Words in Medicine: Creating Space or Enclosing Outcomes
Notes from a Family Meeting, Vol. 5, No. 2
Reflecting on how words are used in medical practice, Rita Charon writes:
“Doctors differ from patients in the ways in which they use language and the purposes to which they put words. Doctors use words to contain, to control, and to enclose. When a patient complains of chest pain, the doctor moves in with a series of questions to pin down the nature of the pain, its time course, frequency, duration, pattern of radiation, and its exacerbating and ameliorating factors. Patients use language to express the sensations of things being amiss. … Because patients don’t know how (or in what) to contain the sensation, they use language to express multiple levels of knowledge: thoughts, feelings, descriptions, associations, metaphors, guesses about causality, and reports of their own behavior in trying to manage the problem. Rather than categorizing and reducing, patients enlarge and embroider. Doctors simplify; patients complicate. Doctors think within physiological and anatomical categories; patients do not have those constraints.”
The primary use of language in healthcare is to craft a story that leads to a diagnosis, and for that story to support the recommended treatment. When I put it that way, it sounds pretty straightforward. However, as Charon suggests, history-taking is a painstaking process. A clinician must undergo an immense amount of training to know what questions to ask and what to do with the answers. The clinicians, not the patients, are the historians.
History-taking looks like a blunt instrument when contrasted with the promises of modern medical technology. As I explored earlier, Drew Leder traced how clinicians move from the experiential text of a patient’s reported symptoms, to the co-constructed narrative text (the history, as we call it), onward toward the physical text with the fallible patient excised, and then finally settling on the instrumental text offered by machines (e.g., scans, labs, etc.), where both fallible humans have been removed. If the primary purpose is to gather and sort through data, then our striving will take us to the machine. Whether the machine can make good on its promise or not is almost a moot point; the machine sets the standard for what we ourselves do.
That’s a pitfall along this path, but the danger doesn’t mean we can stop using language this way. We still need histories of present illness, differential diagnoses, and the like. But I think it could help to recognize other uses of language within the clinical encounter. This is challenging for clinicians because, as Charon continues in her essay, medical training degrades our capacity for “normal human speech”:
“It may be that the price for health care is the loss of the doctor’s fluency, that ability to speak according to the rules of language. This loss may or may not be permanent. It may be that the doctor swings in and out of the capacity for speech. A more sinister possibility is that the doctor is sacrificed to the instrumental endeavor and, having been spoiled for normal human speech, never regains the full capacity for noninstrumental language.”
Other Ways of Speaking
I remember when I was a trainee, I saw a patient who had a complaint that wasn’t within the realm of expertise of the clinician whom I was shadowing. Every so often, the patient would bring it up, and just as often the clinician would dismiss it and redirect the conversation back to their organ of interest. What they were doing was using clinical language to carve a pre-determined path through the clinical encounter.
Clinicians use speech this way all the time. They permit or ban certain issues from the clinical encounter - sometimes explicitly (“You need to ask the social worker about that”), but often implicitly. Clinicians can crowd out any other topic of conversation by flooding the encounter with speech that only permits a technically acceptable outcome: what are we doing about this blood pressure today? When is your colonoscopy? Have you gotten your flu shot? Time’s up! Values collapse onto these biologically relevant phenomena. These things are, of course, important, but the intentional use of language here is to circumscribe a space in which the clinician has control with the tools they have on hand.
This use of language is so potent because it’s effective at what it does: the history and physical, along with any other relevant tests, often does lead to a diagnosis which leads to treatment! The patient is a bearer of a problem and we use language like surgical instruments to identify what that problem is. Or maybe there’s not a problem yet, so then we use language to negotiate a plan for preventing problems. Because the clinical encounter so easily devolves to technique, it may be hard to imagine what other uses of language might even exist, let alone help the clinician and patient in their shared pursuit of health. But there is indeed another way to use language that acknowledges other important things about the patient and the relationship they cultivate with the clinician.
Margaret Walker had this to say about the role of stories in ethics consultation, but it could just as easily apply to the entire clinical encounter: “I’ll use this central idea of narrative as a way to shift perspectives: from thinking about morality as a theory applied to cases, to think about morality as a medium of progressive acknowledgment and adjustment among people in (or in search of) a common and habitable moral world.” Use of language in this paradigm is exploratory, tentative, and open:
“Moral generalities on the narrative view are ingredients rather than axioms. They are ingredient to stories that reveal how problems have come to be the problems they are, that imagine what ways of going on are possible, and explore what different ways of going on will mean in moral terms both for the people involved and for the values at stake. … Narratives are built or constructed, and remain open to elaboration, continuation, and revision; they make more or less sense, and may be more or less stable as they unfold.”
Clinicians are co-authors in the creation of the patient’s narrative. One of the ways they help patients to write this part of the story is through the questions they ask, which open and close certain avenues of thought and possibility. Such conversation also helps to define what kind of relationship this is: is it one between a technician and the machine of the body? Is it between bureaucrat and pleading customer? Is it between priest and supplicant? Is it one of humane accompaniment?
Walker continued:
“…the narrative conception of moral thinking shifts attention to the of interpretation, negotiation, construction, and resolution required by any complex deliberation, as well as to the roles of deliberation. If this sketch of the structure of moral deliberation is even roughly right, knowing specially about ethics and moral thinking can no longer be seen simply as knowing about ethical theories, principles, or concepts and some standard patterns of argumentation in which they are put to work. It is not only knowing what the theories, concepts or arguments are, but knowing what they are for, and understanding under what conditions they can be made to serve.”
The lesson here applies broadly: we need to know what the practice is and also what the practice is for. That doesn’t mean the practice of medicine is wholly idiosyncratic and its telos entirely subjective, which is a risk if we equip ourselves with narrative alone.1 But it does highlight how language could be used to create a space in which this co-authorship could happen, which would allow both clinician and patient to better see the purposes for which medical intervention is best used.
This is why Walker wanted to call the ethics consultant an architect: “A consulting ethicist needs conceptual tools and training, but also a sense of where moral space needs to be created or sustained, and of how to structure that space for an integrated and inclusive process of moral negotiation within the constraints of a particular institution.” So, too, the clinician operating within the institution of medicine broadly and their local clinical institution narrowly. The clinical encounter can become one such place of moral deliberation. It certainly already is by default, but too often clinicians cordon off large swaths of it for the sake controlling what is legible to their technical interventions.
But why give up control? Anatole Broyard, in his autobiographical account of dying from prostate cancer, wrote:2
“It may be necessary to give up some of his authority in exchange for his humanity, but as the old family doctors knew, that is not a bad bargain. In learning to talk to his patients, the doctor may talk himself back into loving his work. He has little to lose and everything to gain by letting the sick man into his heart. If he does, they can share, as few others can, the wonder, terror, and exaltation of being on the edge of being, between the natural and the supernatural.”
The space the clinician creates isn’t out there, like some kind of physical space in the air between them and the patient. It’s a space for “the sick man” in the clinician’s very heart.
But people die in vacuums. Architects don’t just make big boxes. The point of using language in this way isn’t just to have a hole, but to silence and clear away some of the technical clutter that prevents something more beautiful and just as necessary from growing. It’s hard and slow, but the aim is to do more than budge the creatinine in the right direction.
When I took a drawing class in undergrad, one assignment I had was to draw a scene by focusing on the negative spaces - the gaps between the legs of a chair, for example. I wound up with something that looked surprisingly chair-like despite not focusing on the chair. Similarly, using language in the way of creating space allows us to trace the contours of the human heart and spirit. Humans will do what humans do when the technical veneer is pushed away: they cry, they laugh, they ask big questions, they doubt, they confide, the tell stories.
More is needed, but nothing less: carving away things that threaten to overwhelm the humanity of this encounter, turning down the noise on the distractions, and allowing clinician and patient to meet each other as people.
But What Do I Do?
I often return to Alasdair MacIntyre’s observation: “I can only answer the question ‘What am I to do?’ if I can answer the prior question ‘Of what story or stories do I find myself a part?’” The risk of offering a list of maneuvers and techniques without first appraising one’s story and role is that medical practice can so easily co-opt our best intentions for its technical purposes. Space-creating questions can be used not to cultivate humanity, but to manufacture a feeling of trust to make the encounter run more efficiently. It is true trust generally makes things go more smoothly, but I’m less likely to trust someone if I learn they’re trying to earn my trust for the mere purpose of dispensing with me sooner.
My suspicion is well founded. The story in which we find ourselves in modern medicine is powerful and usually irresistible. I’ve seen clinicians abscond, either emotionally or physically, from open spaces when they present themselves. I myself have done so too. I don’t think we can avoid the fact that, at the outset and perhaps forever, any humanizing project in medicine will be vulnerable and delicate. It will always be under threat of deprioritization in favor of the technical and financial goals of the institution.
But there are other stories with different characters. Patients inhabit those stories before they ever enter the hospital, even if their story started in a hospital. So do clinicians. Perhaps rather than give a list of what I might imagine a clinician could say to create space, I’ll instead ask some questions to create a space here.
What’s scary or anxiety-provoking about humane space in the clinical encounter?
What story/stories about health and medicine make humane space difficult to cultivate and sustain?
What story/stories provide a rationale for why we would even want to undertake the endeavor of creating and holding spaces in medicine?
What would a clinician need to inhabit a humane space with a patient and/or their family? What kind of clinician would be able to do this?
Working from such a space, what might a clinician need to help their patient pursue health? Again, what kind of clinician would be able to do this?
Arthur Frank had this to say about that: “Deontology,” that is, rules, duties, and laws, “saves narrative from getting lost in a regress of infinite perspectives, and narrative saves deontology from repeating abstractions that fail to recognize lived complexities.” I would add that it’s through virtue that these things unite: how the good is lived out through a practice has both objective and subjective facets captured by deontological and narrative criteria.
The male pronouns are his, written in the early 1990s when there were surely female physicians but fewer than there are now. I read this passage to include male and female clinicians both.