this is a guy who hasactually taken something that most of us in the cultureof medicine simply find frustrating and sought- set out to do something about it, which i think is really,really interesting. it's a total, 180 degree paradigm shift.

um, and there are canadian examples of medical hotspots. um, i- hamilton, ontario, uh,the hamilton spectator did a series, in conjunction with mcmaster university,called "code red." and what they did was they mapped out the places where, where there arehigh utilizers of healthcare and low utilizers of healthcare. and what they discoveredwere massive differences between hamilton's 130,uh, neighborhoods. one inner city blockcost 2,000 dollars per person

in hospital er and ambulance costs over a two year period. at the same- during the same period of time, one well-heeled rural neighborhood,just 138 dollars a person. that's what, an eightfold or more,15- thirteenfold difference, uh, in a- in, in cost, so really a, a huge difference.no, it's closer to an eightfold. here's another bit of slang, um,that i didn't talk about yet – gomer. um, it's historical slang. it was popularizedon shows like scrubs

and so nobody uses it anymore, but back in "the house of god"it was defined as a patient who's frequently admittedwith complicated but uninspiring and incurable conditions. incurable is really,is... is the operative word. um, it's an acronym and in "the house of god," samuel shem said that it wa- stood for "get out of my emergency room!" that was an east coast derivation. um, there's actually a west coast derivation,

"grand old man of the er." um, and then there's a third derivation, which, i think,is more likely to be the truest and that is this guy, who you don't know in the bottom right, i do. that's a 1960s sitcom called gomer pyle. um, but if you wanna know who gomer was, just think of him as the grandfather of forrest gump. uh, somebodywho is not worldly wise

but, but has an instinctive, intuitive ability to get along with people but at the same time, uh, is,is not really book wise or book smart. um, what that has to do with,with elderly patients with dementia is beyond me but there is- if you actually do, uh, you know,a search of the etymology of, of the word gomer, you know,in reference to patients, they refer to the gomeral simpleton,whatever that means. anyway, that's what it is.

on the other hand, um, you know, nobody uses gomer but they use other slang. uh, today, um, we will refer to patients as social admissions. that means that they're- they have no medical problem that i can fix – dialysis for kidney failure, chest tube for pneumothorax, uh, thrombolytic therapy for heart attacks or strokes – but i can't send them home. and... and you know,social admission suggests

that if that patient's admitted to the internal medicine service, i'm not at all- if i'm the internist, i'm not interested in that patient at all, they're taking up space,they're a bed blocker. that's another bit of slang. um, failure to cope is another one that's used in part of this lexicon. um, and, uh, you know, they can't cope with the vagaries of life, they can't organize their life.

um, some of them make it to a more witty form like dyscopia. "dys" is, is a prefix for- or for difficulty. so, dysuria,difficulty voiding, dys- dyspnea,difficulty breathing, difficulty coping becomes dyscopia and hypocopia. the most egregious bit of slangthat i heard in my search was told to me by this guy,donovan gray, who wrote the book,"dude, where's my stethoscope?" he doesn't use it, he said.

they all say that, by the way, uh,"you never heard this from me." ftd, which is not the floristthat went belly up some time ago, it is, uh, it is three letters that stand for "failure to die." wow is right. so there's a suggestion that,that the patient should have died a long time ago but didn't get the memo. um... part of this is, is i think it's fair to say that young health professionals,

until very recently, were not,were not well trained, weren't given the right equipment, particularly weren't well trained in geriatrics. at the same time, i think we're- we,we still are not attracting people into health professions who adore working with older canadians, which i think is sad because that's where were heading. and that's- if i would wavemy wat- magic wand, i would sayyou have to love elderly patients. if you don't love elderly patients you can't, you can't be a physician,

or a nurse or,or a licensed practical nurse, or a respiratory therapist or what or, or what have you. i want you to hear this bit of tapebecause this may make you a bit angry. um, this is- the four who,who were interviewed in this clip won't make you angry,they're wonderful – nathan stahl, amanda gardhouse,raza naqvi and gillian elston. four young physicianswho early on decided they wanted to become geriatricians. and then they went to their colleagues,

um, who, who reacted when they gave them the news that they were gonna go into geriatrics,have a listen. [nathan stahl]when i committed to geriatrics the reaction that i got from my peers, and from my staff and from my- even some of my mentors at my medical school, was overwhelmingly negative. i was told that i was wasting my talents, that i was too smartto be doing something like that, and how could i pick a specialty where i wasn't actually helping people.

this really bothered me. there is, i believe, a culture of ageism in medicine. [dr. goldman]amanda, you were nodding as he spoke? [amanda gardhouse] i think we all sharenathan's, uh, frustrations in that geriatrics is perceived as a very negative subspecialty. [dr. goldman] raza, do you agree with what you've just heard? [raza naqvi] so, uh, i think absolutely,i think my, uh, kinda stumbling upon geriatrics was very different than a lot of my colleagues. i, i ended up filling in a blockwith geriatrics just to get it done

and 'cause i'd just had a daughter and i needed some time. so, geriatrics is lightand you don't do much is- was the reputation. i came onand, actually, i loved it and as soon as i started telling people i actually liked it, i found myself defending myself a lot. uh, and, and we need to tryto get rid of that stigma that- that's so closely attached,i think. [dr. goldman]gillian, do you agree?

[gillian elston] for the most part,but i wouldn't necessarily say that it's not a respected career choice. i think,just the reaction that i get is well, i'm gladsomebody wants to do it or, good for you,i would kill myself if i had to do that. [dr. goldman] wow,i'd kill myself if i had to do that? [group] [laughter][gillian] no, but like i... yeah, no, i think i've actuallyprobably heard that or like, i would gauge my eyeballs outif i had to spend an hour

with a patient every time i saw them. [dr. goldman] amazing.now, some of that is ageism. right, because we are in a culture that's ageist. and, you know, you haveto get to a certain age when people start to call you,you know, ma'am or sir and, uh, just think that you're- whatever you know is irrelevant. um, and, and would we expecthealth professionals to not come from the culture that,that gave birth to them? part of it though is medical futility,

which is really talking about two concepts. one concept is- and you'll see this sprinkledthrough the medical literature, medical futility meansoffering life-prolonging treatments without hope of successor hope of bringing somebody back to... to a reasonable quality of life. who gets to judge that?very interesting, very subjective. so there isn't a good objective definition for medical futility. the other aspectof medical futility

is what i got to treat you isn't gonna help you. okay, so that's not that it's futile to the patient, it's that it's futilefor me to be treating you 'cause i lack the training and experience, and, and there's an easy fix for that. that means recruit peopleinto health professions who actually have the psychological mindset, who wanna be ableto use that talent and wanna be able to make a difference in the lives of, of seniors.

um, so there's two aspectsto that futility, but that futility manifests itself in many different ways. one of them is the pret- this is slang, getting the dnr. um, the slang, other synonyms,making the sale, closing the deal. it's the pressure that families will feel under- will be put under to sign the do,the do not resuscitate order. um, more recently it's been called,do not attempt resuscitation or and,allow natural death. and, and why do we put families under pressure to sign a dnr?

because unless they sign it the default is that we- if... if their loved one's heart stops,we have to do a full code, and, and yes, sometimes that full code is futile. uh, and, you know,why do we have to do it? because it became the default option thanks to some seminal cases, one of them was the case of karen ann quinlan, a young woman who died of an overdose of alcohol and drugs. well she slipped into a coma, she was placed on a ventilator by her doctors –

this was an american case in the 70s – and, ironically,it was her parents who wanted to take heroff the ventilator so that she could die a natural death, but the doctors fought her. and this case went all the way tothe supreme court in the united states. and the judgment was, you can't- doctors can't make this decision without taking into account the wishes of patients. so that turned into,um, mandatory resuscitation unless you can get patients to, to, uh, to say,

to say, uh,"no, we don't want that." the problem with resuscitation is that television has- tv dramas like er and grey's,more recently have been more realistic, but in the past gave people a sense that a lot of people survive, it's a chance at life, when, in fact,there may be no chance at all. and... and in fact,the statistics show that, that as few as three percentof people over a certain age are actually gonna make it out of hospital alive.

and, and part of the problem hereis that we really haven't been talking about what it means to die, and what it means to be at the end of life, and that's what we need to do. so, the slangis all about trying to get around this weird transaction that has to take place. now, some of usdon't do the transaction or we have a familythat wants a full code but we don't think it's appropriate.

so we're gonna run another bit of slang, something called a slow code. which is walking instead of running to the site of the cardiac arrest, being slow to order drugs,being slow to order treatment, slow to defibrillate,slow to start compressions, and what you're doingis you're waiting until you reach a certain point in time when you can safely say, "this patient has to have irreversible brain damage." and, and so you can call the code.

now, uh, you know,it's- this is deception, it should never be done,but that this even exists is an indication of the- some of the exasperation that's felt within the corridors of medicine. interesting,because bioethicists are beginning to formulate a notion that all of us, not just health professionals, but everybody in society, has to think about what we want at the end of life. and, and that we may have,as patients and family members,

an ethical duty to refuse treatment that's futile. because we're in a lifeboatand we can't afford to have everybody,one at a time, receiving maximum treatment if, if it is futile. um, i can tell youthat physicians know and care and all health providers,certainly nurses as much as... as physicians,respiratory therapists, and others who, who see a lot of seniors at the end of life, know that the system spends morein the last two years

of a patient's life, than in all the other years combined – i've certainly seen that up closewith my own parents – and that patients and familiesare often not aware of this and, and act as ifit's somebody else's problem. and bioethicists are suggestingit is everybody's problem and i think that's very interesting,but the point is, that if you're doing resuscitations on people who ya think, not that they don't deserve it,but that it's futile, that's i- that,that this is a patient

for whom resuscitation was never intended. somebody with multiple comorbidity,somebody who has cancer, chronic kidney disease,chronic diabetes, high blood pressure,chronic congestive heart failure and we're pushing on their chest and sometimes cracking their ribs. and when that happens, you experience something called moral distress, which is the stress that occurs when you know, or believe that you know,the right course of action

but rules keep you from doing that course of action. so, you dowhat your heart says you shouldn't doand it eats you up inside. and this was first described as a risk factor for burnout among nurses and, uh, but can be seen across all healthcare professionals, particularly people who haveto do a full code resuscitations where they think it's utterly futile. and burnout is a stress syndrome characterized by, uh, three things –

emotional exhaustion,decreased satisfaction at work, distancing yourself from patients and co-workers, and really astonishing percentages of health professionals, particularly young peoplethese days, experience, um, one or more of the symptoms of burnout. um, deb lowe, uh, is a nurse who recently graduated from the university of victoria. she was an icu nurse and then she suffered from burnout, and i want you to hear her talking about this,

because some of the slang is a cover for this. [deb lowe] i feel less involved sometimes when i'm there. [dr. goldman] what does that mean?[deb] because in my- um, i'm somebody that really likes to kee- keep current with my practice. i go to a lot of conferences,i do a lot of reading, and i have a notebook that i update constantly. i've been doing lots of that. [dr. goldman] a- aside from,from that sense of commitment, do you think it's affected your day-to-day work in other ways?

[deb]um, i'm probably, with my colleagues, i'm probably a little less sunny at work i would say. um, i- yeah,i've less enthusiasm for the work. i, i complain a lot more than i used to,which i don't like in myself. um, and i, i th- i look at things in a negative light, when that's not necessarily the way they are. um, i, i feel likei don't give people the benefit of a doubtas often as i used to and, uh, i have a harder timeseeing things

from other people's point of view. um, so yeah, i,i think it's sort of, i've cast a bit of a pall over my practice, which is,which is my burnout, which isn't necessarily the way things are. [dr. goldman] are you exceptionalwhen it comes to burnout or are you typical? [deb] uh, uh, i think i'm pretty typical brian, unfortunately. um, where i work,there's a lot of talk

of what we're gonna do next after we're done nurses. [dr. goldman] you and your colleagues?[deb] but done being nursing, yeah. [deb]a lot of people are leaving. a lot of people my agehave been practicing for about four or five years,um, you know, there's a lot of talk of what we're gonna do when we win the lottery. interestingly,she didn't quit. she became a nurse practitioner and now she's happy. and that's important,you can take control of your life.

all too many people stayin the same job for too long when the little voice inside them is saying that they should move on. um, don't have time to talk about that. there's slang, modern slang,for bariatric patients and we have large numbers of them,harpooning the whale. uh, that is actual slangfor putting an epidural catheter in a bariatricor a dangerously obese patient in the second stage of labour. uh, the harpoon is the large tuohy epidural catheter,

uh, epidural catheter needle that is. whales, seals, fluffy. um, tropant,that i discovered in the united states, one plus, two plus, three plus. each plus is 200 pounds,so if somebody is four plus chicago, or three plus- four plus chicago is 800 pounds, three plus midwest is 600 pounds. um, they'll talk about beemer patients. patient who are bmi,that means a high body mass index.

the big gut is called a milwuakee goiteror a bojangleoma. why?it's again, a bit of salty humor. bojangleoma, bojangle like- "oma" is, of course,the suffix for tumor, bojangles is a famousrestaurant chain that serves, uh, fried chicken,and biscuits, and sweet tea. so, the assumption is that if you go to bojangles a little too often, you'll become- you'll develop a bojangleoma. where is that coming from?

well, part of it is the frustration. if you are a paramedic,for instance, and you have to bring somebodywho weighs 400 or 500 pounds down four flights of stairs,you'd better have a bariatric stretcher or you're gonna be in trouble. and, and, you know, the capital costof bariatric stretchers and bariatric ambulances is... is prohibitive, but it's necessary if you've got that patient population. you can see a bariatric wheelchair,bariatric lift,

bariatric stretchers,bariatric operating room tables. you'd better have the equipment and you'd better have the time to look after these patients. why? because, uh,if you're a surgeon and you're taking out their appendix it will take twice as long, it'll be without the proper equipmentto move that gut to the side, and you have to cauterize all the way down, you need special equipmentto hold it out of the way so that you can, you can actually find the appendix and take it out.

and oh, by the way, it takestwice as long to take the appendix out and the patient will get a wound infection, they'll remain in hospital twice as longand they're almost certain to be re-admitted six weeks down the road. so there is real frustration. but what's the common thread to all the slang? frequent flyers, gomers,bariatric patients, mental health patients – there's slang for them – substance abuse patients,indigent, homeless patients,

their numbers are growing, we lack the special expertisein training and, in fact, the right kindof people have not been attracted to health professionsuntil very recently and, so, we don't likehaving them as patients because we were never geared to having them as patients. now, that's clearly something that needs to change. how nice are we to each other? well, you'll be happy to know,even worse.

um, emergency physicians, like me, referred to as referologists,because all i do is refer. um, triage monkey is,is a horrible insult because it's insulting the,the health professionals about whom i have the greatest respect and that is triage nurses. who decide, you know, who,who see this onslaught and sort them which is what to... to what triage is all about. sorting patients into, you go in now,you can wait two hours, you can wait 90 minutes.

and, and, oh, by the way,the ones who are, who are sent to a chair in the waiting room, well, they have to keep re-assessing themto make sure they don't turn into somebodywho better come in right now 'cause you never know when it's goingto be a ruptured appendix or a ruptured ectopic pregnancy,even worse. so, so, calling me,well, a triage monkey, um, not only insults me but really insults, uh, triage nurses. noctor, a nurse practitioner

or a clinical nurse specialist who thinks he or she is a doctor. medwife, a midwifewho thinks he or she is an obstetrician gynecologist or a midwife who- this is- that... so that criticism could be coming from, from, uh, from nurses, from... from labour and delivery nurses, or it could be coming from fellow midwives. if they call a colleague a medwife,what they're saying

is that that midwife isn't a member of the tribe, a member of the club. they subscribe too much to the medical model of labour and delivery, they fit too well in the system, whereas they should be advocating for home births, so we're gonna call them a med- a medwife. more british slang. jack bauer, uh, a physician still up and working for more than 24 hours. blade is a surgeon,dashing, bold, arrogant,

often wrong but never in doubt. and, uh, double-o-doc,a very bad md with a license to kill. you see, uh, worse slang for each other. and, and here's another bit of slang,blamestorming, doling out blame for mistakes,usually to the lowest healthcare professional in the hierarchy. and that reminds me, 'cause i said i was gonna talk about medical errors. like, where does slang like that come from? we have a lot of errors,you know, this is an underestimate,

up to 24,000 deaths per year due to preventable harm, preventable medical errors at canadian hospitals. um, it's probably double that or more. um, and, uh, you know,what's really interesting is that seven out of ten nurses and eight out of tenhospital administrators say that patients are likelyto have serious errors while in hospital. the problem is the culture of medicine.

and in the culture of medicinewe assume that everybody, once they're trained,never makes a mistake. now, you know, intellectually we know that's not true, but, you know, we assume that everybody bats a thousand. and so, the assumption is that no one ever makes a mistake, so mistakes are a red flag either- well they could be a red flag for incompetence. um, you know,if you make one mistake, we'll call that a lapse.

you know, maybe a lapse of attention,maybe you were tired, we'll make an excuse,but, you know, if you've ever wondered, you know, how- you know,would healthcare professionals be happy about revealing a second mistakethree weeks after the first one? oh no, because that speaks to that,that's incompetence. and, and it's interesting, this is such a pervasive assumption that has ramifications. why spend lotsof money detecting errors if nobody's supposed to make errors?

you don't have to because everybody's perfect. now, how you bat a thousandis the health professionals problem and, and, uh, um,you know... errors in medical culture are,are either due to a momentary lapse, or laziness,or a pervasive pattern – take your pick. and, and that's why peopledon't wanna discuss a second error al- all that quickly. the problem- so, so, w- what's the blamestorming, what's the slang all about?

um, well, if nobody makes errorsthen you better find somebody to blame when there's an evident- a bad outcome that occurs. that might be the feeling amongst most health professionals. if you're the leader of the hospital,you may feel a great deal of pressure to show that the hospitalis, basically, sound and error-free but for the occasional lapses by these error-filled human beings. so, what will happenis that you will find somebody to blame quickly so that you can say, "we conducted an investigation,and what we have now

is we found what we can blame for, for this." um, and... and it's kind of an unhealthy attitude. it's an unhealthy attitude, that i would submit to you,comes from shame. on a personal level,healthcare professionals feel very uncomfortable talking or hearing about mistakes. and it's not just our own shame about our own mistakes, but vicarious shame. if i know that somebody's taken off the wrong leg in a hospital,

i might have difficulty making eye contact with them. and i don't know, maybeon a gut instinctive level i'm afraid that if i look at them, i'm going to be admittingthat i'm like them, and if i'm like them,what does that say about me? and, and, uh, so, we are really, really, really uncomfortable with errors. now we come to the conclusion of this talk, uh, and... and what are we gonna do with the slang?

i've revealed a whole bunch of slang, there's a whole bunch of,of other terms that i didn't get to talk about,and i've talked about some of the culture that... that unpacks it. well...in the culture of medicine, we have this thingcalled medical professionalism and, and it's an outgrowth of something that started to happen in the 1980s. you know, we hadthis kind of romanticized version of the physician who will workany number of hours

and have any number of nights on call. the family doctor who's there from cradle to grave, who, who gave birth to youand is there when you die and... and holds your hand in the middle of the night. and, and, you know, first of all,that's not particularly healthy, but, by the same token, a, a lot of those physicianswere replaced by healthcare conglomerates in the united states, the corporatization of medicine.

and there was this belief that a lot of what, you know, that, that nostalgiafor what we used to be that somehow it was lost through the corporatization. and at that time,the late 80s and early 1990s, we began to see expertsin medical professionalism articulating some of the views that we used to believe in intuitively. for instance,you know, you should always show respect for patients, um, you should never let 'em see you sweat,

uh, you should show respect for allied health professionals. so, there are actually signsin hospitals that say,"slang shouldn't be uttered." and there are actually policies that articulate, you shouldn't be using slang that- that's disrespectful. and i endorse that. i don't think you should ever be disrespectful of patients. so one view would be slang is unprofessional. if you hear it,call them into the office,

read them the riot act,get rid of it. there's a problem with that. if you do that, i think you're just going to drive it underground. so, in the same waythat nobody writes flk for funny looking kid on a chart,that doesn't say- doesn't stop them from going, "psst," and turning it into an oral,underground language. after all,the hidden curriculum is,

the concept of a hidden curriculum, is there for a reason. the opposite view,and i had a number of people in my book that talked about it,is that slang is healthy. it provides a way of expressing yourself emotionally, expressing strong feelings instead of stuffing them. so instead of getting rid of it,they would say, encourage it. i'm a canadian,so i'm in the middle. i think,i don't see slang as the problem. i think slang is symbolic language.

now it may be a symptom of disrespect – the tendency to objectify and stereotype patients. and that's a problembecause if your blaming somebody from coming backto the hospital again and again, by labeling them a frequent flyer, you may be missing the fact that they have no better place to go. okay?so, i'm against that. on the other hand, frequent flyer becomes a clue that maybe, if we have a group of patients who are coming back again and again,

maybe we can capture some data about them. and jeffrey brenner did that. he identified the frequent flyers,he calls them superutilizers – so, he jargonized it,so instead of slang – the people who come back again and again to the hospital, and what he did was he took some seed money and captured them. when they were admitted to hospital,he had a team that interviewed them. when they were going home he-the, the team escorted them home, made sure that on the way homethey went to the pharmacy

to bring their prescript- to get their prescriptions, because very often they didn't take their meds. made sure they got their meds, made sure they got their follow up visits, because it's often the lack of follow upor the lack of compliance with meds that led them to going back to the hospital again and again. in addition,he did something devilishly clever. if a ton of patients who keepcoming back again and again are living in this apartment building,what if we built a clinic in the ba-

in the- on the main floor of this apartment building – and he did. and what happened was that,he found them a better place to go and they stopped goingto the the emergency department and being re-admitted to hospital. now, i would maintain to you that ca- that if the slang helps us call attention to a problem, then it's a good thing. if slang tells us- if there's a lotof slang about bariatric patients, there's a good chance that there isn't enough equipment,

bariatric, you know, uh, bariatric stretchers and hoyer lifts, et cetera. so if they're saying,we need better equipment, i'd wanna hear that. i don't want people to just mutter under their breaths. or, worse yet, do an improper lift and blow out a disc in their neck. and that's a true story,that actually happened because they didn't have the proper equipment for... for lifts. so i think that i would listen to it,find out who's using it and why,

and, if the slang is a symbolthat the pa- that... that healthcare professionals are feeling frustrated that they don't have a place to vent their feelings, then, for god sakes, we needto give them a place to vent their feelings. that's all i wanted to say to you. any questions? [audience applause] [jeoff bull] if you have a question,please remember

to speak into the microphone. please feel free. [dr. goldman] nope?yeah, into the microphone. [man]so i wanna thank you for the talk. and i had a question for you, uh, there's a really good articleby haas and shaffir who talked about, uh, cloak of competence in medical school. so, i don't know whetheryou looked into medical students and the language that they use there?

but, uh, they were talking about how medical students are taught, not maybe slang,but they're taught how what may be more importantin medical school is to portray a cloak of competence rather than actual competence, so that in front of their peersand in front of their supervisors they can demonstratethat they know the answer to the question that they're asking and they need to speak in a certain way. so, i just wanted to...

[dr. goldman] that's an interesting observation. yes, i am familiar with that,with that work. um, it- you can have both. so, you have the cloak of competence, uh, and that's what you,that's what you exhibit when you think that you're being monitored,being observed, either by patients and their familiesor by a mentor. seeing that you are talking the talk of a health professional, you sound as if you belong.

in fact,there are cultures of... um, when a, when a groupof surgeons is deciding whether to accept somebody in their midst, they wanna know if they talk like them. so, that- this is a way of showing that you belong, so it reinforces that... that bond. you can have that talkand a whole separate talk that won't be in-that won't appear in that article that you're referring to,

and that consists of the argot or slang. and, and, you know,what i found is that some cultures are more apt to use slang than others. paramedics use it,emergency physicians use it, i think surgeons use it in some- in, in a lot of cultures, um, you have anesthesiologistsin some cultures using it to talk about surgeons, surgeons to talk about anesthesiologists. but there are also cultures that are,i would describe as healthier cultures,

where they don't feel the need to,to use that kind of language. and, i think,the common denominator, uh, is that people who don't feelthe need to use slang feel emotionally validatedin their work and also have an abilityto empathize with their patients and their colleagues. and the empathy gap is a huge one in healthcare. and, i think, you know,some of that has to do with the stresses that...that health professionals are under.

[woman] hello.thank you for your talk. i wanted to talk a little bit about, uh, errors, medication or non-medication errors. and i, i guess, there's a difference between slang and euphemisms, and, uh, i wondered if you could talk to that a little bit? [dr. goldman] sure, so, uh, a- euphemisms you may be talking about complications,unfortunate outcomes. and, and, you know,it- it's interesting, um, medication errors are oneof the, the top causes

of, of errors, preventable harm,in healthcare. uh, and, and, research shows that anywhere from – you know, it's roughly depending on, on the jurisdiction, the type of, type of healthcare system – roughly ten percent. that's the potential, ten percent of medications are in error either, the wrong dose given to the wrong patient, maybe it was mixed – if it's chemo, mixed in the wrong way – um, wrong dosage interval,wrong route of administration. um, you know, very few of them end up i- causing egregious harm.

you know, for instance,the example that i think of in my mind, the one that puts it into focus,is, is the, um, the patient who received four days of chemotherapy in four hours – this was at the cross cancer clinicin alberta – and that patient died, um,of a massive overdose of chemotherapy. uh, and that was caused by a programming error, like, an error in programming a... an infusion pump. um, and, and, you know, the,the fact is that in a complex system, uh, one in which knowledge is doubling every ten years or five to ten years,

whatever it is, three years,whatever, um, that, that, you know,we have more and more medications than we've ever had before and,and it is almost impossible to have any one person be in command of all the knowledge, uh, regarding, regarding the,the full pharmacopeia of, of medications. you have to have a system- and so, and so, humans being humans in a complex system,errors will take place. um, there are, there are cognitive errors that are made.

you know, you might have a systemwhere a nurse is mixing a particular type of medication and is relying on a colleaguewho's watching the nurse do the mixing to make sure that... that everything is being done correctly. um, there's evidencefrom cognitive psychology to show that the second nurse who's doing the observing, if they know them,if they're standing beside them, their, their mind might start to wander,they're thinking, "i, i trust this person,they know what they're doing,"

and so they're not paying attention, they're not paying attention to what's happening. it shows you how complex,how complex it is. um, and, you know,it would be tempting to say that complications are slang for, "i made a mistake." my answer to that is that, is that we're very good at guilting ourselves. we're very good at saying,"that's my responsibility." um, you know,there's a, there's a, you're probably aware of the-of, of the system approach

to error analysis that, uh,that, you know... you may have seenthe swiss cheese model where each transaction,from the first mistake to the harm that's caused to the patient, is represented conceptuallyby a slice of swiss cheese and they say that the first mistakegets propagated into harm to the patient if the holes line up in each slice of swiss cheese. it's a reminder that it's seldom one person's fault. and... and yet,in the culture of medicine,

that shame is so deep-seated that we tend to blame ourselves. and i've met many colleagueswho, um, who blame themselves for somethingthat is clearly not their fault and if they ever- if it ever got takento, uh, a malpractice case, they would win the case. the, the plaintiffwould not win the case because it wasn't negligence,but we see it as negligence, and we seem to- we, we think it's important to... to demonstrate

that personal responsibility for what happens. i think a lot of my colleaguesactually don't like the system concept because they see it as a dodge to personal responsibility. so, so, those aresome random musings and i don't know if i've answered your question, have i? [woman] yeah, i think you...[dr. goldman] okay. [woman]i think the points were good. i liked the, the, um particularly the point about the difference between personal responsibility,

which is an important component of any profession, and then the, um,you know, kind of that swiss cheese model that says it's the system, and trying to find the balancein between those two i think on a, on a real basis is difficult sometimes. [dr. goldman]it is difficult. it is difficult to find a balancebetween taking personal responsibility and system responsibility. and, uh, uh, very few researchers are looking at

the impact of shameon the behaviour of, of people who workin healthcare. but, you know, one- diane aubin,who's doing a phd thesis, uh, at- she used to- she's, she's working at the canadian patient safety institute, she used to work for the canadian medical protective association, and she's doing researchat the university of alberta on, on shame. she's done interviewswith healthcare professionals

and, and there's no questionthat following in the aftermath of an error, healthcare professionals are deeply traumatized. um, in part,because of what they do to themselves and, in part, because the feeling that they've completely lost esteem. their mask,and you were talking about that mask, it, it, metaphorically, alsobecomes a mask of competence that can be shattered by a mistake, and it takes careful rebuilding. it can take a long time to rebuild it,and sometimes it is rebuilt

only by making a dealthat you're going to leave that particular area of practice and move into a less intense area. which i think is a tragedy,because if we could- if we honoured peoplethat made mistakes and made them part of the solution instead of this gut reaction that they're part of the problem, then, then we would actually- not only would we save those people, but we would be able to enjoy their experience. they would be able to teach us how to avoid making mistakes.

and, and i can tell you,you know, i... i you know, i, i started by sayingevery good thing i've ever done has come from a mistake or a setback, and i hope that if i,if i were to leave you with no other message but that one, that would be a good one to leave you with. that, that don't be afraid of your mistakes. at some point you haveto embrace your mistakes because if you- that's how you grow and get better.

you don't may- they may not teach you that, but i'm telling you that that's true. and that's what will- that will keep you going on cold nights when you wake upat four o'clock in the morning wondering,"how did that happen?" anybody else?okay. [jeoff] i've just gotta finish off then. say, uh, one more time,thank you to brian goldman for speaking to us today,it was fantastic.

and, uh, to remind you all,he, uh, is willing to stay a little while longer and chat more informally if you're shy, i guess you're shy and you don't wanna talk on the mic. um, we have free foodand drink over there you're welcome to as well. so, please, uh, hang around,enjoy our reception and, uh, thank you for coming out today.