The Language of Medicine

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The Language
of Medicine
Abraham Fuks, MD, CM
Professor of Medicine, McGill University

1
 3
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Library of Congress Cataloging-​in-​Publication Data

Names: Fuks, Abraham, author.
Title: The language of medicine /​Abraham Fuks.
Description: New York, NY : Oxford University Press, [2021] |
Includes bibliographical references and index.
Identifiers: LCCN 2021016414 (print) | LCCN 2021016415 (ebook) |
ISBN 9780190944834 (paperback) | ISBN 9780190944858 (epub) |
ISBN 9780190944865 (online)
Subjects: MESH: Physician-​Patient Relations | Language |
Attitude of Health Personnel
Classification: LCC R727.3 (print) | LCC R727.3 (ebook) |
NLM W 62 | DDC 610.69/​6—​dc23
LC record available at https://​lccn.loc.gov/​2021016414
LC ebook record available at https://​lccn.loc.gov/​2021016415

DOI: 10.1093/​med/​9780190944834.001.0001
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 Dedicated
to
Sacvan Bercovitch z”l
1933–​2014
Colleague, Mentor, and Friend
Contents

Introduction  ix

I. LANGUAGE IN CONTEXT
1. The Lens of Language  3
2. From Words to “Making Up People”  17
3. The Nature of Metaphor  33

II. THE MILITARY METAPHORS OF MEDICINE

4. The Militarized Arena of Medicine  49
5. Sources of the Military Metaphors of Medicine  63
6. Consequences of the Verbal Wars  77
7. Resilience of Military Metaphors  95

III. FRAMES AND CHOICES

8. In Other Words  109
9. Listening  123
10. A Pharmacology of Words  139

IV. HEALING THE LANGUAGE AND THE LANGUAGE OF HEALING

11. The Physician–​Patient Relationship  161
12. Healing Metaphors  179

Afterword  193
Notes  197
Bibliography  207
Index  217
Introduction

Health and illness are of compelling interest to us all. Health care is a recurrent theme
in our daily newspapers and blogs and is increasingly entwined with big business,
shrinking budgets, partisan politics, and robotic high technology. The successes of
modern medicine and the health professions in general are evident. Trauma care,
organ transplants, intensive care units, coronary stents, and minimally invasive sur-
gery have extended life expectancy and improved the quality of many lives. Public
health measures—​for example, high rates of vaccination of children throughout the
world—​have virtually eliminated serious viral diseases of childhood in many coun-
tries, and greater access to midwives and maternal nutrition has decreased perinatal
mortality. Another remarkable example is the development and deployment of a vac-
cine to prevent HPV (human papillomavirus) infections that will dramatically reduce
the incidence of cervical cancer in the very near future. A more recent one is the ex-
traordinarily rapid development of an effective vaccine for SARS-​Cov-​2.
Amidst these burgeoning benefits, we are beset by announcements of a crisis in
medicine that is one of a set of puzzling paradoxes. By any number of criteria, con-
temporary medicine is doing a fine job, yet people everywhere seem disgruntled with
the state of health care. Patients generally appreciate their own physicians, yet many
have low regard for the medical profession as a whole. What patients seek is flexible
and ready access to their physicians and continuity of care. Above all, they want a phy-
sician who will listen to them. A clinician who is present to and for the patient, and
whose engagement and commitment are made clear in attentiveness and listening.
Perversely, the length of the typical medical interaction has shortened substantially,
and the patient community has increasingly turned to the Internet to unearth what
is often substandard and risky advice. Patients’ involvement in their own care can
make an important contribution, but it cannot serve as a substitute for thoughtful
encounters with health care professionals. Even as practicing physicians complain
about third-​party interference in medical decision-​making, young graduates, con-
cerned with the quality of their own lives, choose non-​traditional practices in clin-
ics with fixed hours and interchangeable doctors. The unintended consequences of
such choices are a mode of work and trajectory of care that span seconds and minutes
rather than months and years and undermine the development of a long-​term clinical
relationship. We may have arrived at an era of stroboscopic medicine. Patients experi-
ence brief episodes of disjointed care in walk-​in clinics and urgent care centers. While
offering convenient access, such services cannot offer the relational care that patients
generally seek.
The structural stresses in the health care system are reflected in the non-​ending
search by medicine for new models of care. Thus, we have witnessed the advent, with
x Introduction

great fanfare, of person-​, patient-​, and client-​centered care. We now have targeted
care, personalized medicine, precision medicine, and genetic prognostication. It is
often not clear whether such trumpeted innovations ever move beyond the rhetorical
phase to actual implementation. These seemingly new, yet often poorly defined, pro-
posals reflect an underlying confusion and instability in the conceptual frameworks
of health care.
New technologies have also introduced an array of unintended consequences.
Electronic health records prevent many errors in prescriptions and improve the ac-
cessibility of hospital and clinic files. Paradoxically, however, the desktop computers
that make this possible have become competitors for the physician’s attention that is
directed to the machine and away from the patient in the room. Patients express dis-
comfort when the doctor’s eyes are turned to the screen rather than the person’s face
and the physician’s hands are on a keyboard rather than a stethoscope. The same com-
puters enable the examination of thousands of medical records and millions of data
points so that clinical scientists can spot trends and generate hypotheses that may
lead to better care. Yet, the nascent field of artificial intelligence is often viewed by
the public with some concern and even trepidation. This may in part be the result of
the mystery that surrounds neural networks; even the experts are not always certain
how this software arrives at its conclusions. However, this fear may also be a result of
the sociocultural images evoked by the infelicitous phrase, artificial intelligence, that
leads to the implicit question: Will robots replace doctors?
Another unanticipated result of technologies for noninvasive imaging are the in-
cidental and irrelevant findings by powerful imaging machines that lead to need-
less follow-​ups and sometimes risky interventions. The phenomenon of so-​called
incidentalomas has brought new meaning to the word serendipity, though without
its traditionally happy connotations. These CAT scanners and MRI magnets permit
marvelous feats of diagnosis but do their work by sending beams through patients’
bodies without, paradoxically, illuminating the persons who brought their troubles
to their physicians in the first place. The physician can once again inspect results on
a computer screen without addressing the patient. Finally, the most recent headlines
pointing to leaders in biomedicine who failed to reveal serious conflicts of interest
have also, and quite understandably, undermined the trust of a vulnerable public.
These social, economic, and political forces have resulted in enormous strains on the
doctor–​patient relationship that is the basis of diagnosis, treatment, and care.
Clinical medicine is enacted in the clinic and hospital, and the participants are
the patient and physician. The relationship between these two persons is mediated
through language and the interactions between them enable understanding and
healing. This dyadic interplay is the locus of the practice of medicine and all the var-
ious forces and pressures alluded to previously impinge directly or indirectly on this
focal point that is the clinical relationship.
This book is grounded in the notion that the language used by physicians and
patients in their interactions, and the words, metaphors, and concepts that form
the societal discourse within and about medicine and health care reflect and inflect
 Introduction xi

clinical care. The words we choose and use in any social and personal interaction
shape the messages we convey and are the means of transferring information. Words
reflect the emotional content of our statements and reveal the states of mind of the
interlocutors. Moreover, the words we have and use have the power to shape our
views of the world and the people and objects within it. Words frame and reshape
our thoughts, since language not only names the world in which we live, it also acts
to constitute our reality—​to create it and mold it. Clinical interactions are particu-
larly sensitive to the words and linguistic frames that are employed by the participants
to communicate concerns, illuminate meanings, and achieve their goals. The stakes
are high for both patient and physician and the issues at hand are fraught with sig-
nificance and tension. Patients listen with great intensity to the words of the physi-
cian whose diagnostic judgments and prophetic prognostications may turn daily lives
topsy-​turvy. Furthermore, patients are trying to decipher the implicit meanings and
subtexts beneath the surface of the medical discourse to understand the implications
for their health and well-​being. And, of course, they wish also to grasp the emotional
resonances of the doctors’ words to calibrate the seriousness of the situation and as
metrics of their caregivers’ engagement and concern for their plight.
The first part of the book, Language in Context, begins with a description of clin-
ical practice as seen through the lens of language. The relationship between patient
and caregiver is mediated by language with impact. Words are used by the patient to
narrate the story of the illness and to convey its meaning and import for that person.
In turn, the doctor’s apprehension of the narrative and its transformation into the
story in the medical chart are both linguistic acts. The words chosen by these inter-
locutors in the clinical arena may reveal bias, signal concern, herald misfortune, or
support healing. Words are hardly neutral modes of communication. They convey
and reveal emotion and influence the listener’s state of mind. Putting words to things
may bring them to our attention and make certain ideas apparent to us. Language
influences our thoughts and can enhance or diminish the relevance of both the con-
crete and the metaphysical by shaping the frames of our perception. In Chapter 2, we
explore the idea that language organizes our “house of being” and how that concept is
especially relevant to an analysis of clinical care.
Metaphors occur approximately every twenty-​five words in daily spoken and
written language. They create new understandings by carrying meanings from one
domain to another and thereby shift attention toward certain aspects of a thing or
idea and away from others. Metaphors open new doors while closing others and re-
shape our views of the world we inhabit. To set the scene for the major themes of the
book, we therefore describe metaphors in Chapter 3: their prevalence, impact, and
role in language and discourse.
Part II, The Military Metaphors of Medicine, comprises four chapters that elabo-
rate and dissect a major thread of this work, namely, that the most common metaphor
of the language of medicine invokes wars, fights, and enemies—​to wit, the war on
cancer, the fight to eradicate polio, the campaign against opioid addiction. We fight
disease under doctors’ orders, targeting magic bullets with precision medicine. Drug
xii Introduction

companies develop the therapeutic armamentarium and patients may be survivors.

We begin with the most prevalent of this class of metaphors and trace its origins
through the history of medicine in Chapters 4 and 5. A number of hypotheses have
been proposed on the genesis of such linguistic tropes with examples as far back as
the early seventeenth century. Chapters 6 and 7 deal with the variations of the war
or military metaphor by attending to the protagonists, the enemies, and the allies.
Who is fighting whom and why? Who are the winners and losers? While these may
appear to be innocent stylistic choices, in actuality these verbal wars have unfortunate
consequences. For example, when the surgeon is armed to extirpate a tumor, the pa-
tient becomes the passive field of battle and suffers collateral damage. Or, a diagnostic
search for the reified disease becomes the object of the physician’s attention and the
patient is transformed from an ill person to a vessel bearing the invader. At the same
time, the ubiquity of such metaphors requires an explanation. If they are deleterious
to our understanding of medical care, if not to care itself, why are they so prevalent
and pervasive? What accounts for their resilience despite their linguistic side effects?
These questions are followed by a broader appreciation of the effects of the military
metaphor in reframing the relationship between doctor and patient. Their interac-
tion becomes reshaped and undermined by these tropes whose influence may alter
the attitude of physicians to their craft. Doctors learn to deal with disease and are
blinded to illness; diagnosis becomes a search for an offending agent or invader rather
than an understanding of the patient’s life story and the reasons for seeking med-
ical care; preventive medicine is rendered as border walls blocking foreign viruses;
and public health is reshaped as epidemiological announcements of high states of red
alert against influenza or drug addiction. All such consequences of the language we
use in and about medicine are hardly conducive to the type of clinical care to which
we aspire in which ailing patients encounter attentive physicians who choose to un-
derstand the needs, goals, and implicit meanings of those who seek care, in order to
provide healing.
Part III, Frames and Choices, explores specific aspects of clinical practice. If mil-
itary metaphors are not good for our health, what other tropes can we envisage?
Perhaps there are alternative framings of disease and illness that may better serve
patients and their caregivers. For example, illness as a journey permits the caregiver
to serve as guide or navigator and offers the ill person an option of being the driver or
engaged passenger, depending on that individual’s inclination. It also provides a con-
tinuing narrative of the trip that flows from and perhaps back to the antecedent state
of health. From the Western medical canon, we can recall and recover constructs of
balance and disequilibrium as metaphors for health and illness in which restoration
serves as the goal of care. From older cultural traditions we learn of flows, fluids, and
their disturbances as causal explanations of illness, and from physics we learn the no-
tion of resilience to indicate the patient’s capacity to recover from illness and trauma.
In Chapter 9 we shift our attention from words to their modes of transmission.
Our Western cultural tradition tends to privilege talking over listening. Yet, a series of
interviews with patients revealed that the most valued attribute in seeking a physician
 Introduction xiii

is the caregiver’s capacity to listen. Listening is not simply a means to gain relevant
information from a person seeking care. Careful listening indicates genuine engage-
ment by the physician and transmits an intention to provide care. Colleagues from
psychiatry and pastoral care have taught us that the acts of talking and listening are
themselves means to restoration and healing.
The most remarkable instance of the power of words is that of the placebo.
Regarded as interference by some pharmacologists and acts of deception by young
medical students, placebos are the most impressive and least appreciated example of
the impact of language in therapy. Clinicians embody the placebo effect, yet remain
skeptical of its power. We try to discern the reasons for this paradox, and then review
the generic presence of the placebo effect in clinical care and its putative causal mech-
anisms. Chapter 10 offers a comparison between drug therapies and the effects of
placebos and concludes with the concept that words have the power to help or harm.
We must therefore consider a framework best described as a pharmacology of words.
We briefly consider the trope of time. The common expression that time is money
attests to its value as a metaphysical commodity. Time is both minutes on a watch
and a perception of time invested in caring and care. Time can be understood as an
enacted metaphor with unspoken yet clear meanings. We have witnessed the advent
of stroboscopic medicine in which clinical care is provided in short flashes of minutes
after weeks to book an appointment and hours in a waiting room. This is not unique
to medicine since the societal metronome seems to have accelerated inexorably, has-
tened by the Web and abbreviated communiques over social media. Are these inno-
vations a boon or burden for clinical practice, for patients and their physicians?
Part IV, Healing the Language and the Language of Healing, returns to a consid-
eration of the patient–​physician relationship in Chapter 11 and the various models
that have been developed to describe this focal point of clinical care. In Chapter 12 we
see how the lens of language offers a view of clinical medicine that is steeped in words
and discourse and reiterates the importance of linguistic tropes to the understanding
and care of persons who are ill. The book closes with the following question: If the
prevalent military metaphors undermine and obstruct much-​needed solutions to the
current state of health care, thoroughly imbued with inappropriate language and its
consequences, then how do we heal the metaphors that constitute an ailing system?
Our challenge is to reframe the clinical relationship to foreground awareness, lis-
tening, reflection, and a renewed attentiveness to the power of words and their impact
for good and ill in order to fulfill the mission of care.
 I

LANGUAGE IN CONTEXT