I am delighted to report that my short piece on language in medicine has just been published in Sexually Transmitted Infections. In contrast to much discussion among medics, my piece is a linguist’s reflection on medics’ and patients’ language.  In today’s post, I want to explore one of the issues I raised in the text: certainty.

Certainty for me is a linguistic issue and so, I need to tell you a little about modality. Modality is to do with the expression of the speaker’s attitude towards the proposition they render in their utterance; to what extent the speaker commits or distances her- or himself from what they say. The concepts that modality deals with are truth, and related to it necessity and possibility as well as obligation and permission. Here I’m dealing with epistemic modality, the capacity of clauses to express the speaker’s certainty as to what happened, or, her/his certainty that what they say is true. At the most certain, the language is a simple statement in third person, plural or singular, without any qualifications. Statements such as “God exists.” convey the speaker’s certainty at its highest. Modalisation, in contrast, introduces an aspect of degree and thus making propositions weaker or stronger. And so sentences like “There might be alien civilisations”, “Aliens have probably visited the Earth.” through ‘might’ and ‘probably’ render the writer’s uncertainty.

And so, language can convey how certain I am about what I am telling you. What interests me is how certain doctors construct themselves to be. Let’s take the following sentence:

This is the treatment for your condition.

It followed a question I asked, which I can’t remember now, as the answer took me aback. It was spoken with authority, after it was finished, the doctor looked away, focusing on the computer in front of her. The sentence signed her off; it finished our interaction. The utterance not only conveyed the doctor’s certainty, it also rendered her as the powerful one. Her utterance simply put me back in my place and told me not to even attempt leaving it. That’s exactly certainty for you.

But when I started thinking about it, I had two reflections. First, I couldn’t remember a doctor speaking to me hesitantly. It’s always full-on certainty. I promise you this, you have this, this is the medication and so on, and so forth. I simply cannot remember “I think” or “might” (but I might be biased!). Rather, I remember  sentences like:

• The evidence is…
• If you don’t speak their language they won’t hear you.
• Patient empowerment puts the patient in the heart of services.

All written at top certainty, all, if anything, reinforce the power dynamics between doctors and patients. All probably doing the opposite of what they purport to.

Of course, I understand that certainty makes you a ‘real’ doctor, one who knows, knows well and communicates it with certainty. Hesitation undermines you, you look helpless as you don’t know and cannot speak in a god-like fashion. I understand all that. But consider the other side. I accept that I will not persuade you by saying that I, for one, find your certainty irritating. But how about being human? Apart from doctors, no one is always certain. So, how about stepping down from the firmament and join us, mere mortals? I know, it’s hard.

Now, the second thing I thought was about a paper I was writing about medics and psychologists’ clinical notes. The contrast between medics talking about uncertainty and the notes which were consistently written at the highest level of certainty could not be starker. In hundreds of notes, I haven’t found a single one which indicated hesitation or uncertainty. Oh no, when they wrote, clinicians wrote flooring the accelerator. Always knowing, never wondering, let alone hesitating. They were writing the truth!

Moreover, judging by my own experience, patients do not simply make all-or-nothing statements, always sure about what they say. In fact, I am always astounded by the number of times I say “I don’t know.” to my doctor. Why? Well, because I bloody don’t know.

Before I continue, I would like to offer an anecdote. A colleague of mine, a social scientist, wrote a paper for a medical journal. He wrote the paper in the way ‘we’ write it, making all sorts of reservations, trying to strike a balance between what can be said with some certainty and what must be said with much uncertainty. He sent the article off only to see it returned with a comment that all this uncertain language must go. He must write about what things are really like, not about what they might probably, who knows, appear. Medicine is about certainty, not hesitation!

The second example I want to give is a sentence I’ve seen so many times, and every time I cringe:

People die by suicide.

And every time I see it, I want to say: No, they don’t! Because the sentence is much more interesting than it appears. At face value, it simply describes reality – this is what happens, I, the author, am completely certain about it. Much like ‘Water boils at 100 degrees centigrade’. Simple. The problem is that while pretending to simply describe reality, the sentence actually introduces a particular way of speaking about suicide. For the sentence is mostly used in a debate about how to refer to taking one’s life I described previously; it opposes the use of ‘commit suicide’. But the way it does it is quite unhelpful, as it uses the phrase ‘die by suicide’ with a sleight of hand. It does not refer to the phrase, but refers to reality and suggests that this is what happens.

When I was thinking of an example to give, I remembered a recent article story about an ‘illegal immigrant’.  The headline of the article was

Illegal immigrant aged 13 arrested walking along M5

Really? A 13-year old illegal immigrant? How about a child, for pity’s sake? Indeed, Twitter was full of indignation directed at the representation of that child, which, incidentally, appeared in other newspapers as well.

And here is the problem. Much like the Daily Express decides to call a child ‘an illegal immigrant’, proponents of ‘dying by suicide’ offer their label as if it were the way to describe the tragedy. Yet, judging by the responses under the post in which I raised the issue, as well as a short Twitter discussion, things are way more complicated to allow a number of people simply to assert that ‘people die suicide’. And I would prefer an honest and open debate than an ex-cathedra assertion what reality is ‘really’ like.

Is this post  an apology for lack of certainty and hesitation? No, not really. I fully understand that there is a balance to be struck between appearing completely certain and uncertain, though it’s worth remembering that there is a whole spectrum between the two poles. This post is an appeal for some reflection about where you, a medic sitting in front of me, would you like to be on the certainty-uncertainty spectrum. But also which part of reality do you want to describe with full-on certainty and, crucially, what does it mean when you do? And, yes, in an ideal world, I would like this reflection to lead to a conscious decision on your part where you want to be, how certain you would like to appear to me. Because, you see, I do notice, probably like quite a lot of my fellow patients.

That said, as ever, I haven’t got any simple answers (it all soooo depends), let alone advice. Both as a linguist and as a patient, I could not offer a quick guide to doctor’s certainty. But you could at least wonder how to speak to me, let alone how to write about me. Stop to think, please. Certainty matters.