Thursday, July 14, 2005

Retired doc's suggestion for medical curriculum,Part 12, Beware the language we teach you

Still another mandatory item for the retired doc's medical student's reading list is a 1997 Annals of Internal Medicine article, "The Language of Medical Case Histories" by Dr. William J.Donnelly. The idiosyncratic language of the medical case presentation, particularly, as demonstrated to and executed by physicians in training not only communicates certain facets of a patient's medical problem(s) but it also affects the thoughts and actions of the players who speak those lines.
Dr. Donnelly tells us about medical "Language Maladies". He lists seven, I found number 3 particularly interesting. He speaks of the "agentless passive". An example is " the spleen was palpable" as opposed to I ( Dr. X.) palpated the spleen. This rhetorical device gives the observations of physicians an objective, authoritative status. The case is presented as a view from a " depersonalized nowhere" which obscures the narrator's role and her potential failures in gathering and interpreting the information and obscures the fact that all clinical "knowledge", from the history to the lab tests, to the biopsy and autopsy is less than certain, incomplete, provisional and subject to change. It gives a degree of solidarity to tentative analyses and conclusions.
Number 4 speaks to the loss of standing for a forum for the patient's understanding or lack thereof and the patient's fears and sufferings. ( Note I seem obligated to say patient and not person, another symptom of how our language influences how we think).
Dr. Donnelly explains how verbs are used to establish and maintain a hierarchy of credibility and reliability with patients at the bottom rung, physicians in the middle and laboratory tests at the top. Patients "claim" and ""deny", doctors "observe" and " find" and lab tests "reveal" ( as in the Chest x-ray revealed".)
As Dr. Donnelly says not all of the practices are the "deadliest of sins" but collectively they tend to ignore the "person of the patient" and are at odds with the probabilistic, observer-mediated, provisional nature of all clinical knowledge. He offers some suggestions to mitigate all of this. His first listed suggestion is to introduce the patient as a person, e.g. Mr. Jones and regularly refer to him in that way rather than always as the patient. The entire article is worth reading and thinking about at whatever level of medical training or experience you find yourself.

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