Language and medicine

Language and medicine    

 

  A lot has been written on language and medicine. More than one might imagine, judging by the extent to which the research in this hybrid field – which staked its place on the Great Map of Knowledge essentially in the 1980s1 – has had a demon- strable impact in three areas we might take to be“diagnostic”: medical language itself, communication between patients and physicians, and our everyday discourse about illness and disease.2 The second of these areas alone has spawned an extensive body of literature, which percolates down slowly into medical education and medical practice. For practical reasons, this chapter will concentrate on western biomedicine (vs. other models of medicine studied, e.g., by medical anthropologists and semioticians) and on research in and about English. The choice of topics for inclusion, and their relative foregrounding and backgrounding, reflects to a degree my own biases and interests within the field. It could not be otherwise. This chapter is organized into five sections. Section 1 touches briefly on doctor– patient communication (surveyed in depth in Ainsworth-Vaughn, this volume), focusing on differences in thinking, orientation, and research methodology between studies coming out of biomedicine and studies from humanities and social science fields. Section 2 deals with medical language as an “occupational register” and its constituent written genres. Section 3 looks at the literature–medicine interface, not- ably at theoretical notions and approaches to the reading/interpretation of texts that medical discourse analysts have borrowed from the field of literature, in particu- lar the study of narrative. Section 4 deals with metaphors, in and of medicine. Section 5 probes the relationship of medical language to the “real world” of sickness and health.

We regret that this line of inquiry can no longer be pursued by Fleischman herself due to her untimely death from myelodysplastic anemia.

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Doctor–Patient Communication

By far the lion’s share of literature on language and medicine is about doctor–patient communication. As this is the topic of a separate chapter (Ainsworth-Vaughn, this volume), I limit my remarks here to noting interesting differences between the ap- proaches and methodologies of researchers from biomedicine and those of discourse analysts, coming mainly from linguistics, English for science and technology (EST), and social science fields. Discourse analysts (DA) tend to look at lexicogrammatical features (lexical choices, tense–mood variables, hedging devices, pronouns and passive voice, transitivity rela- tionships), discourse structures and organization (“moves,” schemas and frames, them- atic progression, topic–focus relations, foregrounding and backgrounding), features of conversation analysis (turn-taking, structures of adjacency), and particularly at the functions these phenomena fulfill in the discourse forms in question. By contrast, the interactional analysis systems (ISAs) developed within medicine – “observational instruments” (the term itself is revealing) designed to analyze the medical encounter – typically involve the methodic identification, categorization, and notably quantifica- tion of salient features of doctor–patient communication. Ong et al. (1995) compare twelve such systems with regard to what they measure, their clinical relevance, obser- vation strategies used, “inter-rater reliability validity,” and “channels” of commun- icative behavior (i.e. applicability of the model to verbal and/or nonverbal behavior). Their study is based on 112 publications on doctor–patient communication from medical journals on hospital practice, medical education, social aspects of medicine, and in several medical specialties (notably oncology).3 This research is highly quant- itative (findings are based on survey/questionnaire data) and minimally linguistic, in the sense that the variables investigated involve general phenomena of commun- icative behavior (posing questions, interrupting, using technical language, giving “bad news”), physician and patient attitudes (about death, bad diseases, how much information to give patients), patient expectations, and measures of patient satisfac- tion (the influence of certain communicative behaviors on “patient outcomes”). For the most part, this literature does not look at texts (spoken or written), hence there is virtually no analysis, distributional or functional, of lexicogrammatical features, dis- course organization, or rhetorical conventions. There is some attention to semantics (Bourhis et al. 1989; Hadlow and Pitts 1991), since the meaning of isolated words is easier to study using the methodologies these studies employ. In order to produce the kinds of data ISAs are designed to manipulate, communic- ative behaviors must be identified (e.g. as “privacy behaviors” or “high physician- control” vs. “low physician-control” behaviors; Stewart and Roter 1989), categorized (e.g. as “instrumental” (task-focused, cure-oriented) vs. “affective” (socioemotional, care-oriented)), and quantified. On the basis of two studies in their survey, for example, Ong et al. report that only 7 percent of “affective” behavior is conveyed verbally

 Medical Language and Discourse Genres

French writer Julien Green once observed that while thought flies, words walk. Jammal (1988) comments similarly that science flies and its terminology walks – typically at a pace that lags far behind scientific advances. There is less literature than one might expect on medical language, the occupa- tional register of a tribe of white-coated speakers that gets passed from one genera- tion of physicians to the next through the highly ritualized institutions of medical education. It is widely recognized as what sociolinguistics would call an “in-group dialect,” i.e. largely opaque outside the medical “confraternity.”

 

 Spoken and written genres

     The literature on medical language tends to concentrate in two areas: doctor–patient communication (section 1 above and Ainsworth-Vaughn, this volume), where the focus is on spoken discourse, and the language of particular genres of medical dis- course. The latter are primarily written, save for case presentations, formal oral per- formances made by physicians in training to their peers and superiors, typically in the context of hospital “grand rounds” or other types of case conferences. The case presentation is a highly conventionalized linguistic ritual5 involving stylized vocabu- lary, syntax, and discourse structures which, when examined under a linguistic microscope, reveal tacit and subtle assumptions, beliefs, and values concerning patients, medical knowledge, and medical practice to which physicians in training are covertly socialized (see Anspach 1988). With regard to spoken language, attention has also been paid to the in-group dialect physicians use in speaking to one another, notably about patients (cf. Klass 1984; Donnelly 1986; and Anspach 1988: 358–9 for additional references). The (largely ethnographic) literature on this topic uses medical language

 Vocabulary of family medicine .

    Dixon (1983) looks at the vocabulary of family medicine and finds it sadly wanting, offering up “a restricted and very biomedical view of the world.” In the International Classification of Health Problems in Family Care, which serves as a dictionary for re- search in family practice, he notes a sizable vocabulary for classifying and describing respiratory infections, but only one word for poverty. Similarly, infectious diseases are categorized and subcategorized, while marital and family problems are presented in amorphous chunks (1983: 360). Occupying a kind of half-way house between the everyday language patients use to talk about the “lifeworld”7 and the technical lan- guage of the biomedical world, the language of family practice in particular, Dixon argues, needs to be modified so as to make more of a place for human values in a professional framework that is largely committed to a reductionist, biomedical view of health. (One finds this theme reiterated throughout the literature in humanistic medicine.)

 Technical language and ordinary language

    Some attention has been paid to the linguistic “gray area” in which the occupational register of medicine overlaps with ordinary language (Hadlow and Pitts 1991; Fleischman 1999; sporadically in the literature on doctor–patient communication). Occupational registers provide an efficient code for the transfer of information among specialists. Within knowledge communities, they provide a practical and convenient shorthand for talking about complex matters specific to a field. They are largely opaque outside the esoteric circle. A particularly slippery situation arises when technical language passes for ordinary language, i.e. when words have meanings – different meanings – in both dialects. Looking at psychological disorders the names of which have entered common parlance (e.g. depression, hysteria, eating disorder, obsession, “psychomatic” disorders generally), Hadlow and Pitts (1991) and Kirkmayer (1988) find that patients and medical professionals have different understandings of these terms

 History date  of admissions

 

  The patient is a 21 year old Gravida III, Para I, Ab I black female at 32 weeks gestation, by her dates. She states that she has been having uterine contractions every thirty minutes, beginning two days prior to admission. The patient has a history of vaginal bleeding on 10/23, at which time she reports she was seen in the Emergency Room and sent home. Additionally, she does state that there is fetal move- ment. She denies any rupture of membranes. She states that she has a known history of sickle-cell trait. PAST MEDICAL HISTORY: Positive only for spontaneous abortion in 1980, at 12 weeks gestation. She has had no other surgeries. She denies any trauma. She denies any allergies. REVIEW OF SYSTEMS: Remarkable only for headaches in the morning. She denies any dysuria, frequency, or urgency. She denies any vaginal discharge or significant breast tenderness. HABITS: She denies tobacco, alcohol, coffee, or tea. MEDICATIONS: She takes pre-natal vitamins daily. FAMILY HISTORY: Positive for a mother with sickle-cell anemia. It is unknown whether she is still living. The patient also has a male child with sickle-cell trait. Family history is otherwise non-contributory.

Medical records are, conventionally, highly condensed summaries of large amounts of information. The example above is more fleshed out, less elliptical, than many. Hunter (1991: 91) sees the minimalism as “a goal of medical storytelling and an emblem of the efficiency that is an ideal of scientific medicine.” Most analysts of this genre focus on (1) how case histories are written – and how they might be improved – and (2) the “translation process” through which patients’ stories of illness find their way into the medical record, transformed into instances of disease by the terse, objectifying, formulaic code that is the norm for this genre (cf. Mishler 1984; Kleinman 1988; Anspach 1988; Donnelly 1988, 1997; Hunter 1991: ch. 5; Charon 1992; Poirier et al. 1992; Smith 1996). Case in point: an individual tells the interviewing physician in training about his puzzled shock and dismay after not- ing passage of a black or “tarry” stool. This gets translated in the student’s written account as “melena.” Donnelly comments: “In one stroke, substituting ‘melena’ strips the event of the patient’s wonder, shock, and dismay and consigns it to a universe of anonymous stools blackened by the presence of digested blood. Not only has the patient’s subjective experience been objectified, but its particularity has been tran- scended by an abstraction” (1988: 824). Among “questionable language practices” of the conventional case history, Donnelly (1997) includes:

Categorizing what the patient says as “subjective” and what the physician learns from physical examination and laboratory studies as “objective.” It is true that these terms . . . can be used ontologically, as I believe Weed intended when he made the[m] . . . part of the problem-oriented medical record. . . (subjective mental states and processes versus objective physical and biological phenomena). Unfortunately, the distinction is more commonly understood, especially in a science-using activity, epistemically, marking “different degrees of independence of claims from the vagar- ies of special values, personal prejudices, points of view, and emotions” [Searle 1992: 19]. Inevitably, then, categorizing what the patient says as “subjective” stigmat- izes the patient’s testimony as untrustworthy. On the other hand, calling physical findings and laboratory studies “objective data” gives an air of infallibility to the quite fallible observations of doctor and laboratory.

1. Depersonalization, i.e. the separation of biological processes from the individual.

 See the opening sentence of the excerpt above; throughout this excerpt the woman is referred to as “the patient” or “she,” no name, and ellipted altogether from statements of the physician’s observations (“positive for. . . ,” “remarkable (only) for . . .”). 2 Omission of agents, e.g. through existential “there was. . .” constructions and agentless passives. These have the effect of emphasizing what was done rather than who did it let alone why a decision was made to engage in a given course of action.18 3 Treating medical technology as the agent (“The CT scan revealed . . . ,” “Angiography showed . . .”). These formulations carry the process of objectification a step further than the passive voice: not only do the writers fail to mention the person(s) who performed the diagnostic procedures, but they also omit mention of the often complex processes by which angiograms and CT scans are interpreted. In treating medical technology as if it were the agent, such formulations support a view of knowledge in which instruments rather than people create the “data.” 4 The use of non-factive predicators such as “states,” “reports,” and “denies” (Anspach calls these “account markers”), which emphasize the subjectivity of the patient’s accounts.

What distinguishes this study from many others is not only its lucid and insightful analysis of the style of this genre of medical discourse, but also the author’s attempt to ferret out the (unconscious) epistemological assumptions informing this style (1988: 369–72). Language, as Dr. Freud reminds us, is never innocent. Another illuminating study of the medical case history is Francis and Kramer- Dahl’s comparison (1992) of the title essay of Oliver Sacks’s collection The Man Who Mistook His Wife for a Hat (Sacks 1985) with a “standard” case report of a patient with the same neuropsychological disorder. Through a nuanced analysis of lexicogram- matical patterns (using Halliday’s transitivity model), the authors show how Sacks’s linguistic choices reflect his beliefs about neurologically afflicted human beings, their condition.

 Narrative in medicine

     Narratologists who have studied (nonfictional) narrative are keenly aware that what storytellers provide is not a verbal icon of a pre-existing structure of real-world experience. Rather, they cull from, and configure, the experiential database from which the story is constructed, notably in ways that support “the point” they wish to make in telling the story (see, e.g. Labov 1972; Fleischman 1990: section 4.1). This commonplace of narratology comes as “news” to at least some researchers who have undertaken to analyze medical case histories from a narrative point of view.

   Narrative “voice” and point of view 

  Literary narratology insists on a distinction between “narrative voice” (who is speak- ing?) and “point of view” (whose perception orients the report of information?).23 Since narrators commonly undertake to tell what other individuals have seen or experienced (this is standard in the medical chart or case history, where the patient’s words and experiences are entered into the record using the physician’s language), it is necessary to keep these two notions distinct at the theoretical level. In theliterature on medical discourse the two notions are often conflated and the terms used inter- changeably. Poirier et al.’s discussion of “the absent voice of the patient” (1992: 7–9) is really about the absence from the chart of the patient’s point of view (they mention, in fact, that the Subjective entry in SOAP notes (see section 2.3.2) typically begins with a direct quote from the patient). This use of the term “patient’s voice” is also encountered in regard to pathographies (section 3.3). King and Stanford (1992) implicitly address the issue of point of view in arguing for a “dialogic” (patient and physician) rather than the traditional “monologic” (physician only) storying ofpatients. In the studies surveyed in this connection, the collapsing of the theoretical distinction between voice and point of view is not problematic, though it could be, a fortiorisince in “medically plotted” stories, the observing, narrating speaker is conventionally effaced and the story written as if “the medical facts” speak for themselves. Bioethics cases in particular can be “evidentially” problematic as a result of the case writer’s failure to properly identify participants’ distinct points of view, all reported through the narrator’s voice. Chambers (1996b) discusses a case that revolves around what to do about a psychiatric patient who refuses to complete a course ofelectroshock therapy but has become violent and suicidal. What Chambers finds problematic about the ethicists’ write-up of this case in their textbook, which claims to present “accurate accounts of actual cases,” is that although there are three points of view in this story – the physician’s, the patient’s, and the ethicists’ – the story told reflects only the point of view of the physician (as determined by

identifying linguistic features).

    Pathography

   Narratives about an experience of illness have proliferated in America over the past several decades, notably in the form of biographies and autobiographies oftenreferred

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to as “pathographies.” Hawkins (1984, 1993) surveys this burgeoning body of literat- ure, tracing the metaphors and patterns of myth-making at work, and examining the ways in which writers of pathographies borrow from the metaphorical archetypes – the journey, war/battle, death and rebirth, the body/soul analogy – to describe and come to terms with the experience of serious illness. Whereas Hunter (1991) sees pathography as a genre of protest literature against the medical reification of patients (see n. 10 on the “metonymic imperialism” through which “patients” are transformed into “cases”), Hawkins views it as complementary to the medical case report. Using a striking visual metaphor, she observes: “Case reports and pathography function as mirrors set at an oblique angle to experience: each one distorts, each one tells the truth” (1993: 13). A comparison of two reviews of Hawkins 1993 (= H.), from the journals Theoretical Medicine (TM) and Literature and Medicine (LM), sheds illuminating light on the ideo- logical divide alluded to above (section 1) between a traditional biomedical approach and a humanistic approach to illness. The reviewer for TM, a psychiatrist, fails to engage H.’s study on its own terms, opting instead to elaborate his “dislike [of] the genre to which Hawkins gives the name of pathography” (the term is in fact from Freud). Too often, he opines, “pathographies represent an attempt to impose the patient’s subjective interpretation as an objective fact,. . . a kind of power trip.” H. makes clear that she reads pathography not for reportorial accuracy but to understand the prevalent metaphors used by illness sufferers to “formulate” their experiences.24 In her view pathography “restores the person ignored or cancelled out in the medical enterprise, . . . [and] gives that person a voice” (1993: 12). Is it a bias of psychiatry (or of the particular reviewer) or is it endemic to biomedicine that “effective therapy may depend on convincing the patient that his voice is wrong, or at least unhelpful” (TM)? By contrast, the reviewer for LM credits H. with giving these narratives of illness experiences “the status they deserve as a major resource for clinical teaching and reflection.” As an occasional reader of pathographies, I share the TM reviewer’s dismay at the tabloid quality of many of these accounts, those in the New Yorker and Sacks’s A Leg to Stand on (1984) being notable exceptions.25 However, I recognize their value as cultural documents, of particular interest for their use of metaphors. Which brings us to the topic of the next section.

 

 The body and its metaphors

   As linguists, anthropologists, and cultural investigators of the body have long recog- nized, in virtually every language and every culture body parts serve as metaphors.

Medicine’s metaphorical

 “exports” In any culture the body provides a powerful set of metaphors for talking about society and the “body politic” (Benthall and Polhemus 1975; Staiano 1986), about social institutions, and about the character of individuals (on the influence of the medieval doctrine of the humors/temperaments on our contemporary vocabulary, see Geeraerts and Grondelaers 1995). It follows, then, that the body’s ills will become metaphors for “the ills of society” (see n. 29). The illness/disease metaphors that medicine has “exported” are too numerous to list. Some that come readily to mind are being blind to reality, deaf to all entreaties; having a lame excuse, an anemic economy, or your style cramped. Public transit systems become paralyzed, traffic arteries blocked, college majors impacted. The terms pathology/pathological have extended their domain of reference from “the branch of medicine that studies diseased tissues” to groups, individuals, or behavior “deviating from a sound or proper condition” (the relation- ships in that family are pathological, standard languages are pathological in their lack of diversity). As various investigators have pointed out, Sontag in particular, epidemic diseases offer wide possibilities for metaphorization to the social body or body politic (the term epidemic itself has become a metaphor, as in an epidemic of house selling).

ordinary metaphorical imagination

.

 Language in Relation to the “Real” World of Sickness and Health

      Warner (1976) offers a brief but penetrating cross-cultural exploration, Whorfian in inspiration, of language’s role in shaping our conceptions of health and illness. Changes in biomedical practice and orientation since the mid 1970s render certain of his observa- tions now inaccurate (though nonetheless insightful). Still, the study stands as one of the few in the linguistic literature to address the issue of how the lexicogrammatical resources of a language influence speakers’ conceptions of illness and disease (this issue looms larger for medical anthropologists and semioticians than for linguists).

Naming across language

        Kay (1979) studies the lexicon of illness terms used by bilingual Mexican-American women. This is a paradigm study on issues raised by bilingualism and “medical biculturalism” (the coexistence of different health systems), with implications for medical anthropology (e.g. though the vocabulary of disease terms reflects linguistic and cultural interference, the different names do not represent compartmentalized participation in different health systems; cognitions of illness seem to be situated within a single unified theory) as well as for linguistics (new disease names emerge, and changes are observed in the meanings of established disease names). Among linguistic changes, Kay shows that in some instances an English term is simply bor- rowed (virúses “viruses” and microbios “microbes” replacing animalitos “little ani- mals”), in others a cognate is coined from an English disease name (fiebre de heno, literally “hay fever”); terms no longer useful may be dropped (mal ojo “evil eye” and metonymic daño “witchcraft,” lit. “harm” caused by witchcraft), while some Spanish disease names lacking equivalents in English, or in modern biomedicine generally, may be retained, but with a shift in the meaning (bilis “bile” is now the term for “gall- bladder disease”; mollera caída, lit. “fallen soft spot,” is coming to mean “dehydra- tion”). 

 

REFERENCES

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 The effect of physician behavior on the collection of data. Annals of Internal Medicine, 101, 692–6. Benthall, J. and Polhemus, T. (eds). (1975).

 The Body as a Medium of Expression. London: Allen Lane. Bourhis, R., Roth, S., and MacQueen, G. (1989).

 Communication in the hospital setting: a survey of medical and everyday language use amongst patients, nurses, and doctors. Social Science and Medicine, 28(4), 339–47. Boyd, J. W. (1996). Narrative aspects of a doctor–patient encounter.

 Journal of Medical Humanities, 17(1), 5–15. Brandt, A. (1988). AIDS and metaphor: toward the social meaning of epidemic disease. Social Research, 55, 413–32. Brock, H. and Ratzan, R. (eds). (1988).

 Literature and Medicine, 7: special issue on “Literature and Bioethics.” Burnside, J. (1983). Medicine and war: a metaphor. Journal of the American Medical Association, 249, 2091.

Burton, D. (1982). Through glass darkly: through dark glasses. In R. Carter (ed.), Language and Literature. An Introductory Reader in Stylistics (pp. 195–212). London: Allen and Unwin. Carter, A. H. (1989).

Metaphors in the physician–patient relationship. Soundings, 72(1), 153–64. Carter, A. H. and McCullough, L. W. (eds). (1989). Soundings, 72(1), 7–164: Special section on “Metaphors, language, and medicine.” Cassell, E. (1976). Disease as an “it”: concepts of disease revealed by patients’ presentation of symptoms. Social Science and Medicine, 10, 143–6. Cassell, E. J. (1985). Talking with Patients. Vol. 1: