When I was a boy I had to wear glasses, sometimes thick ones. I remember being an odd one out, there were very few other children with glasses at the time. But I was different from them too. I often had to wear a patch on one of the lenses. When it happened, I just wanted to disappear.
It was all because my strabismus and I write about it on my blog for the second time, because it’s an important story for me (below a link to the first story). Though I have not worn glasses for about 30 years or so, I still remember the names I was called and the fights I got into because of my glasses. I hated my glasses with a vengeance and when I finally took them off in my early twenties, I couldn’t be happier, despite the fact that I think I looked well in them. My glasses were too deeply associated with too many negative things.
Now, fast forward about 20 years and I’m sitting in a British doctor or optometrist’s office having my eyes checked. I was asked about ‘the history’ and told about my strabismus. The optometrist (or doctor) responded with something like:
OK, so you had a squint.
I didn’t react the first time, but after a second time, I politely but firmly said I hadn’t – it was strabismus, to which she said, it was one and the same thing. And I somewhat more firmly said it wasn’t and that I would rather she used medical language. She looked at me with a sort of ‘What’s your problem, man?’ look. I so didn’t care.
You see, there is nothing ‘squinty’ about my strabismus. It’s not a squint, it’s not ‘strab’. No, it’s strabismus. For me (and I only speak for myself) when you use colloquial language to refer to my eyes, you make light of all the sh…I had to take when I was a boy. You make light not only of my trauma and pain, but you also make light of my mother’s years of persuading me not to throw my glasses away. That’s why it’s strabismus. The medical term depersonalises it, detaches me from the experience of the white patch on my glasses and all the mocking it attracted.
This long-winded story sets the scene for this blog post. I want to write about medical language in doctor-patient interactions. This is, of course, a well-known issue to discourse analysts dealing with language in medicine (starting with the work of Elliot Mishler), but I want to take a different point of view, one inspired by a recent BMJ debate on language (#BMJdebate).
The way I see it, there are two main points made in such debates. First, clinicians should not use medical ‘jargon’ because patients don’t understand it, so clinicians (and other professionals) should dumb down the way they communicate. Second, clinicians shouldn’t use medical language, because somehow non-medical language allows them to communicate with the patient better. This is because
If you don’t speak their language, they will not hear you.
as I once read (here is the link to my comment on the sentence and the first time I used the ‘strabismus story’).
To be honest, I’m always amused by such instructions, especially the notion that in order to communicate with me the clinician must somehow go down to ‘my level’. I can’t count the times I talked or asked about current research and medics were only looking at me in bewilderment, as if I had crossed some major line. The good ones, there were a few, had the courage to say: “I don’t/didn’t know” and I do respect this, others just looked reproachfully. It’s them who should dumb down, innit? Still, I find both rules only patronising and I’d better leave it at that – this is a polite academic blog. And the arguments of ‘acronyms’ are not worth responding to.
So, let’s go back to linguistics. Both instructions rendered as all-or-nothing rules make no sense and, if anything, they show how much language is misunderstood. Let me explain (for the zillionth time): linguistic communication is contextual, it happens here and now and given that those communicating juggle identities, values, goals, backgrounds, habituses and umpteen other things, you simply cannot prescribe one all-purpose mode of communication with them. It’s impossible. In other words, what will work for me, a middle-aged professor with a strange name and history of strabismus, is unlikely to work for Andy, a 70-year-old grandfather and Liverpool fan or Amy, a 12-year-old schoolgirl who dreams to be an astronaut, and for….
I mean, you really don’t need to be a linguist to understand that you communicate differently with your pensioner parent and with your teenage child. And to be completely honest, it always puzzles me no end that medicine (well, at least some of it) is yet to discover it. A simple fact that just about any competent user of language understands (though might not reflect on it).
Now, these 0-1 rules have interesting consequences. They are supposed to be aimed at ‘me’, but what they achieve, in fact, is that the patient in ‘patient-centred’ is a homogenised, faceless nobody; a social role not a person. Because I don’t really care for ‘patient-centred’, I care for ‘Dariusz-centred’ and that’s very different, indeed. Paradoxically, just as the patient was blanked before being ‘in the centre’, they are now blanked by being put into a class of people who apparently all need one and the same thing. This is because as long as you see yourself as a clinician, you see me as a patient, and this frame sets up the way we communicate. And no matter how much you want to find it, there is no such thing as ‘patient’s language’, there isn’t and there cannot be.
However patient-centred you might be, you still see me in institutional terms, looking for a communication procedure. And there are no communication procedures! It is only by shedding the institutional frame can you actually talk to me like real people do. Just like you can, presumably, talk to your partner, neighbour, child, as well as John and Mary from round the corner. ‘Patient-centred’ is precisely so difficult because it should focus on me and not on me-as-patient. And while I prefer ‘medical jargon’ more often than not. John, whom you will see after me, might not. And it is only through knowing me and building a relationship with me that you will know it.
Jonathon Tomlinson writes:
The depth of relationship between a GP and his/ her patients is linked to greater efficiency as the description above shows and was confirmed by a study published last year. The study showed that more problems and more emotional issues were raised and discussed when relationships were deeper.
What can be added to this, I hope, is that the relationship you have with your patient also lets you speak to them in a way which is useful to them. And so, rather than wondering about the ‘patient’s language’ and having communication debates, it would be much better to have relationship debates, exploring how to build a relationship with your patients. Yes, of course, relationships are also built through language, but, more importantly, they are built over time and the language-relationship dialectic develops over time. And no no procedures.
But there is another aspect to all this. I cannot remember how many times I tweeted that it is people who use words and focusing only on words makes little sense. So, why do I get hung up on ‘squint’. Well, it’s because it’s always part of a particular interaction. Strictly medical language in my ‘eyes-talk’ sets up a particular kind of relationship between me and the health professional. ‘Squint’ introduces a different relationship, one which was always imposed on me, always with a sort of ‘matey’ attitude, or perhaps patronising a touch, as if I could not possibly understand ‘strabismus’. ‘Squint’ suggests an attempt to speak ‘my language’ and I resent it. It also introduces a sort of informal tone in talking about something which, still after so many years, is painful. It’s not the word itself, it’s what the person using it tries to achieve with it.
If someone asked me whether I had a preference, I would probably say that I prefer medical language, but it’s not a huge issue. Why? Because someone bothered to ask and that would be my way of acknowledging the gesture. The question would also set up a different relationship between us, one of negotiation and respect, and the word ‘squint’ would cease to be so important. It would be used in a different context.
Language is contextual, it’s used by people. Some of them are nice, some of them are not. That also applies to doctors. Some of them negotiate our relationship, some of them simply see the patient (obviously, one to be centred on). It’s really not about the language, it’s about who uses it and what for.