Affiliations: Cleveland Clinic Foundation, Cleveland, OH,
Thomas Jefferson University Hospital, Philadelphia, PA
Correspondence to: Alejandro Arroliga, MD, The Cleveland Clinic Foundation, Pulmonary, Allergy and Critical Care Medicine, Director Fellowship Program Cleveland Clinic Foundation, 9500 Euclid Ave, Department G62, Cleveland, OH 44195-0001; e-mail: firstname.lastname@example.org
I read with interest the article by Griswold et al (May 2005).1 The article characterized the patients who are more likely to have a high number of visits to the emergency department (ED). The study was well-conducted, confirmed previously reported data, and moved the field forward by adding solid new information.
In their article, the authors referred to the patients who had a high number of visits to the ED as “frequent fliers.” I think that the use of this term, besides being misleading (patients do not get a free trip or enjoy visiting the ED frequently), dangerously stereotypes this group of patients. Stereotyping our patients should be avoided in medicine because it may lead to prejudice that will exacerbate the disparities in health care.2This group of asthmatic patients has to deal with frequent asthmatic attacks that are poorly controlled. By calling them frequent fliers we add a stereotype to the specific sociodemographic characteristics reported by Griswold et al, which may impact the behavior of the physician during medical encounters. We should not forget that there have been reports suggesting that the race and socioeconomic status of the patient influences the physician’s perception of them.3
Language plays an important and subtle role in the transmission of stereotypical views.4Linguistic biases are believed to play a significant role in the transmission and maintenance of stereotypical views. I am concerned that by using the term frequent fliers in a prestigious journal such as CHEST, the medical community, without intention, minimizes the patient’s problem and encourages an inappropriate use of slang in everyday practice. Remember the words recently written in a piece by Dr. Michael Burg: “What’s off hand slang or shorthand lingo for you (physicians) really packs a wallop when it reaches a patient’s ears.”5
We have carefully read and considered Dr. Arroliga’s letter regarding our recent article, and we share his concern regarding the negative impact of stereotyping—not only of patients in the practice of medicine, but also of those who may express things differently than he thinks correct. We hesitated to put the term frequent flier in our article—due to its informality—but its use is so prevalent that we thought it might help shine some light on this important problem.
What do we know about the term frequent flier? In the airline industry, frequent fliers are valued customers who frequently travel by air. Most of the trips taken by this relatively affluent group are not for free, nor are most of the trips for pleasure. We know from personal experience that the miles usually are accrued during the course of work-related travel that actually takes valuable time away from friends and family. In emergency department (ED) parlance, frequent fliers are those who frequently seek health care in the ED. Period. They represent a mixture of very sick people who are forced by their illness to frequently visit the ED, others who seem to choose the round-the-clock schedule of the ED and the ability to receive diagnostic testing and interventions more quickly than in regular outpatient care, and a variety of other groups. In using the term frequent flier in our article, we do not intend to imply—as suggested by Dr Arroliga—that all of these patients come for free or that they enjoy utilizing the ED. On the contrary, we sought to identify and characterize this important group of patients with high ED utilization.
We are pleased that Dr Arroliga otherwise enjoyed our article and that he ultimately concluded that it “moved the field forward by adding solid new information.” We hope that it motivates people to address ongoing health-care disparities in the management of asthma and many other conditions.
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