On medicine’s ‘dirty words’

A friend sent me an article on ‘dirty words’ in medicine. It’s yet another postulate to replace a set of words with another set of words, another exercise in futility. I thought I’d respond, though, increasingly, it does feel like banging my head against a wall.

Here are the seven dirty words (the number 7 is so symbolic that I do wonder whether it’s just a coincidence):

  • allied
  • clinical
  • doctor
  • interdisciplinary
  • medical
  • my
  • patient

The replacement of three of these words has similar rationale.  The word ‘clinical’ is dirty because it “needlessly narrows the scope of practice”, ‘medical’ should be replaced for the same reason, as does ‘interdisciplinary’.  Easy? Like a Sunday morning.

Let’s just imagine that from tomorrow the students will go on the ‘experiential placement’. Does anyone really think reality will somehow change? And the activities the student will take part in will be different? The assumption that changing words will re-haul the reality outside language is beyond simplistic.

Incidentally, has no one noticed that calling Brexit ‘a great opportunity’ hasn’t really changed the minds of people who oppose Brexit? I also that an edict demanding that President Trump be called ‘the great president’ will result in people opposing him suddenly thinking he is a great president.

But what really irritates me is something different.  The author’s argument seems to suggest that only he and the astute people like him are able to see through the dreadful veil of the words like  ‘clinical’ or ‘interdisciplinary’ and see what reality is really all about. And, in an act of kindness, they help the rest of us who do not have the privilege of such sight. So, they take us by the hand and lead into clarity we would never ever achieved without changing the words.

And then there are the replacements. The arguments to replace ‘dirty words’ with ‘clean words’ (these labels are extraordinary, quite frankly) never consider the new word-wonders.  Changing ‘clinical’ to ‘experiential’ is far from innocent as it shifts the focus of what happens from the context/activity to individual/experience. And if the author is really telling me that I would want doctors simply to soak up the atmosphere rather than have clinical experience, he should think again!

The final point I want to make here is that medicine seems unable to understand that the word ‘clinical’ or, indeed, ‘patient’ today means something else than it meant, say, 50 years ago. And there is nothing strange or peculiar about it. Just like medicine changes, so does its vocabulary. I’m no historian of medicine, but I would bet my bottom dollar the word ‘medicine’ means something quite different than a few centuries ago and somehow we live with it. And please, it doesn’t mean that you need to start a campaign to change the word into ‘personology’, because medicine is now ‘person-centred’.

Now, having commented on the three ‘narrow’ words, I want to comment on two others: ‘patient’ and ‘my’. I’d like to start by saying that the author can take his objections to ‘patient’ and shove them…. To say that the word ‘patient’ is dirty (whatever it might mean) is just stupid and I do apologise for the strength of this statement. As the author pronounces his patient-centeredness, it does not involve asking the patient what they would like to be called. If that’s patient-centred care, I am Prince Charming of Neverneverland!

Moreover, please spare me the etymological quirks which are always used in the case of ‘patient’. They are never, for example, used in reference to ‘doctor’, a word which, etymologically, should never be used in the case of medical doctors. It is, just like ‘patient’, because nobody cares about the etymological roots of such words.  The implications the author refers to are dead and very few people are interested in them.

But let us assume that that these connotations are live. People commonly associate the word ‘patient’ with ‘passivity and forbearance’ and suffering. Well, what’s wrong with it? I keep thinking that medics want to me to become ‘participant’ in order to suggest that I am not an object of their gaze. And I am! I keep hearing that when done properly, shared-decision making is a wonderful way in which to do medicine, and I keep saying that I am yet to see it. The ‘dirty’ connotations of ‘patient’ are just about right! So, are you really interested me or are you interested in showing yourself in a good light?

Let me end this part by saying that words cannot render how much I don’t want to become a participant. The word is just wrong.

And now we come to my favourite ‘dirty word’, the pronoun ‘my’. The replacement of ‘my’ into ‘our’ is worst idea the author has. No, the pronoun ‘my’ is a beautiful word, it is ‘our’, the most manipulative of words which is a problem. The author writes:

However, using the first-person plural pronouns “we” and “our” conveys the message that while a single leader may coordinate care, the patient does not belong to any one provider. (…) The use of “we” and “our” must be accompanied with a sincere intent for shared responsibility.

I can already see the new training programmes in how to achieve ‘sincere intent’, followed by training in ‘genuinely sincere intent’.  I must also admit that the ‘single leader’, instead of doctor,  just threw me on my knees. Don’t limit yourself – let’s go for ‘single god’.

The problem with this statement is that it is extremely one-sided and ignores that words suggesting shared responsibility can easily be taken to dilute responsibility. ‘We’ often means no one, as no one claims responsibility for what happens to me. Who exactly is responsible for referring me to a hospital, when a medic says ‘we referred you’ (here is my earlier post on ‘medical me’)?

Yes, ‘we’ does suggest that behind the medic there is someone else. But consider the following questions. Who exactly is talking to me when you say ‘we’? What group of people exactly are you referring to when you use ‘we’? Are you perhaps speaking for medicine in general? Or are you referring only to the team you are part of? No, there is nothing ‘clean’ about first-person plural, in fact, it only introduces ambivalence.

If you think that referring to a group is necessary, then say who exactly it is that you refer to. For example, why not say something like

Drs A and B and I think/refer/suggest….

I’d go even further. ‘We’ goes right again the notions of ‘patient-centeredness’ or shared-decision making. This is precisely because by using it you obfuscate, you withhold the entirety of information. You hide behind ambivalence, while at the same time you construct yourself as part of a larger group. In such a way your own judgement and your own decision becomes something else. That’s why I ask doctors who is ‘we’ when they use the pronoun. Interestingly, answers are not forthcoming.

Time to conclude. My first point is that if you really want to change the words – do. I really couldn’t care less. Such changes are inconsequential. They will probably make you feel better, doctor, and if you design the study right, you will get a better score on the patient satisfaction questionnaire. Does it matter? Not a bit.

Every time I read another article about ‘language’ in medicine and I see how changing a word is a priority, I just despair. I really wish medics worried about medicine.

I also have two suggestions. The expression ‘dirty words’ in reference to words people use in reference to themselves is inappropriate. Yes, I understand the George Carlin reference (I do like George Carlin), but perhaps you could stop and think. You know, like, the change of context between stand-up comedy and medicine is perhaps too large? But perhaps therein lies the moral. Instead of wondering about a word or two, you could start wondering about context.

And so, my other suggestion is that if medicine does need insight into language, it should start with understanding the context of communication.


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