Crude Awakening: Should Interventional Cardiology Come Clean on Dirty Talk?

“Deep-throat” a catheter, inflate a balloon to “manly pressures,” stent a “widow-maker,” “violate” an artery, or refer a patient for a “blow job” (balloon angioplasty): most interventional cardiologists can give you an example of the off-color slang and sexual innuendo still heard in the cath lab, but the majority agree it’s time to leave it behind.

The offensive terms are far less common than they used to be—everyone who spoke with TCTMD made a point of saying they rarely hear them now and when they do, they believe they’re being used innocently and not with malintent. They also agree, though, that outdated language speaks to an era when sexualized jokes and cringeworthy terms were more tolerated.

“There are terms that are used that have to go,” Kirk Garratt, MD (ChristianaCare, Newark, DE), past president of the Society for Cardiovascular Angiography and Interventions, told TCTMD. “They're used benignly—I really don't think I know any interventionalists who’ve used those terms in an intentionally demeaning manner—but look, haven't we learned the lesson that words really matter? We're still trapped in this place where our subconscious biases emerge and we're not sufficiently sensitive to their impact.”

“There are a lot of terms used in the cath lab that when you hear them for the first time, you are sort of like, really? Did I just hear that?” Kimberly Skelding, MD (Confluence Health, Wenatchee, WA), observed. “And then you realize that people are using this terminology and many aren't even thinking about what their words are meaning. So I don't think that people use this terminology specifically to make people feel uncomfortable, at least not most of the time, but I think that we need to be more sensitive to the fact that the terminology may not be appropriate for all the players in the room.”

Words Matter

Ajay Kirtane, MD (NewYork-Presbyterian Hospital/Columbia University Irving Medical Center, New York, NY), told TCTMD he heard someone use the term “deep-throat” during a case review and realized many people training in other parts of the world may not know the sexual connotations of the term, which shares the name of a pornographic film from 1972. Hearing it prompted Kirtane to tweet that it “bothered” him and to propose that “deep seating” a catheter—a term that is now much more widely used—be universally adopted instead.

Speaking with TCTMD, Kirtane stressed that what was particularly “jarring” for him during the case review was the innocence with which the term was used. “I’d almost bet that the person was just repeating a term he’d heard without even understanding its meaning,” Kirtane said. “Beyond the fact that I don't use the term myself, it really struck me when I thought of it that way: hearing it from a nonnative speaker. Even for those who rail on about ‘cancel culture,’ is this a term that one would really want to defend? I just don’t see any reason why an interventionalist would compare what they are doing in a patient’s coronary artery to a term describing a sexual act derived from a movie in the 1970s.”

There are at least three good reasons to get rid of these juvenile and sexualized terms, according to Garratt.

“The first is the respect factor,” he said. “In my opinion, we're still evolving out of that mid-20th century paradigm in which white males dominated and had the liberty to say whatever they liked that was dismissive or demeaning of someone else who was not a white male or was otherwise disadvantaged in some manner. It’s simply disrespectful. And we need to be sensitive to the fact that people are hurt by our words and we should guard against causing that harm.”

The second reason, Garratt said, is the “maturity factor.”

“They are some that look at interventional cardiologists as the cowboys of cardiology. It’s an old boys club and they're sort of clowning around all the time. It's not surprising then that others outside of interventional cardiology don't always take us as seriously as a group of clinical providers,” he said. “If we want to be taken seriously, we need to behave in a mature and respectful manner.”

The third reason is safety, Garratt argued, noting that he’s been involved in cath lab safety, evaluation, and management for at least 20 years. “It's just a remarkable truth that mishaps in the catheterization laboratory and out of the catheterization laboratory are all too often tethered back to very poor communication and the use of jargon of any type, whether it's demeaning or not,” he observed. “Again, I don’t know of any interventional cardiologists that have intentionally tried to obfuscate or muddy waters about what they were up to through use of jargon, but the unintended consequences of jargon can be to do exactly that.”

Skelding, too, pointed out that that much has been said and written about the “locker room atmosphere” of surgery, cardiology, and other areas of medicine. “Honestly, for many people, including myself, we are used to working in that environment and it just becomes noise. But I think that young people coming into the field are much more sensitive to these issues, to the terminology, and to their comfort level and [they] want to be welcomed and feel included. And this language is not inclusive or welcoming.”

Changing Times

Not everyone could come up with ready examples of offensive cath-lab vernacular, suggesting that the problem may already be fading into history. Shazia Hussain, PhD (University Hospitals of Leicester NHS Trust, Leicester, England), who has worked in cath labs in both the UK and Canada, said she hasn’t come across many offensive terms or sexualized language.

“There are a few archaic terms, such as ‘deep-throating’ that come to mind. But to be honest, it's not used very often, and I think it's used even less now as people become more aware,” she said. “This really should not discourage those who want to pursue a career in interventional cardiology and certainly as a female interventionalist, I have never had cause to feel uncomfortable in any way.”

Haven't we learned the lesson that words really matter? Kirk Garratt

In Hussain’s opinion, “poor choice of terminology in the cath lab per se is not a major issue that discourages trainees and so doesn’t need to be addressed specifically. There are far more important issues that need to be dealt with in order to make cardiology inclusive, namely bullying, harassment, and concerns about work-life balance.”

Michelle Connolly, MBBS, PhD (King’s College Hospital NHS Foundation Trust, London, England), likewise, said that “deep-throating” was the only term she could think of and she’d heard it used by a senior fellow very early in her interventional career.

“I think this terminology has no place in the cath lab,” Connelly told TCTMD, pointing out that the vast majority of responses to Kirtane’s tweet agreed that it was vulgar and that he was right to call it out. “A better term is ‘deeply or overengaged,’ or better still, use a guide extension catheter!” she said in an email.

A More-Inclusive Space

But Skelding, Hussain, and Connolly all made the point that interventional cardiology still struggles to attract women. Fewer than 6% of consultant interventional cardiologists in the UK are women, said Connolly; Skelding put the US number at 4.5%.

“There is important work being done in this space to try to increase representation of women in the specialty,” said Connolly. “While I don’t think such terms are barriers to women considering intervention—challenges in achieving work-life balance and flexible working patterns are far more important—their ongoing use in some cath labs as highlighted by Dr. Kirtane does our specialty no favors.” 

“There's some reason that women aren't going into interventional cardiology,” Skelding agreed. “So I think we need to start looking at all these aspects of the culture that might deter someone from choosing this career.”

Several physicians interviewed by TCTMD pointed out that it’s not just about inclusiveness and comfort-level amongst the cath lab team, but also the patients on the receiving end of the procedures these terms are used to describe.

“With patients we want to be professional and thoughtful at all times,” Skelding said. “Certainly if a patient is awake and hearing this terminology, there is a potential for people not being comfortable and to potentially even being offended.”

It's not about what you say, it's about how you're heard. Kimberly Skelding

That goes beyond sexualized terms for procedures, Hussain pointed out, saying she thinks swearing in the cath lab is a bigger issue. “That's quite commonplace and can cause distress to patients who, if they're not sedated, can hear the conversation,” she said. “That is definitely something that some interventional cardiologists need to be more mindful of, especially if things are not going to plan.”

It's not a question of being too thin-skinned, Kirtane said, or not being able to take a joke. “For those who insist or think that people need to be ‘tough enough’ to handle jokes in poor taste in order to have success in the field,” he said, “first that’s not true, and second I’d surmise they likely don’t know what real toughness is.”

But several cardiologists contacted for this story declined to be quoted or didn’t respond to requests for interviews, suggesting that no one wants to be considered a killjoy or lacking a sense of humor.

“To be honest, I think a lot of people don’t want to talk about this, and even the people that wanted to talk or that were willing to talk about it did so with some degree of discomfort,” Skelding said. “Because you don't want to be the one the one that brings this up, you know what I mean? But I really think it comes down to basic decency, and this verbiage might be very offensive to someone else. It's not about what you say, it's about how you're heard.”