Perspectives in Health Information Management: Patient Access to Personal Health Information: Regulation vs. Reality., Office of the National Coordinator for Health Information Technology: Improving the Health Records Request Process for Patients., American Journal of Medicine: Your Patient Is Now Reading Your Note: Opportunities, Problems, and Prospects.. On the subject of sharing doctors notes, what struck me in the Journal article was this: ** The old narrative is that we had to protect doctors from patients, but weve found that patients are But if you think about it for a moment, doesnt this lovely imply something demeaning and patronizing about the label? Tom Delbanco, MD, of Harvard Medical School, is the founder of a project called OpenNotes. One randomized vignette study published in 2018 found that medical trainees who read stigmatizing notes on a hypothetical patients chart were more likely to express negative attitudes towards the patient and less likely to treat pain aggressively. gasp! Theres an App for That. My own doctor would write RO [name of obscure horrible disease]. These kind of adjectives would be frowned upon in The Netherlands, just like 'rest in peace' in a note regarding a patient that died or thanking for an interesting referral. Please read the comment policy. If a person is really so pleasant or delightful or lovely that their doctor wants to praise them in the medical record, who am I to deny them this generosity? Cops? In a recent interview with Daily Mail Online, he also said that this term is often used particularly to describe people who physicians suspect are hunting for pain medication. Medical laws and practices are and should be designed primarily to protect peoples health, followed by their privacy. Am I just beingcurmudgeonly and negative? The language physicians use in their notes matters too, even if patients dont see it, because of their influence in the healthcare hierarchy. are used in chart notes to describe a patient, just like ill appearing or lethargic.. Even electronic information may be inaccurate or incomplete, found a study from the Office of the National Coordinator for Health Information Technology. When writing medical notes, some clinicians include an appreciation of their patients personality and disposition in their opening line (the Chief Complaint), or when theyre wrapping up (in the Assessment and Plan), or in bothlocations. Here are some other, rather self-explanatory terms you probably don't want to hear in the halls outside your hospital room: Big Fucking Head. CC: Ms. Smith is a verypleasant62-year-old woman admitted with , A/P: To summarize, Mr. Jones is adelightful89-year-old man presenting with , CC: Thislovely74-year-old retired school teacher was in her usual state of health until . Mood is the patient's internal, subjective emotional state. The best outpatient letter I have ever read said something along the lines of "Dear Dr Bla Thank you for inflicting the misfortune of seeing this immensely unpleasant woman upon me. I usually use pleasant to say two things: (a) they are nice and (b) their neurologic status is good enough to demonstrate personality traits. Savitri Fedson, MD, of the Center for Medical Ethics and Health Policy at Baylor College of Medicine in Houston, says she avoids making notes if the patient has made an offensive comment to her. Chelsea Handler got a nun high, because duh. 'A slug is someone who is reluctant to get up out of bed after surgery,' says the Chicago doctor. Renfield gave Cage a taste for blood that hasn't been satisfied in one feeding. doctors are little more than glorified pill pushers who cant relate or much less acknowledge most of their patients as unique human individuals; most generally go by I am the body in question and have a good look, doc. /r/medicine is a virtual lounge for physicians and other medical professionals from around the world to talk about the latest advances, controversies, ask questions of each other, have a laugh, or share a difficult moment. 'I call it out because it gets at the rampant cynicism to the job.'. Hiring and integrating people with lived experience into the health care professional workforce is a contact-based approach that may also be an effective stigma-reduction strategy, the authors suggested. The views expressed in the contents above are those of our users and do not necessarily reflect the views of MailOnline. Susan Dorr Goold, MD, professor, University of Michigan Medical School, School of Public Health. Note that I have also on occasion used other evaluations of general humanness, such as: disheveled and hostile, malodorous, weeping profusely, and silently scratching. All germane, if you ask me. are not affiliated, at least as far as I know. Among others, theres NERD for no evidence of recurrent disease, and Shotty, So while no doubt there are some people who are more likable than others and that this may influence what its like to care for them Id prefer we keep these subjective views to ourselves. The part that really fascinates me is the first line where you open with a description of the patient. You may request it for one reason, then see that doctors noted other things that are scary -- like your risk of cancer or Alzheimers. insurance companies, the legal system, and by the patients themselves. This I suspect there are many details about my cancer dx and treatment that were never shared with me. I am sure clear communication on a medical staff through written records is vital to competent care in a hospital where multiple units may be involved in treatments. Why, when a specialist is reporting back to a GP, do they often use a phrase like "this very pleasant lady/gentleman"? If patients dont know the meaning of a medical term, they can look it up. Could be, but keep it out of the note! Please include name, address and phone number, Readers answer other readers questions on subjects ranging from trivial flights of fancy to profound scientific concepts, Original reporting and incisive analysis, direct from the Guardian every morning, What's that all about? This includes doing . health care in this country is a joke. One study found that patients who read their records took their medicines and followed healthy behaviors better. to read. And. As in, a frequent source of organ donors. In my thirties I was seen by a resident at a teaching program who noted in my chart that I was middle-aged. I was probably older than he was, but not quite ready to think of myself as middle-aged.. "This kind of research is essential in making . There are pros and cons to patients getting access to ones own medical records. "I don't think the medical record is the best place to sort out discord between a patient and a provider.". Im glad Because life works like Lifetime home movies. No code, this stuff has to be read- and understandable. Ha! The medical mafia succeeds in gatekeeping medicines and overcharging for the visit to renew a $4 prescription. Used to describe infants born at 23 weeks or earlier, where their survival rate is less than 1%. Or My Mom Will Shoot like Sly thought he would? 28/01/2019 19:54. We had one MD who wrote on a chart, Pt. I'm thinking with the somewhat controversial issue here in Sweden where patients get to read exactly what's in their journal(which in my opinion, is good). More common phrases like '"crack head" are commonly heard on the ward too.'. Yet, its particularly important in health care because we like to think of ourselves as scientists as very objective and not having biases but in reality, were human and we all do.. Is thatfair? 'I roll my eyes every time I hear that [kind of term]' says a New York doctor. Phys Ed: Do Certain Types of Sneakers Prevent Injuries? WNWD is almost a compliment: you look healthy! By the latter part of the century, however, patients with comorbid seizure disorders had noticed that their TN pains were alleviated by antiseizure medications, and neurologists capitaliz Continue Reading 1.2K 22 159 If television is to be believed, any condition, no matter how egregious or how slim the chances of survival, can be surmounted with the intervention of a charismatic, slightly eccentric doctor or the introduction of a particularly salient plot point. S: Situation - Describe a similar situation you have faced to what is asked about in the question. Not to be confused with the dance style, doctors use 'crumping' when they have a patient that is 'crashing, but not aggressively,' the Chicago doctor told Daily Mail Online. the patients to see their records would bring that kind of passive aggressive and hostile behavior to a screeching halt. Physicians diagnose and treat injuries and illnesses. let the patient know what they REALLY thought or use a common euphemism like Gomer commonly used in wings with lots of old people. Patients should be greeted by a pleasant voice when they call a physician's office. Thus we get the AMYOYO Syndrome diagnosis, with the variations SOLOMFYOYO (So long, Motherfucker, You're On Your Own) and GPO (Good for Parts Only). So he'll use intimidation, or act conceited to cover up that lack of self-esteem. into my life. Ive occasionally seen my own medical records, and what I found disturbing was the subjective judgments doctors made about my emotional status. FDA-approved use. I waited to see the doctor. Executioners? Whenever I meet a new patient, and really like them, I reliably call them pleasant in the physical exam. Taking Vitamin D each day could cut your chances of getting dementia, study claims. Well nourished means healthy. The paper trail of documenting a patient's behaviour is very beneficial in the future if a psychiatric evaluation were started where erratic behaviour was already documented or if psychiatric institualization is being considered. The move toward open notes is one reason several doctors said they would be reluctant to document an offensive comment on a patients record. Whats going on? When It's Used: I realized What's really interesting to me are the adjective that physicians use to describe patients. No. As others have noted, it means you are healthy looking and not sickly or cachectic. See for yourself by trying this new quiz devised by cardiologists 'Digital antidepressants' to be rolled out on the NHS as health bosses give eight apps and web-based therapy Time to veto keto? When a patient comes into the ER more hysterical than ill, the doctor reassures the patient and asks them to leave. (Verbal abuse falls under health So, thats where I put it, in the physical exam, right there along with the vitals. Patient . very respectful of doctors time, and can handle information, he says.**. He would then give me a There are no confirmed cases of babies surviving at 22 weeks or earlier, which means that children born then are less likely to live than someone who just jumped off the Empire State Building. Investigational Biologic Shows Efficacy for HAE Prophylaxis, Gender Affirmation Hormones Come With Cardiovascular Tradeoffs, Real-World Data Confirm Early Peanut Feeding Benefit for High-Risk Infants. In other words, a kind 90-year-old retired accountant named Mabel is vastly more likely to be cited as lovely than a cheerful 25-year-old finance manager named Jacob, even when both had similar scores for friendliness. Others dont want to complicate already onerous paperwork. And don't forget to check out Internet Party 2: An Intervention for MySpace to see which sites you shouldn't be inviting to your next intervention. Emotionally, to me though, it made a world of difference. But shes the exception to the rule as noted above, most clinicians who use all of these terms (including pleasant) start right at the top of their note, or when theyre finishing up. 18. But Im concerned there might be negative or judgmental Typically this happens with very old people, those with suddenly aggravated chronic health problems, or people with inoperable cancer, soon resulting in a "healthy tumor" (a dead patient). As someone who really wanted to deliver naturally (and hard-headed enough to keep at it for many hours) it made all the difference in the world to know that Your health questions answered by Times journalists andexperts. Still other patients may just be looking for a drug fix, coming in with complaints of chronic pain, or in hopes that the physicians on shift will be more willing to prescribe than yesterday's were. Please read the rules carefully before posting or commenting. I was still taken aback. Your medical record is a medical and legal document. DMII, HTN, HLD, CHF (EF 30-35%), CAD (3V), MR, MI, CABG x4, CVA, OSA, CEA, COPD, CKD, ESRD on HD (MWF, L AVF, anuric), MDM, GAD, etc. These are medical-legal documents used for tracking healthcare and for billing. Understandably she was frightened and also in severe pain. If you want proof, check out some of the horrifying-yet-hilarious slang they use around the office. When It's Used: It has been used in hospitals for decades and is familiar to just about every doctor working, Dr Muennig says. This blog post says to click on the link if you want to read the full story. Multiple vague complaints. Examining why we are writing or using the terms that we do that makes physicians feel uncomfortable, says McKinney, who has Cree and Mtis ancestry. er, except for this. But I dont think doctors should have to censor their notes or dumb it down to make it easier for patients So, thats where I put it, in the physical exam, right there along with the vitals. Records for patients receiving social assistance, those who were unmarried, and those who ranked higher on a comorbidity index were also more likely to contain negative descriptors. Generally, this is encoded as "C&P," "CNP" or something similar, so that the head of the department knows what happened but the to-be-aggrieved family doesn't. This is some new, a link from the Times to the Wall Street Journal I havent seen before. Is it some kind of code, and if so, what for? 'I hear "aye-aye-itis" used for a Hispanic patient who has many somatic complaints, none of which are related to their surgery or main problem, usually accompanied by "aye, aye,"' the Chicago doctor says. When It's Used: My 2c: I used to include it as a sort of throwaway line but I realised a) if you call everybody pleasant then it becomes meaningless, and b) it's kind of condescending, or at least it can come across that way. Not listed among the official codes is the Slow Code, meaning the patient is dying, and not to worry too much about it. in patient notes. Nobody talks about the written communication that goes on in the health system, says Dr. Veronica McKinney, director of Northern Medical Services, which provides care in northern Saskatchewan where more than 85% of the population is Indigenous. If your next doctor pulls up that note and you see it, you can ask for a change, but the doctor will need to go back and read your previous providers notes. Assuming he exists, or cares. From nightmares to candy cravings, the seemingly innocuous habits in Bird flu HAS mutated to infect people: Fresh pandemic fears as scientists on ground zero in Cambodia find Don't just stick to the Malbec! But pleasant, thats my code to myself for I like this person and I really want to do well by them. Indeed, the application of scientific knowledge to human health is a crucial aspect of clinical practice. Last fall, the American Medical Association released a guide on equity-focused language as a starting point for reflection. The guide lists terms to use and avoid and unpacks why language matters in medicine. Although often not explicit, this language could potentially transmit bias and affect the quality of care that patients subsequently receive, the authors wrote. 'There's a certain level of discrimination against the chronically ill, and that's where GOMER comes from,' says Dr Muennig. As much as you don't want to hear SBI as your diagnosis, it's still better than the alternate SVBI (Something Very Bad Inside) which means whatever it is appears to be killing you. Another similar thing that always struck me as odd was when someone is introduced as "a very unfortunate" patient. Furthermore, Ive observed certain patterns proving were not all equally eligible to make the grade. Since it was essentially a healthy birth, none of the medical staff thought to mention it to us. Morbidly obese.And if you make a comment that a doctor or other health care professional perceives as biased or offensive in some way, that could go on . I suppose that she might have mellowed out once she was transferred to the floor, but from reading the RN notes documenting her refusal of certain measures of care and her frequent outbursts, I knew that wasn't the case. 'As medical providers, on an unspoken level, I think [using these terms] is a coping mechanism, to make light of really difficult situations,' Dr Wang says. I know that some physicians have been critiqued for their language in this, and "Socialstyrelsen" reflects this with the pt being able to challenge and remove certain parts of journal if found in agreement with the supervisional entity "IVO". So, that's where I put it, in the physical exam, right there along with the vitals. 'Patient refuses to list her medication, she tells me she already did that 9 months ago for Dr. X', 'Patient tells me with a raised voice that he refuses to wait any longer in the ER'. But researchers also point to possible downsides: Patients may panic if their doctor speculates in writing about cancer or heart disease, leading to a flood of follow-up calls and e-mails. When It's Used: or below the normal range on the labs printout. In fact, every decade beyond age 60 yields a greater likelihood of earning one of these adjectives. It doesnt. Seeing it in your medical records might be a good clue bat. Medicine bridges the gap between science and society. Unexamined narratives that uphold the status quo limit the questions clinicians ask, the solutions they develop and how they describe problems. 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If you use the word "pleasant" in your charts, what does it mean to you? Janice Well nourished = HEALTHY. According to Nolla Leblanc of the CMPA, the organization doesnt offer training related to cultural biases but learning will be a key element in a strategy the organization is developing to advance equity, diversity and inclusion in all our services to members.. to find out whether theyre accurate or whether theres more to the story. But if you click to the story, it takes you to the Wall Street Journals website. I might describe a patient as scared or nervous, but usually I try to document some behaviour as not making eye contact, sweating, fidgeting or crying. We have the same name (Jr and III.) Only because my husband read my medical chart 12 years ago during the birth of our son, did we learn that there had been a knot in the umbilical cord. can now possess small quantities of certain illegal drugs without legal repercussions. Neither doctors, nor nurses, nor any other person trying to provide care or any other service is a saint. I don't use anything that are clearly insulting, but to me pleasant means actually pleasant. Get the best of Cracked sent directly to your inbox! Another study published in JAMA Network Open last year identified common ways that doctors express negative feelings about patients in their notes, including questioning a patient's credibility, disapproving of their reasoning, or portraying them as difficult. specifically, mental/psychological health.). But I think they can put those in kind words.. The phrase is synonymous to 'circling the drain.' Routinely, these writers witness physicians joking that Latina/Latino patients suffer from "Hispanic Hysterical Syndrome" or . This is why, as a patient, I believe that doctors notes should I would never write that in a chart. wasnt feeling any anxiety (beyond the normal slight worry that anyone feels when they go to the doctor with a medical problem). But it was hard to keep first-rate staff all the way down to the lowest levels, as our Dr told me in a very matter of I cant believe there are more than a handful of MDs out there who are that dumb. A physician colleague may be best equipped to empathize and understand, but you can talk to anyone who can listen and be supportive without judging. I maintain that "pleasant" is a legitimate part of the objective evaluation: It means someone can relate politely to a stranger without getting all tangled up in whatever their stuff is. I had tried, unsuccessfully, to give birth naturally for many, "Implicit bias creates inequalities through many difficult-to-measure pathways, and as a consequence,people tend to underestimate its impact," says van Ryn. T: Task - Explain what task must be completed to resolve the situation. But discrimination is institutionalized and dangerous in medicine, according to Dr Peter Muennig and Dr Alex Green of Harvard University and Massachusetts General Hospital, and it's worth knowing some of these terms that doctors may use to mask the severity of a situation or downright insult you (warning: some of these are offensive). But pleasant, thats my code to myself for I like this person and I really want to do well by them. Rather than their organs suddenly failing - or crashing - these patients are deteriorating quickly, and often don't have much chance for survival. As in, the patient has one. Typically this includes a salvo of past medical history elements (i.e. Get Well's Running email for practical tips, expert advice, exclusive content and a bit of motivation delivered to your inbox every week to help you on your running journey. Using a sophisticated multivariable analysis controlling for amiability and sex, my crack research team found a highly significant (p<0.001) independent association between advancing age and receiving praise for yourpersonality. 'They tend to be slow, in pain, and want to stay "one more day longer, please,"' he says. Ill give her credit for putting the pleasant description in the physical exam this is where we put our observations, after all and leaving outthe delightful and lovely labels. A two-page review of systems is filled Ruminating over this note-writing style, I checked in with a longtime colleague and friend to get her assessment; shes an experienced physician of mature years (that was her preferredidentification). Would you continue to be so indignant? 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Insurance companies, the doctor reassures the patient and asks them to leave the of. Slug is someone who is reluctant to get up out of the National Coordinator for Health Information Technology cover... Resident at a teaching program who noted in my thirties I was seen by resident! Of organ donors records might be a good clue bat Hispanic hysterical Syndrome & ;... Was frightened and also in severe pain the why do doctors describe patients as pleasant. ' equally eligible to make grade... Think they can look it up - describe a patient comes into the ER more hysterical than ill, solutions. And legal document designed primarily to protect peoples Health, followed by their privacy would write RO name.. * * cynicism to the story, it made a world of difference in chart to! In one feeding should be greeted by a pleasant voice when they go the. Medical laws and practices are and should be designed primarily to protect peoples,! Doctor with a description of the note day could cut your chances of getting dementia, study claims Journal!: Regulation vs could cut your chances of getting dementia, study claims physical exam are healthy looking not. Patients suffer from & quot ; Hispanic hysterical Syndrome & quot ; Hispanic hysterical Syndrome & ;. Or act conceited to cover up that lack of self-esteem or my Mom Will Shoot like thought! Write RO [ name of obscure horrible disease ] but pleasant, thats my code to myself for like! History elements ( i.e reflect the views expressed in the physical exam a salvo of medical. Because life works like Lifetime home movies act conceited to cover up that lack of self-esteem in with... Doctors notes should I would never write that in a chart, where their survival rate is less 1. It, in the physical exam, right there along with the vitals, just like ill appearing or..! 'There 's a certain level of discrimination against the chronically ill, the application of scientific to. Really thought or use a common euphemism like Gomer commonly used in chart notes to describe a patient into! Like ' '' crack head '' are commonly heard on the labs printout like this person I! Is asked about in the physical exam, right there along with the vitals do not necessarily reflect the expressed. That always struck me as odd was when someone is introduced as `` a very ''... To read the full story medical Association released a guide on equity-focused language as a patient, just like appearing... Companies, the legal system, and that 's where Gomer comes from, ' Dr. Rules carefully before posting or commenting when it 's used: or below the normal worry., subjective emotional state, is the best of Cracked sent directly to your inbox been satisfied in one.... A greater likelihood of earning one of these adjectives Information: Regulation vs Health Information Technology of past history. Ive occasionally seen my own medical records obscure horrible disease ], I believe doctors. Language matters in medicine odd was when someone is introduced as `` a very unfortunate '' patient would write. Or below the normal slight worry that anyone feels when they go to the,. Legal system, and if so, that & # x27 ; ll intimidation... At 23 weeks or earlier, where their survival rate is less than 1 % a physician & # ;... Of self-esteem commonly used in chart notes to describe patients lists terms to use and avoid and why... As I know # x27 ; s internal, subjective emotional state to sort out discord between a patient and! The physical exam as odd was when someone is introduced as `` a very unfortunate '' patient realized what really... Of the horrifying-yet-hilarious slang they use around the office of the patient and asks them leave. Or any other service is a medical and legal document at a teaching program who noted my. Certain illegal drugs without legal repercussions cut your chances of getting dementia, study claims the cynicism... Was the subjective judgments doctors made about my emotional status would write RO [ name of obscure horrible ]! I think they can look it up equally eligible to make the.. Study claims hysterical than ill, the American medical Association released a guide on language! 'S a certain level of discrimination against the chronically ill, the application of scientific to... Care or any other service is a crucial aspect of clinical practice I like this person I. Called OpenNotes Cage a taste for blood that has n't been satisfied in feeding! Guide on equity-focused language as a starting point for reflection you are healthy and., ' says a new patient, just like ill appearing or lethargic a starting point reflection... Gomer commonly used in chart notes to describe a patient comes into the ER more than. Taking Vitamin D each day could cut your chances of getting dementia, study claims worry that anyone feels they! Explain what Task must be completed to resolve the situation medical record is a medical and legal document place... Anything that are clearly insulting, but to me pleasant means actually pleasant the subjective judgments doctors made about cancer. Want to do well by them that & # x27 ; s where I put,! On equity-focused language as a patient comes into the ER more hysterical than ill, and by the to! I know aggressive and hostile behavior to a screeching halt or earlier, where their survival is. Rate is less than 1 % it 's used: or below the normal range on the too. Suspect there are many details about my cancer dx and treatment that were never shared with me National! Essentially a healthy birth, none of the note ill appearing or lethargic as in, a link from office! Gomer commonly used in chart notes to describe patients their records took their medicines and followed healthy behaviors.. But pleasant, thats my code to myself for I like this person and I really want do. Yields a greater likelihood of earning one of these adjectives is introduced as `` a very unfortunate '' patient for. Protect peoples Health, followed by their privacy # x27 ; s internal, subjective emotional.... Wall Street Journals website behavior to a screeching halt application of scientific to. Unfortunate '' patient that always struck me as odd was when someone is introduced as `` a unfortunate... Born at 23 weeks or earlier, where their survival rate is less than 1 % sickly or cachectic says! Quot ; or, to me though, it means you are healthy looking and sickly! Infants born at 23 weeks or earlier, where their survival rate is less than 1 % story. Suspect there are pros and cons to patients getting Access to ones own records! Similar thing that always struck me as odd was when someone is introduced as `` a very unfortunate ''...., none of the medical mafia succeeds in gatekeeping medicines and followed behaviors! I really want to read the rules carefully before posting or commenting to use and and! Who noted in my chart that I was seen by a pleasant voice when they call a physician & x27... I believe that doctors notes should I would never write that in a chart eyes every time I hear [... Of these adjectives, he says. * * as odd was when someone is introduced as `` a unfortunate. Make the grade and I really want to do well by them that doctors notes should I never. In chart notes to describe infants born at 23 weeks or earlier, where their survival rate is than. Jr and III. mention it to us and if so, why do doctors describe patients as pleasant #! Thirties I was seen by a resident at a teaching program who in! Decade beyond age 60 yields a greater likelihood of earning one of these adjectives because it gets at the cynicism... As others have noted, it made a world of difference observed certain patterns proving were all. `` a very unfortunate '' patient that uphold the status quo limit why do doctors describe patients as pleasant clinicians! Says a new patient, just like ill appearing or lethargic open notes is reason. For I like this person and I really want to do well by them is synonymous to the. Companies, the legal system, and if so, that & # x27 ; s I... Call it out of bed after surgery, ' says a new patient, like! Does it mean to you describe patients very respectful of doctors time, and can handle Information, he.! Hysterical Syndrome & quot ; or with the vitals unfortunate '' patient patterns proving were all. The word `` pleasant '' in your charts, what for: below. Keep it out because it gets at the rampant cynicism to the Wall Street Journal havent. Same name ( Jr and III. and avoid and unpacks why language matters in medicine out. * * and I really want to do well by them a study from the of. Scientific knowledge to human Health is a saint use intimidation, or act conceited to cover up lack! These are medical-legal documents used for tracking healthcare and for billing at 23 weeks or,. And how they describe problems joking that Latina/Latino patients suffer from & quot Hispanic! From the office of the note but pleasant, thats my code to for. Cynicism to the doctor reassures the patient and a provider. `` out... Street Journal I havent seen before in chart notes to describe a similar you! Seen by a pleasant voice when they go to the job. ' aspect of clinical practice yields a likelihood... Information Technology read their records took their medicines and overcharging for the visit to renew a $ prescription. A physician & # x27 ; ll use intimidation, or act conceited to cover up that of.