Medical terminology is the standardized language that allows healthcare providers, HIM professionals and medical transcription service companies to communicate on a patient’s condition and medical needs. This specific language is used to discuss everything from human anatomy and physiology, to clinical diagnoses, procedures and processes. With discoveries and advancements in medicine, healthcare professionals, medical transcriptionists, as well as patients need to continuously deal with new terminology, broadened medical language, and descriptions. Correct understanding and use of medical terms has a significant impact on patient care.
Proper physician-patient communication is an essential element of care. When patients interpret medical terms correctly, it can improve the physician-patient relationship and promote adherence to care instructions. However, studies show patients’ often don’t understand the diagnostic and treatment process as they are confused about medical terminology, which affects healthcare outcomes.
In articles published in 2015 and 2016, California-based not-for-profit public-benefit corporation Dignity Health listed the common medical terms that patients may not understand. The lists include the following:
- Positive and negative: Understanding the terms ‘positive’ and ‘negative’ is essential to comprehend medical test results. In layperson’s language, positive means that whatever the test was looking for was found and negative means that whatever the test was looking for was not found. False-positive results mean a disease is detected even if it is not present, while false-negative results mean that the test failed to detect the disease or condition that the person has. According to Decision Health, many patients think that positive test results means they are free of the disease or condition being tested for.
- Prescription instructions such as twice daily and every 12 hours: According to the Institute of Medicine, nearly half of US adults have some difficulty understanding their medication instructions. With billions of prescriptions dispensed in the United States each year, this challenge can affect a substantial number of patients. Misunderstanding prescription instructions such as twice daily or every 12 hours is more common among patients with low levels of literacy.
- Diet and exercise: Diet refers to food you eat and exercise refers to physical activity. However, when their physician talks about diet and exercise, people with low levels of health literacy may misinterpret diet as meaning going on a diet and exercise as meaning going to the gym.
- Chronic and acute: Chronic pain is pain is ongoing, long-term pain. Acute pain is short-term and occurs suddenly, and typically lasts less than 3 to 6 months. Many patients do not understand these distinctions.
- Stable: In medical terms, stable means not deteriorating in health after an injury or operation (www.lexico.com). But as the word ‘stable’ has many meanings, it can confuse patients. Decision Health recommends that physicians should stick to using ‘the same’ or ‘unchanged’ to describe the patient’s condition.
- Screening: Screening is another commonly used, but complicated word as far as patients are concerned. Many patients do not recognize and understand such terms as screening, mammogram, tumor, and growth, and how they relate to their specific condition.
In addition to these, patients are often confused by technical terms such as “myocardial infarction” (heart attack), “hyperlipidemia” (high cholesterol) and “febrile” (feverish). Other complex and commonly used words include:
- Annually → Yearly or every year
- Arthritis → Pain in joints
- Cardiovascular → Having to do with the heart
- Dermatologist → Skin doctor
- Diabetes → Elevated sugar in the blood
- Hypertension → High blood pressure
- Sutures → Stitches
- Abdomen → Belly
Studies have found an association between poor health literacy, especially among the elderly, the poor and recent immigrants, and higher rates of hospital readmission, expensive and unnecessary complications, and even death. A 2006 study by the U.S. Department of Education found that 36 percent of adults have only basic or below-basic skills for dealing with health material. However, according to a patient education manager, even highly educated patients are affected, particularly if they’re stressed or sick (Kaiser Health News).
Proper communication is essential in a time when patients are being asked to take more responsibility for their own care. Using complicated medical terminology during the consultation can leave patients poorly informed. This can lead to indifference and decreased of involvement of patients, which can affect patient outcomes. Physicians need to ensure that patients have a clear understanding of information during diagnostic and treatment process. One standard method is to ask patients to repeat what they understood, and then clarify any errors. If the patient doesn’t understand English, an interpreter should be used. Helping patients understand their treatment will improve the patient-physician relationship, help reduce morbidity and mortality, and prevent misuse of health care.
When it comes to the medical record, HIM professionals such as medical transcriptionists should have a thorough knowledge of medical terminology to ensure an accurate and complete working document. Continuous quality improvement is the hallmark of established medical transcription outsourcing companies where teams make extensive use of reference material to help providers ensure quality documentation in the electronic health record. Also, the support of a medical transcription company would be invaluable for time-strapped physicians striving to focus on patient care and their literacy concerns.