Wednesday, September 8, 2010


My September 4 posting, “Tribes,” gathered mixed reviews. While the Seattle Post-Intelligencer called it “…absolutely brilliant…” the New York Times described it as “…the debris of a demented mind…” As my mother told me, you can’t please everyone.

What I was trying to lead into was the notion that patients and doctors occupy the same real estate but separate perceptual dimensions. Seeing slightly different versions of reality, they behave accordingly. Whether we’re a patient or a doctor, recognizing the quality and depth of difference is crucial to effective communication.

I regularly attend our local hospital’s “tumor board.” This weekly meeting, mandated for hospital accreditation, is a valuable forum in which oncologists receive input from nurses, technicians, social workers and other physicians in order to fine-tune patient care. When my wife asked me what exactly goes on in these meetings, I was tempted to invite to her to one, but then I realized that for all she’d understand medicalese, she might as well attend the Bulgarian parliament.  

“Patient is a fifty-year-old male with a high-grade, stage IV liposarcoma with mediastinal mets. CT scans showed one enlarged paratracheal node. Biopsy revealed extensive pleomorphism.”

That’s easily comprehensible to the medically trained, but others would need several pages of translation. And that’s fair, since shorthand, or jargon, is necessary in most professions. A carpenter might say, “Run a series of two-by-sixes down this mudsill on sixteen-inch centers.” 

Jargon is especially suitable to physical reality, the primary field of medical training. You don’t just have cancer, you have a stage IV liposarcoma with mediastinal mets. Just as the Inuit are said to have two dozen words for various types of snow, physicians use a language that finely parses medical complexities.

We docs get little training, though, in the non-physical aspects of illness, such as subjective sensation, emotions and meaning, so our language in that department isn’t as rich. I’ve often heard docs call patients “emotional” without elaborating further, so I’m left wondering whether they’re sad, depressed, anxious, angry, hysterical, or desperate. A basic difference between the doctor tribe and the patient tribe, then, is that the physician vocabulary is rich for the physical world but poor for inner nuance, and the opposite is usually true for patients. 

When the patient complains, “I’m in pain,” expect to the doc to prescribe a mild painkiller, the drug with the least expense and side effects—and probably least potency. That’s not a bad decision, after all, but it’s based on a dearth of incoming information, since there’s pain and there’s pain. Unless the doc has experienced her own variety of pain levels and knows to ask, the pain of others looks generic to her. (A suggestion has arisen more than once in our cancer support groups: “No one should be allowed to treat a disease they haven’t had themselves.”) 

Patients can overcome this disconnection by expanding their own language, expressing their pain in more detail, offering the doc a deeper peek into their suffering. “It doesn’t just hurt, Doc. It takes me over. It feels like I’m being electrocuted. If it lasts even for a few hours, I can feel my personality change.” Whoa. How about a little codeine, then?

Language doesn’t just describe reality; it also prescribes it, instructs us in what to see. An oncologist I know is asked several times a day, “Will I die from this cancer?” He could truthfully answer, “Well, yes, probably.” But knowing how patients will likely react to that, he says instead, just as truthfully, “I don’t know. But I do think you’ll live with it the rest of your life.” 

Here's another example of prescriptive language. When medicines seem not to work, docs can feel useless and frustrated. Some head that off by explaining, “The patient failed the treatment.” Of course, it would be more accurate to say the reverse, but here docs are using language to treat themselves.

There’s far more to write about patients’ and physicians’ different worlds, but that’s all I can do today. I have tomatoes to pick.

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