When a mnemonic becomes dangerous

Fat.

One tiny word. One voluptuous, full-figured concept.

Several weeks ago, amidst a conversation regarding the risk factors for cholelithiasis (i.e., gallstones) during a chief concern small group session for preclinical students, my preceptor ushered in an aurally convenient yet unsettling mnemonic utilizing alliteration that has apparently been in the works among medical education for a while now, known as “the 4 Fs”: female, fertile, forty, and … fat.

Yes, you read that right.

Despite my instructor’s best efforts to soften the blow by visibly cringing and sharing her own disapprobation towards this memory trick, the pregnant pause that ensued in that small classroom that afternoon was not only palpable but its silence deafening. The moment the word represented by the final “F” was uttered, my eyes darted around the room only to reassuringly see a mix of familiar reactions that engendered a feeling of tacit solidarity around me: some were of utter disgust, others of restrained discomfort, and a few of surprise and confusion.

I gulped.

Immediately, I wondered why this mnemonic was extant and why we have not extricated ourselves from using it. What kind of journey has it gone through to survive the protean conditions of an ever-evolving medical education landscape that positions itself as an entity that seeks to affirm dignity in and foster respect towards patients where “chief complaint” has now become “chief concern” and “compliance” changed to “adherence” under new educational jurisdictions?

Ostensibly, this bewilderment towards “the 4 Fs” presupposes the idea that “fat” confers stigma upon and connotes a pejorative meaning towards the individual it is intended to characterize. Barring the progress and efforts of various factions of the contemporary fat-acceptance movement towards the reclamation of the word “fat” as a positive, the spearheading of its volitional self-directed use as a form of self-empowerment and restoration of bodily agency, and a more nuanced discussion around what the word “fat” currently connotes to different groups of people and stakeholders. “Fat” as a human descriptor continues to occupy a largely derisive space among many social circles, one of which is prominently the medical community.

And thus I became curious about what other mnemonics are still formally (or informally) institutionalized and used in medical didactics that reprehensibly encode subliminal prejudice and discrimination that could lead to differential treatment of and harm, even, towards patients by those justifying its use simply on the grounds that the mnemonic makes things “easier to remember.”

And to that end, where do we draw the line?

If there were a mnemonic to remember risk factors or a particular disease script involving developmental impairment, is it appropriate to use the word “retarded” along with other words that begin with an “r” sound?

What if having multiple sex partners is a risk factor for a particular condition, can we use “slut” as one of the words that would be enumerated among a diagnostic checklist of other non-neutral “s” sounding descriptors?

Where do we draw the line between just inoffensive enough to keep something for the sake of smooth information storage and recall ease and too disparaging that irrespective of memory convenience we need to do better and come up with an alternative way to learn and teach the concept?

Moreover, you may be inclined to wonder how we could possibly ascertain the subjective appraisal and reception of our words by our patients when one person is so vastly different from the next, and if there is some litmus test or general heuristic we can employ to navigate all subsequent approaches to mnemonic construction in medical education that would effectively reduce harm towards patients and ameliorate discomfort and hostility within the medical learning space.

To that end, I implore you to ask yourself, “Would I be okay saying this to my patient and not just to the medical trainees, employees, and students I am teaching or to myself in my own head?”

To return to our original example, if your patient asked you, “On what basis did you determine that I was at an elevated risk for cholelithiasis?” Would you feel comfortable responding with, “Well, you are a female, you are in your 40s, you are fertile, and you are fat.” If the answer is “no,” or you felt even a scintilla of unease just now imagining yourself uttering that response to your patient, then you likely should try to reassess the language you are using to learn, encode, and teach risk factors for gallstones, for example.

Reflexively, I parlayed my understanding of how the current modeling industry works and suggest that — similar to how fashion models who represent more curvy — voluptuous body archetypes are no longer called “fat” or “plus-size” even, but instead “full-figured” to be more language-sensitive and politically correct, we adopt and incorporate “full-figured” into the lexical repertoire as not only a replacement for “fat” in “the 4 Fs” but also “fat” in general in any setting used to talk about patients.

I am particularly an exponent of using “full-figured” specifically for “the 4 Fs” as opposed to other positive descriptors such as “curvy” and “voluptuous” because “full-figured” preserves the integrity of the aural convenience of alliteration employed by “the 4 Fs” that justifies its continued use and does not require a complete overhaul of the mnemonic.

Words are powerful. They can change the course of a patient’s life. And we have the responsibility of ensuring that that change is a positive one. Whether we like it or not, the language we use to understand our patients shape our unconscious (and conscious) biases and preconceived notions, and are formidable propagators of prejudice, discrimination, and even insidious harm when deployed inappropriately.

As medical professionals, we owe it to our patients to be lodestars for dignity affirmation and respect conferral. This begins with heightened self-accountability, a re-evaluation of our diction, and an extirpation (and replacement) of unpalatable, deprecatory words baked into our everyday medical education and communication. We should extend our commitment to optimizing care into challenging the lexical status quo and making better the lives of those we took an oath to serve — our patients.

Jay Wong is a medical student.

Image credit: Shutterstock.com

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