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The medium and the message
Patient Education and Counseling 41 (2000) 117–125 www.elsevier.com / locate / pateducou
The medium and the message Marshall Marinker* Guy’ s, King’ s and St Thomas’ Medical and Dental School, King’ s College London, 5 Lambeth Walk, London SE11 6 SP, UK Received 10 January 2000; received in revised form 24 April 2000; accepted 8 May 2000
Abstract Communication between doctor and patient is examined in relation to ways of describing the institution of medicine, the rules of engagement between doctor and patient, and the language they employ. Medicine and its institutions are presented in metaphorical terms; a theatrical taxonomy of consultations between patient and doctor is suggested; and patient–doctor communication is considered in the light of the pervasiveness of mistranslation. Because it is possible to invent a wide range of alternative metaphors for medical institutions, to envisage many different sorts of dramatic possibilities in the patient–doctor encounter, and to develop a respect for the particularity of all language, optimism is expressed about the future of research, teaching and practice in doctor–patient communication. 2000 Elsevier Science Ireland Ltd. All rights reserved. Keywords: Patient–doctor communication; Medical teaching; Communication; Medicine
1. Introduction It is a pleasure to be here in Chicago. Eight years ago, I was invited to give a similar opening keynote at a Toronto conference on Communication in Medicine. When you invited me to be here today, I searched my computer archive for that original script. Of course I was going to cheat a bit, save on the effort of thinking, re-work some of the old material, pass it off today as something quite new. But re-reading this 8-year old script, I now experience a curious sense of dislocation from many of *Tel.: 1 44-20-7607-3139. E-mail address: [email protected] (M. Marinker).
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the assumptions I made then about the nature of the patient–doctor encounter. My Toronto paper was full of enduring truths and confident assertions. My Chicago paper is decked out only in the rags of shifting values and diffident questions. Last week my wife and I went to a revival, at London’s Donmar Warehouse, of Tom Stoppard’s play The Real Thing. It’s a play about young people falling in and out of love, about broken promises and broken hearts. We had first seen The Real Thing some 25 years ago. As we left the theatre my wife looked puzzled. ‘‘That’s not the original story. It was quite a different play’’, she said. ‘‘Stoppard must have changed everything’’. I thought for a moment
2000 Elsevier Science Ireland Ltd. All rights reserved.
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and said, ‘‘No. Stoppard has changed nothing. It’s we who have changed’’. So my thesis is this. The role of the doctor is now transforming — transforming because the role of the patient is being transformed. And these transformations, because they are accelerating, will over the coming decade, increasingly disturb both doctors and patients as communicants. As my title, borrowed from Marshall McLuhan’s famous dictum [1], suggests, I will be looking at the ways in which the medium of the medical consultation becomes itself the message of medical competence and concern. If the message has to change, so must the medium. Medicine has always been concerned with the twin agendas of bio-mechanics and a biography. And the turbulences that these sometimes conflicting agendas generate are made manifest as problems with communication, problems that have most often been presented as deficiencies in the skills of the actors. I want to suggest that these problems lie elsewhere — not in the mouths of the actors, but in the unresolved conflicts inherent in the script of medicine.
2. Metaphor Gareth Morgan in a book called Images of Organisations [2] suggests that we can understand organisations best, if we think in metaphors. He argues that metaphors provide illuminations; that they permit us to see one aspect of the human experience much more clearly in the sharp light of another; that they spring the surprises that constitute the inventions of science, and the revelations of art. This use of metaphor fashions a sharp tool for the analytical dissection of art, linguistics, theoretical physics, psychoanalysis, social theory, and much else. Today I am going to attempt to adapt this tool to an analysis not only of the institutions, but also of the contexts and the dialogues, of medical practice. That is to say, of both the medium and the message of medicine. Morgan develops a taxonomy of organisational metaphors. His typology, heavily influenced by neoFreudian theory, presents us with images of the organisations within which we work, that seem part of common experience, but are in fact familiar in a
rather strange way. How does metaphor illuminate the modern Western medical school? His first metaphor is the very familiar one of the organisation as ‘machine’, with its emphasis on central control, explicit rules, rigid discipline, uniformity, specialisation of function and predictability. This is the medical school of obsessively detailed aims and objectives, tight timetables and iterative assessments and evaluations, evidence-based-medicine and multiple choice questionnaires. This mechanical metaphor, Morgan argues, is still the dominant mode in the industrial economies, the metaphor that most powerfully defines most of our institutions. Michel Foucault in his Naissance de la Clinique [3] describes the birth of modern medicine in the 18th century. The term la Clinique is really untranslatable from the original French. It has a very telling double meaning in that precise language. La clinique refers to the central location for medical practice and discovery, what we now call the teaching hospital. But at the same time it describes a specific methodological approach to the diagnosis and study of diseases. In the case of la Clinique it marks the 18th century shift of the doctor’s gaze from the patient as sufferer, to the patient as concealer of the hidden and interior surfaces of the disease. Foucault employs this mechanical metaphor, in presenting us with ‘medicine’ as a Cartesian philosophy, and the ‘patient’ as Descartes’ ‘l’homme machine’. Another Morgan metaphor is the institution as ‘organism’. Here, there is a prime concern to preserve the internal environment, while at the same time discovering ecological niches by continuously adapting to the changing external environment. This is the medical school designed for contemporary competition, where research is valued in terms of the size of the grants necessary to nourish the academic body. It is the medical school where loyalty to its peculiar traditions is made manifest by the progress of its favoured alumni to high office in its own teaching hospitals. It is the medical school of the sports clubs, the fraternities, the graduation ceremony and the re-union dinner. Perhaps Morgan’s most intriguing metaphor is what he terms the organisation as ‘psychic prison’. Here the members of the organisation and their endeavours are constantly trapped by half-suppressed memories of the organisation’s real or believed
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history. Drawing on Jungian imagery, he suggests that organisational life can be understood in terms of the relationship between fools, magicians, warriors, high priests, lovers and other symbolic characters. This is the medical school of the pathology museum and the portrait galleries and the eponymous wards and lecture theatres and prizes. It is the medical school of story and fable, whose alumni have engraved their household names on some very important diseases; the school where ghosts darkly preside over tradition, where upstart bohemian fashions like communication skills or social sciences are introduced into the curriculum only over the very long-dead bodies of past heroes and their contemporary historians.
3. Images of the consultation I want to suggest that just as Morgan’s use of metaphor gives us new insights into our institutions, so metaphor illuminates our images of the medical transaction. For example, we make much of probability in our teaching of clinical medicine. Here is another metaphor. The clinic as casino reveals the consultation as a game of chance. This metaphor is at once close to the spirit of science and to the spirit of commerce. The uncertainty principle may have been invented to explain the phenomena of subatomic physics but may also explain aspects of the work of doctors. The electron can no longer be known to exist in a particular place, but rather to have a tendency to exist. My own diagnoses were always a bit like that. The whole of clinical medicine is a game for gamblers. Clinical training consists in studying form, where to place the best bets, and how to cover them. Communication at the gaming table or at the bookie’s booth is pretty guarded, not to say pokerfaced. In communicating with the patient, the cards of diagnosis and prognosis are to be kept very close to the chest. Central to clinical teaching has been the assertion that diagnosis and treatment follow the problemsolving methods of modern science. Here the metaphor is medical practice as laboratory, in which the consultation is an experiment. The traditional
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values of double-blindness and emotional neutrality in the search for evidence, predict the tone and scope of the sort of communication you can expect in this human laboratory. Other metaphors throw light on what has been happening to medical practice in my own country. Margaret Thatcher’s robust libertarian politics may seem a fading memory, but her values still infuse our thinking more than we know. The most prevalent metaphor in the UK today is hers — the National Health Service as market, the hospital as shop, the patient as consumer. No metaphor better reflects the spirit of our age. The language of medical audit sits comfortably here. There is a preoccupation with standards and accounting. Each parcel of communication may be expected to contain an agreed quantum of carefully elicited patient health belief. Nothing characterises the consultation as commodity so clearly as the checklist interrogation of the video performance. With diligence, each component can be identified and marked as present and correct. But to what purpose? And with what meaning?
4. The play’s the thing One of our most powerful, if unconscious, images of the consultation is clearly revealed in the teaching methods we employ. We make much of role play, of actors as patients, of students as actors. I am talking about the metaphor of the consultation as theatre. I’m going to describe four categories of consultation, each with its distinctive and peculiar content, style, and language. The first is the consultation as detective story. Classically the detective story consultation begins with the question, ‘‘What seems to be the trouble?’’. Note ‘‘What seems to be’’ and not ‘‘What is the trouble?’’. Indeed the doctor will often show intense irritation if the patient, spoiling the game, should say ‘‘I think it’s my heart doctor’’. Such hubris on the part of the patient is intolerable. It is, after all, the research scientist who is writing the script. The doctor wants to hear about breathlessness, swelling of the ankles and the like, so that his intellectual skills can be properly exercised, preferably with a
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diagnosis substantially hidden from vulgar view. In one of Agatha Christie’s ‘whodunits’, it was the policeman who did the murder: but he was camouflaged by his uniform as the disease may be camouflaged by the patient. This sort of consultation, essentially rational and instrumental, assumes certain values. To succeed here, the communication has to be clear and unambiguous. The doctor takes a history, which uncannily resembles a rehearsal of the physical examination to come. Learning to communicate in this way involves a careful training (rarely made conscious) in what to ignore, what not to hear, and above all what not to share. The quality of communication may then be judged by what is remembered, by the validity and the reliability of the messages, and by the compliance achieved. The second consultation in my typology is the romance. It may be a comedy of manners, or a history, or a tragedy. Here there is no emphasis on finding the culprit. Rather there is an exploration of the patient’s situation, a concern with identity, and a search for ways of coping with life. Typically the doctor starts such a consultation not with the question ‘‘What seems to be the trouble?’’, but rather ‘‘How can I help you?’’. Because the intentions of this consultation are concerned with the person’s biography and not only with the medical history, the language is different. The questions are often ambiguous, hardly questions at all. The answers are open to a number of interpretations, and all of them may hold some truth. In Harold Pinter’s play Old Times a married couple in middle life is visited by a woman who was the wife’s best friend 20 years ago. At the end of the play it is not always clear whether we are in past or present time; it is not clear whether the husband and his wife’s best friend had been lovers, or indeed had ever known one another; we are not even sure whether the two women are not simply different portrayals, different perceptions, of the same woman. Many of our consultations are like that. If you go to see Old Times, it can be very confusing indeed if you are expecting to see an Agatha Christie detective story. Old Times is not a play concerned with what or how things are being done, with the factual history demanded by bioscience. Like so many clinical encounters Old Times
is concerned with all the counterfactual histories of our imaginations. The third type of consultation is a ritual. Cinderella is an example. Here the power of the theatrical experience depends on encountering what seems to be already known: the content of the story and its denouement. Of course the quality of the performance is important. But actors and audience are celebrating in a relatively safe form, dark forgotten conflicts and hoped for resolutions. Here there is no attempt to find out what is wrong, still less is there an attempt on the part of any of the characters concerned, doctors or patients, to embark on a journey of discovery or self disclosure. The intentions of this sort of consultation are containment, remembrance and denial. Some sort of ritual is being enacted, a prescription repeated again and again; an old complaint rehearsed but unexamined. The acts performed by doctor and patient seem far removed from the rational discourse of modern medicine. Twenty-five years ago, I took part in a study of consultations in general practice, in which little seemed to happen — save the repeated prescription for the same unvaried medication. The research, under the leadership of Michael Balint, was published in a monograph called Treatment or Diagnosis? [4]. What we uncovered surprised us. Most often these consultations were acted out according to a very tight scenario, with a script which varied little between one performance and the next. These consultations also seemed to be innocent of any sensible component, concerned with our traditional ideas about diagnosis and treatment. They were also devoid of emotional content, of the kind which would allow some insights into motivation and the possibility of change. On the contrary, the intention seems to be to limit intimacy. The doctor here was taking part in a pantomime. Pantomimes are serious drama. In the consultation as ritual, there appears to be a contract that the communication should remain predictable, replicable and, above, all opaque. In Cinderella, the fairy tale which enchants children in the pantomime obscures the origins of the story, the terrible rivalry between Cinderella and her sisters, the separation of the mother into the good who is dead, and the wicked stepmother who punishes and denies. Still darker is the now forgotten archetype of the fairy tale prin-
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cess: the dirt-encrusted Aschputel, who can only be saved and transformed by an act which is perhaps most delicately described as ‘fitting the foot into the slipper’. How will you judge communication here? You will look in vain for new information, for problem solving, for empathy, insight, interpretation or even just good old fashioned clarity of instructions. Cinderella is a performance for anthropologists and teachers of communication in medicine, and small children. And so to my fourth category of consultation as drama: mysterious, disturbing, experienced often, acknowledged rarely. In Dario Fo’s Trumpets and Raspberries the protagonist is a Communist trades union official who becomes the managing director of the Fiat Motor Company. At least I believe that is one way of describing what happens. It’s a bit difficult to be sure. There seems to be no narrative. The centre does not hold. There is an anarchy of ideas and feelings. Everything is in fragments. To put them together, to make them cohere in some way, we create a Theatre of the Absurd. Sometimes rational biography, a sense of cause and effect, come to be seen as goals which are not only too ambitious for the consultation as theatre, but also positively dangerous for the patient. The doctor may approach the patient’s world most safely by abandoning the drive to co-author a biography, and content herself with something much more fragmentary. How, then, are we to value the quality of communication in medicine, given this diversity of metaphor, language and drama, all of which express in different and conflicting ways, the vaunting tasks of medicine? In describing the consultation as commodity, experiment, lesson, game of chance, and drama, I wanted to hint at the variability of our clinical encounters. For those concerned to teach and do research about communication in medicine, and for those students and practitioners who become convinced that communication is not just a grace note in a good consultation, but is actually the very stuff of medicine, it becomes important, at any moment in the clinical encounter, to know approximately in which metaphor, or in which piece of theatre, we are acting. The clues, I suggest, are to be found in the language that we use.
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5. Language The American philosopher Richard Rorty [5] is typical of so-called post-modernists in asserting that all languages are contingent (on time, place, particular circumstances). In Rorty’s (and, for that matter, in my) post-modernist view, health and healthcare are created by the language, or rather the conflicting languages, that we are conditioned to use. In the face of diversity of languages Rorty urges irony. By irony he means both a willingness to question the validity and the assumptions built into ones own language, a consciousness of the relative poverty of any one individual language, and so a respect for, and an openness to, the languages of others. When I was a schoolboy in the 1940s the prevailing wisdom was that the study of Latin was a pre-requisite to the study of medicine. It seemed strange to me then that a dead language, however, elegant its form and noble its literature, should be thought relevant to the practice of modern bio-science. As it turned out, the London medical schools had by 1950 caught up with Flexner, and it was chemistry not Latin that was in fact the one essential requirement for admission to the medical course. So I did not, after all, have to learn modern medicine in a dead language. Or so I thought. The irony of my discovery about Latin was that by the early 1950s the language of medicine itself was so enfeebled by disuse that it was already close to linguistic death. Instead my teachers were increasingly employing the vibrant languages of the biological sciences, and even at times lisping uncertainly and self-consciously in the transatlantic accents of the newer psycho-social sciences. As to the theory and practice of medicine, this was already enshrined in a classical language quite as dead as Latin and Greek. Nobody actually spoke it any more. The generalists had finally disappeared from the staff of the hospital and had taken their words and grammar with them. What scientific enquiry now demanded was highly differentiated researchers, whose neologisms created micro-Esperantos for small tribes of readers of increasingly specialised journals. The modern teaching hospital had consequently transformed itself into a Technical Tower of Babel.
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It was the poet William Blake who asserted that scientific truth resided in ‘‘minute particulars’’ — a claim that he made not only for scientific truth, but for truth in art and virtuous behaviour. Today medical thought is increasingly determined by the burgeoning of arcane technologies, by these very minute particulars, quite distant from one another. In the words of the 20th Century Irish poet WB Yeats ‘‘Things fall apart; the centre cannot hold.’’ His poem was in fact about the Second Coming of Christ, not about contemporary medicine, and he wrote ‘‘The falcon cannot hear the falconer’’. In terms of the analogy that I am drawing, the different specialists and their patient are all out of earshot of one another. Some 10 years ago in the New England Journal of Medicine, Robert Myerburg [6] noted that ‘‘Faculty members in Departments of Medicine are having increasing difficulty in communicating with each other’’. This is not, I believe, simply a problem in understanding each other’s technical jargon. The problem lies, rather, in the subtly different values embedded in what superficially may look like a common medical language. And it concerns the problems of translation. We all know that if you translate a French poem into an English poem, you do not get a faithful reproduction of the original. You get a new poem — perhaps not as good as, perhaps much better than the original, but something that is subtly and importantly different. As long ago as 1970, in my contribution to the book The Future General Practitioner [7], I compared the language of the general practice consultation with the language of poetry: ambiguous, rich in allusion and pun. Communication in what Jacob Bronowski [8] described as this ‘‘multi-valued language’’ contrasts with what he describes as ‘‘the single-valued language of natural science’’. Yet it is this second language, the language of most contemporary research, which shapes our ideas about evidence, truth and meaning in clinical medicine. If the single valued language of science limits our thinking about communication, so too does another foreign tongue: the language of lawyers. Legal language, fashioned for the purposes neither of art nor science, confuses both single- and many-valued communication. It is a language designed for the
purposes of assigning responsibility, culpability, contract, boundaries and fairness. In medicine it is manifest in the language of rationing and prioritising. And it is at its most powerful and treacherous when it speaks of rights to health and care. How should doctors communicate these ideas: how should patients respond? Last year, in a paper about health care entitlements I gave, in illustration, two real life cases which had been reported to me in a student tutorial. I called the patients, with unoriginal anonymity, Mrs Jones and Mr Smith. Mrs Jones was a 55-year old Afro-Caribbean woman who complained of swollen legs. This was an old complaint for which she had been taking diuretic tablets prescribed by her recently retired previous doctor. Her new doctor, young and well trained, could find little in the way of swelling and nothing in her records to explain or confirm any relevant diagnosis. Tactfully this is what she explained, and declined to repeat the prescription. Mrs Jones became angry. However, the doctor now noticed that on an earlier occasion her patient’s blood pressure had been rather raised. Clutching at a straw she took it again now, and perhaps because the patient was vexed, the pressure was again modestly up. She related this good news to Mrs Jones. Now, if indeed she proved to have high blood pressure, the doctor would certainly be able to prescribe her diuretic tablets: these were, after all, a recognised and legitimate treatment for hypertension. The reply was emphatic: ‘‘I don’t want to have the tablets for high blood pressure. I want to have the tablets for my swollen legs.’’ The entitlement which Mrs Jones was seeking was to be ill on her own terms. Mr Smith was in his 70s. He complained of recent pain and tenderness in the left rib cage. The doctor could find no obvious cause for this, but bearing a number of serious possibilities in mind, she ordered a battery of blood tests. It is not unusual in the face of such puzzling presentations to embark on a clinical fishing expedition. Unhappily, this time the doctor actually caught a fish. The chemical pathologist had detected a high level of alkaline phosphatase, had carried out further tests, and urged the general practitioner to refer Mr
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Smith for a bone scan to confirm his diagnosis of localised Paget’s disease. By now the patient was more than a little bewildered. The pain in his ribs had stopped, and he no longer felt ill. He now had no problem. But somewhere, outside his body, in a laboratory in the hospital miles away, there was a diagnosis and a disease to which he was being firmly wedded, but of which he wanted no part. His life was being mistranslated — expressed in the wrong language. He did not want a scan. Mr Smith was claiming the entitlement to be well on his own terms. I’m going to return in a while to a specific problem with translation. Now I want to turn to the medium of medicine. The very structure of health care and services, the context of the communication, is being transmogrified.
6. Configurations The coming developments in information technology, genomics, biometry, tele-medicine, robotics, unimaginable interfaces between body and machine, will force a massive re-invention of health services and organisations. These have scarcely changed in the UK over most of this century. Essentially the business of diagnosis and treatment is still carried out on two sites: the shop-sized general practice within a mile or two of the patient’s home, staffed by omni-potential but low-technology doctors and nurses; the hyper-market-sized general hospital within a short bus-ride, dealing with everything from child-birth to depressive illness and open heart surgery. The mapping of the human genome will usher in a radical re-structuring of the pharmaceutical and biotechnology industries. Yet the very use of the common phrase ‘the health services industry’ begs intriguing questions about the future shape and size of all our health-related organisations. I predict that these will be re-formed in the image of the new clinical science. This re-invention must begin by questioning the appropriateness of our great institutions in terms of their size, homogeneity and conformity. In place of the present hierarchical arrangements of care, we will see complex networks of location
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and people. It is from web-like images associated with the ecosystem and the internet that the new health care organisations will derive their structure and function. The drivers for this will include the democratisation of knowledge, increasingly potent software, global tele-communications, the personal bio-sensor woven into the very fabric of the body, and the patient-held medical record on a ‘read-andwrite smart card’. The institutions will change, and so also the tasks and training of health care professionals. Although the doctor may still be concerned with what Lord Cohen called the three tasks of the doctor — ‘diagnosis, diagnosis, and diagnosis’, the diagnostic task will be transformed. The outline is already clear in current practice. Problem solving at the patient’s side will be based on computer interrogated history, data from biosensing monitors, Bayesian computer analysis, and the immediate availability of a second opinion by teleconferencing (to a patient in London, from a specialist in Los Angeles). Most initial contacts will be with clinical nurses operating from small primary units located in high streets and hypermarkets, business and commercial centres, central transport terminals and schools, or communicating on-line. Such changes, when I first adumbrated them only 5 years ago, seemed somewhat exaggerated or at least far distant. Yet many elements of them are currently being introduced by the UK government as an integral part of our NHS. In terms of state-of-the art interventions, patients will wish to go to centres of excellence, and will know where they are. The quality of these centres’ performance will in part be a function of the quantity of their cases treated. One writer in a book on Clinical Futures [9] quotes a surgical colleague: ‘‘Twenty-five years of experience in paediatric cardiac surgery have convinced me that the sickest neonate with severe congenital heart defects could be safely transferred to the other side of the world to be treated in a specialised unit’’. Clinical care will first become fully industrialised (it has not quite yet) and then immediately postindustrialised. It will be essentially episodic, and what we now think of in UK general practice as a relationship — a relationship in which both doctor and patient share a biographical task — will in future
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become fragmented into a kaleidoscope of brief encounters. Remember please that I am forecasting not desiring. In the UK the traditional division of labour between general practitioners and hospital-based specialists resulted in the evolution of two quite distinct diagnostic tasks. I have described them as follows: The task of the specialist is to reduce uncertainty, to explore possibility, and to marginalise error. That of the general practitioner is to mediate between the predicament of the individual and the potential of bio-science: i.e. to tolerate uncertainty, explore probability, and marginalise danger. But the necessity for this previously crucial division must now be questioned on both technical and moral grounds. Now the patient herself will participate much more actively, and will herself fulfill many of the past roles of the generalist. The dominant mode of communication in health care, the core values, may now move from partisan advocacy to technical competence: from intimate biography to bio-mechanical possibility; from fairness to efficiency. Have I shocked you? Well, consider this. Arguably the great European humanitarian tradition in medicine was most completely developed in 20th century British general practice under the NHS. It included intellectual skills in ‘multi-paradigm’ clinical thinking, the interpretation of diverse data, the analysis of complex moral issues, a sensitivity to the patient’s social and psychological life, a sometimes passionate advocacy and partisanship. But like William Blake’s ‘invisible worm’ in his poem about the ‘sick rose’, at its heart, this humanitarian tradition harboured its own ‘dark secret love’ — a scarcely concealed if well intentioned paternalism. Perhaps in the past this was a necessary anodyne. After all, even in the second half of this century, the limited powers of medicine could never quite match the grandeur of the iatric promise. Today, however, medical technology is beginning to catch up with medicine’s rhetoric. If we are serious about the moral intentions of teaching communication to future clinicians, the agenda will shift from the enhancement of the doctor–patient relationship to the true liberation of both patient and public. It is a paradox that in pursuit
of this moral goal, we will have to retreat from the isolating consolations of evidence-based-medicine, and content ourselves with patient-based-compromise. It must be feared that with patient-based-compromise, the health outcomes will be far from the optimum that therapeutic trials would suggest. Doctors and patients together will, of course, in having changed the clinical agenda, have meanwhile radically redefined the meanings of both ‘health’ and ‘outcomes’.
7. An error of translation I promised finally to return to problems with translation. The ideal of a whole person medicine was always more or less conceived in reference to the Freudian unconscious, its manifestations in the doctor–patient relationship, and its understanding of illness as an expression of the patient’s deepest self. But for the past half century medicine, or rather the patient, may have been the dupe of an epic error of translation, with far-reaching implication for the form and content of communication in medicine. Bruno Bettelheim in his 1982 study ‘Freud and Man’s Soul’ [10], describes how the persistently inaccurate translations of Freud’s work from the original German into English, resulted in a serious misrepresentation of the intentions of psychoanalysis. This intellectual crime, Bettelheim claims, was compounded by the hijacking of psychoanalysis by American psychiatry. Freud’s writing, in what has been described as a very beautiful and poetic German, can only be precisely understood in the very specific cultural context in which he wrote. Translations traduce. The majority of Freud’s fellow professionals and academics would be expected to be familiar with the classics, for example, with the text of Sophocles’ play Oedipus Rex. They would easily recall the slow steps that led Oedipus to the dreadful truth that he was the son of Jocasta and Laius, the mother he had bedded, the father he had murdered. But they would be equally aware, generally aware as part of the culture of the Viennese intelligentsia of the day, of the part that both Laius and Jocasta had
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played in accepting what the Sphinx had told them, and so plotting to kill their child. Bettelheim suggests that this original focus in the Oedipus story — on the consequences of the unconscious murderous feelings of the parents, and not simply on the murderous impulses of the son — puts quite a different spin on the so called ‘Oedipus Complex’, from what it became in the world of anglophone psychiatry. This story is offered only in evidence of the seductions of mistranslation. There is a much deeper mistranslation of Freud that points to the heart of our concerns today. In English his translators have rendered Freud’s use of ‘Psyche’ as ‘mind’ or even ‘intellect’. But the classic picture of Psyche, the lover of Eros, is of a beautiful young woman with the wings of a butterfly. ‘Psyche’ means both butterfly and soul in classical Greek. This, Bettelheim points out, invests Psyche with connotations of ‘beauty, fragility and insubstantiality’. In many other cultures butterflies are symbols of the soul. Even the different stresses that we give in German and English to what appears to be almost the same literation, can cause the meaning to somersault. In German ‘Psychoanalyse’, and in English ‘psychoanalysis’. In English the accent on the first halfword, on analysis, suggests a Baconian experiment to determine the constituents of the mind. In German, the emphasis on the other, the first half-word, on Psyche, suggests an exploration of not of the mind, but of the soul. If Bettelheim is right in his assertion that Freud was concerned with the state of man’s soul rather than with the working of the patient’s mind, it can be argued that much of our claim to a whole person medicine is only another example of iatric flagwaving imperialism; that medical doctors are not, after all, secular soul surgeons; that they have never had the training; that they have never had the mandate. The language of doctor-mediated beneficence, empathy, holism, and the interpretation of illness, in
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fact the language that I spoke throughout the whole of my clinical lifetime, already sounds archaic, another dead or at least a dying language, in the world of genomics, robotics, and electronically democratised knowledge. We do not yet have that millennial vocabulary which will allow us to speak at once of the bewildering possibilities of biomechanics, and of our intimate biographical journeys. We have not yet constructed a grammar that will establish the rules by which we may safely trade-off our private desires in health care, and the public good. The text of our core values as doctor, patient and citizen, cannot be written in the language of 20th century medicine. With the advent of the patient as partner in the production of her own health, as architect in the design of our future health institutions, and as citizen in defending the values of a public service, we will need a different, a more robust language. This is the message that is encrypted in the unfolding medium of modern medicine.
References [1] McLuhan M. The Gutenberg galaxy. London: Routledge & Kegan Paul, 1962. [2] Morgan G. Images of organisations. London: Sage, 1986. [3] Foucault M. La naissance de la clinique. London: Tavistock, 1973. [4] Balint M, Hunt J, Joyce R, Marinker M, Woodcock J. Treatment or diagnosis. London: Tavistock, 1970. [5] Rorty R. Contingency, irony and solidarity. Cambridge: Cambridge University Press, 1989. [6] Myerburg RJ. Departments of medical specialities. New Engl J Med 1980;330:1453–5. [7] The Royal College of General Practitioners. The future general practitioner, learning and teaching. London: BMJ Publications, 1972. [8] Bronowski J. Science and human values. London: Penguin, 1956. [9] Marinker M, Peckham M, editors. Clinical futures. London: BMJ Publications, 1988. [10] Bettelheim B. Freud and man’s soul. London: Tavistock, 1982.
The medium and the message Marshall Marinker* Guy’ s, King’ s and St Thomas’ Medical and Dental School, King’ s College London, 5 Lambeth Walk, London SE11 6 SP, UK Received 10 January 2000; received in revised form 24 April 2000; accepted 8 May 2000
Abstract Communication between doctor and patient is examined in relation to ways of describing the institution of medicine, the rules of engagement between doctor and patient, and the language they employ. Medicine and its institutions are presented in metaphorical terms; a theatrical taxonomy of consultations between patient and doctor is suggested; and patient–doctor communication is considered in the light of the pervasiveness of mistranslation. Because it is possible to invent a wide range of alternative metaphors for medical institutions, to envisage many different sorts of dramatic possibilities in the patient–doctor encounter, and to develop a respect for the particularity of all language, optimism is expressed about the future of research, teaching and practice in doctor–patient communication. 2000 Elsevier Science Ireland Ltd. All rights reserved. Keywords: Patient–doctor communication; Medical teaching; Communication; Medicine
1. Introduction It is a pleasure to be here in Chicago. Eight years ago, I was invited to give a similar opening keynote at a Toronto conference on Communication in Medicine. When you invited me to be here today, I searched my computer archive for that original script. Of course I was going to cheat a bit, save on the effort of thinking, re-work some of the old material, pass it off today as something quite new. But re-reading this 8-year old script, I now experience a curious sense of dislocation from many of *Tel.: 1 44-20-7607-3139. E-mail address: [email protected] (M. Marinker).
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the assumptions I made then about the nature of the patient–doctor encounter. My Toronto paper was full of enduring truths and confident assertions. My Chicago paper is decked out only in the rags of shifting values and diffident questions. Last week my wife and I went to a revival, at London’s Donmar Warehouse, of Tom Stoppard’s play The Real Thing. It’s a play about young people falling in and out of love, about broken promises and broken hearts. We had first seen The Real Thing some 25 years ago. As we left the theatre my wife looked puzzled. ‘‘That’s not the original story. It was quite a different play’’, she said. ‘‘Stoppard must have changed everything’’. I thought for a moment
2000 Elsevier Science Ireland Ltd. All rights reserved.
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and said, ‘‘No. Stoppard has changed nothing. It’s we who have changed’’. So my thesis is this. The role of the doctor is now transforming — transforming because the role of the patient is being transformed. And these transformations, because they are accelerating, will over the coming decade, increasingly disturb both doctors and patients as communicants. As my title, borrowed from Marshall McLuhan’s famous dictum [1], suggests, I will be looking at the ways in which the medium of the medical consultation becomes itself the message of medical competence and concern. If the message has to change, so must the medium. Medicine has always been concerned with the twin agendas of bio-mechanics and a biography. And the turbulences that these sometimes conflicting agendas generate are made manifest as problems with communication, problems that have most often been presented as deficiencies in the skills of the actors. I want to suggest that these problems lie elsewhere — not in the mouths of the actors, but in the unresolved conflicts inherent in the script of medicine.
2. Metaphor Gareth Morgan in a book called Images of Organisations [2] suggests that we can understand organisations best, if we think in metaphors. He argues that metaphors provide illuminations; that they permit us to see one aspect of the human experience much more clearly in the sharp light of another; that they spring the surprises that constitute the inventions of science, and the revelations of art. This use of metaphor fashions a sharp tool for the analytical dissection of art, linguistics, theoretical physics, psychoanalysis, social theory, and much else. Today I am going to attempt to adapt this tool to an analysis not only of the institutions, but also of the contexts and the dialogues, of medical practice. That is to say, of both the medium and the message of medicine. Morgan develops a taxonomy of organisational metaphors. His typology, heavily influenced by neoFreudian theory, presents us with images of the organisations within which we work, that seem part of common experience, but are in fact familiar in a
rather strange way. How does metaphor illuminate the modern Western medical school? His first metaphor is the very familiar one of the organisation as ‘machine’, with its emphasis on central control, explicit rules, rigid discipline, uniformity, specialisation of function and predictability. This is the medical school of obsessively detailed aims and objectives, tight timetables and iterative assessments and evaluations, evidence-based-medicine and multiple choice questionnaires. This mechanical metaphor, Morgan argues, is still the dominant mode in the industrial economies, the metaphor that most powerfully defines most of our institutions. Michel Foucault in his Naissance de la Clinique [3] describes the birth of modern medicine in the 18th century. The term la Clinique is really untranslatable from the original French. It has a very telling double meaning in that precise language. La clinique refers to the central location for medical practice and discovery, what we now call the teaching hospital. But at the same time it describes a specific methodological approach to the diagnosis and study of diseases. In the case of la Clinique it marks the 18th century shift of the doctor’s gaze from the patient as sufferer, to the patient as concealer of the hidden and interior surfaces of the disease. Foucault employs this mechanical metaphor, in presenting us with ‘medicine’ as a Cartesian philosophy, and the ‘patient’ as Descartes’ ‘l’homme machine’. Another Morgan metaphor is the institution as ‘organism’. Here, there is a prime concern to preserve the internal environment, while at the same time discovering ecological niches by continuously adapting to the changing external environment. This is the medical school designed for contemporary competition, where research is valued in terms of the size of the grants necessary to nourish the academic body. It is the medical school where loyalty to its peculiar traditions is made manifest by the progress of its favoured alumni to high office in its own teaching hospitals. It is the medical school of the sports clubs, the fraternities, the graduation ceremony and the re-union dinner. Perhaps Morgan’s most intriguing metaphor is what he terms the organisation as ‘psychic prison’. Here the members of the organisation and their endeavours are constantly trapped by half-suppressed memories of the organisation’s real or believed
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history. Drawing on Jungian imagery, he suggests that organisational life can be understood in terms of the relationship between fools, magicians, warriors, high priests, lovers and other symbolic characters. This is the medical school of the pathology museum and the portrait galleries and the eponymous wards and lecture theatres and prizes. It is the medical school of story and fable, whose alumni have engraved their household names on some very important diseases; the school where ghosts darkly preside over tradition, where upstart bohemian fashions like communication skills or social sciences are introduced into the curriculum only over the very long-dead bodies of past heroes and their contemporary historians.
3. Images of the consultation I want to suggest that just as Morgan’s use of metaphor gives us new insights into our institutions, so metaphor illuminates our images of the medical transaction. For example, we make much of probability in our teaching of clinical medicine. Here is another metaphor. The clinic as casino reveals the consultation as a game of chance. This metaphor is at once close to the spirit of science and to the spirit of commerce. The uncertainty principle may have been invented to explain the phenomena of subatomic physics but may also explain aspects of the work of doctors. The electron can no longer be known to exist in a particular place, but rather to have a tendency to exist. My own diagnoses were always a bit like that. The whole of clinical medicine is a game for gamblers. Clinical training consists in studying form, where to place the best bets, and how to cover them. Communication at the gaming table or at the bookie’s booth is pretty guarded, not to say pokerfaced. In communicating with the patient, the cards of diagnosis and prognosis are to be kept very close to the chest. Central to clinical teaching has been the assertion that diagnosis and treatment follow the problemsolving methods of modern science. Here the metaphor is medical practice as laboratory, in which the consultation is an experiment. The traditional
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values of double-blindness and emotional neutrality in the search for evidence, predict the tone and scope of the sort of communication you can expect in this human laboratory. Other metaphors throw light on what has been happening to medical practice in my own country. Margaret Thatcher’s robust libertarian politics may seem a fading memory, but her values still infuse our thinking more than we know. The most prevalent metaphor in the UK today is hers — the National Health Service as market, the hospital as shop, the patient as consumer. No metaphor better reflects the spirit of our age. The language of medical audit sits comfortably here. There is a preoccupation with standards and accounting. Each parcel of communication may be expected to contain an agreed quantum of carefully elicited patient health belief. Nothing characterises the consultation as commodity so clearly as the checklist interrogation of the video performance. With diligence, each component can be identified and marked as present and correct. But to what purpose? And with what meaning?
4. The play’s the thing One of our most powerful, if unconscious, images of the consultation is clearly revealed in the teaching methods we employ. We make much of role play, of actors as patients, of students as actors. I am talking about the metaphor of the consultation as theatre. I’m going to describe four categories of consultation, each with its distinctive and peculiar content, style, and language. The first is the consultation as detective story. Classically the detective story consultation begins with the question, ‘‘What seems to be the trouble?’’. Note ‘‘What seems to be’’ and not ‘‘What is the trouble?’’. Indeed the doctor will often show intense irritation if the patient, spoiling the game, should say ‘‘I think it’s my heart doctor’’. Such hubris on the part of the patient is intolerable. It is, after all, the research scientist who is writing the script. The doctor wants to hear about breathlessness, swelling of the ankles and the like, so that his intellectual skills can be properly exercised, preferably with a
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diagnosis substantially hidden from vulgar view. In one of Agatha Christie’s ‘whodunits’, it was the policeman who did the murder: but he was camouflaged by his uniform as the disease may be camouflaged by the patient. This sort of consultation, essentially rational and instrumental, assumes certain values. To succeed here, the communication has to be clear and unambiguous. The doctor takes a history, which uncannily resembles a rehearsal of the physical examination to come. Learning to communicate in this way involves a careful training (rarely made conscious) in what to ignore, what not to hear, and above all what not to share. The quality of communication may then be judged by what is remembered, by the validity and the reliability of the messages, and by the compliance achieved. The second consultation in my typology is the romance. It may be a comedy of manners, or a history, or a tragedy. Here there is no emphasis on finding the culprit. Rather there is an exploration of the patient’s situation, a concern with identity, and a search for ways of coping with life. Typically the doctor starts such a consultation not with the question ‘‘What seems to be the trouble?’’, but rather ‘‘How can I help you?’’. Because the intentions of this consultation are concerned with the person’s biography and not only with the medical history, the language is different. The questions are often ambiguous, hardly questions at all. The answers are open to a number of interpretations, and all of them may hold some truth. In Harold Pinter’s play Old Times a married couple in middle life is visited by a woman who was the wife’s best friend 20 years ago. At the end of the play it is not always clear whether we are in past or present time; it is not clear whether the husband and his wife’s best friend had been lovers, or indeed had ever known one another; we are not even sure whether the two women are not simply different portrayals, different perceptions, of the same woman. Many of our consultations are like that. If you go to see Old Times, it can be very confusing indeed if you are expecting to see an Agatha Christie detective story. Old Times is not a play concerned with what or how things are being done, with the factual history demanded by bioscience. Like so many clinical encounters Old Times
is concerned with all the counterfactual histories of our imaginations. The third type of consultation is a ritual. Cinderella is an example. Here the power of the theatrical experience depends on encountering what seems to be already known: the content of the story and its denouement. Of course the quality of the performance is important. But actors and audience are celebrating in a relatively safe form, dark forgotten conflicts and hoped for resolutions. Here there is no attempt to find out what is wrong, still less is there an attempt on the part of any of the characters concerned, doctors or patients, to embark on a journey of discovery or self disclosure. The intentions of this sort of consultation are containment, remembrance and denial. Some sort of ritual is being enacted, a prescription repeated again and again; an old complaint rehearsed but unexamined. The acts performed by doctor and patient seem far removed from the rational discourse of modern medicine. Twenty-five years ago, I took part in a study of consultations in general practice, in which little seemed to happen — save the repeated prescription for the same unvaried medication. The research, under the leadership of Michael Balint, was published in a monograph called Treatment or Diagnosis? [4]. What we uncovered surprised us. Most often these consultations were acted out according to a very tight scenario, with a script which varied little between one performance and the next. These consultations also seemed to be innocent of any sensible component, concerned with our traditional ideas about diagnosis and treatment. They were also devoid of emotional content, of the kind which would allow some insights into motivation and the possibility of change. On the contrary, the intention seems to be to limit intimacy. The doctor here was taking part in a pantomime. Pantomimes are serious drama. In the consultation as ritual, there appears to be a contract that the communication should remain predictable, replicable and, above, all opaque. In Cinderella, the fairy tale which enchants children in the pantomime obscures the origins of the story, the terrible rivalry between Cinderella and her sisters, the separation of the mother into the good who is dead, and the wicked stepmother who punishes and denies. Still darker is the now forgotten archetype of the fairy tale prin-
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cess: the dirt-encrusted Aschputel, who can only be saved and transformed by an act which is perhaps most delicately described as ‘fitting the foot into the slipper’. How will you judge communication here? You will look in vain for new information, for problem solving, for empathy, insight, interpretation or even just good old fashioned clarity of instructions. Cinderella is a performance for anthropologists and teachers of communication in medicine, and small children. And so to my fourth category of consultation as drama: mysterious, disturbing, experienced often, acknowledged rarely. In Dario Fo’s Trumpets and Raspberries the protagonist is a Communist trades union official who becomes the managing director of the Fiat Motor Company. At least I believe that is one way of describing what happens. It’s a bit difficult to be sure. There seems to be no narrative. The centre does not hold. There is an anarchy of ideas and feelings. Everything is in fragments. To put them together, to make them cohere in some way, we create a Theatre of the Absurd. Sometimes rational biography, a sense of cause and effect, come to be seen as goals which are not only too ambitious for the consultation as theatre, but also positively dangerous for the patient. The doctor may approach the patient’s world most safely by abandoning the drive to co-author a biography, and content herself with something much more fragmentary. How, then, are we to value the quality of communication in medicine, given this diversity of metaphor, language and drama, all of which express in different and conflicting ways, the vaunting tasks of medicine? In describing the consultation as commodity, experiment, lesson, game of chance, and drama, I wanted to hint at the variability of our clinical encounters. For those concerned to teach and do research about communication in medicine, and for those students and practitioners who become convinced that communication is not just a grace note in a good consultation, but is actually the very stuff of medicine, it becomes important, at any moment in the clinical encounter, to know approximately in which metaphor, or in which piece of theatre, we are acting. The clues, I suggest, are to be found in the language that we use.
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5. Language The American philosopher Richard Rorty [5] is typical of so-called post-modernists in asserting that all languages are contingent (on time, place, particular circumstances). In Rorty’s (and, for that matter, in my) post-modernist view, health and healthcare are created by the language, or rather the conflicting languages, that we are conditioned to use. In the face of diversity of languages Rorty urges irony. By irony he means both a willingness to question the validity and the assumptions built into ones own language, a consciousness of the relative poverty of any one individual language, and so a respect for, and an openness to, the languages of others. When I was a schoolboy in the 1940s the prevailing wisdom was that the study of Latin was a pre-requisite to the study of medicine. It seemed strange to me then that a dead language, however, elegant its form and noble its literature, should be thought relevant to the practice of modern bio-science. As it turned out, the London medical schools had by 1950 caught up with Flexner, and it was chemistry not Latin that was in fact the one essential requirement for admission to the medical course. So I did not, after all, have to learn modern medicine in a dead language. Or so I thought. The irony of my discovery about Latin was that by the early 1950s the language of medicine itself was so enfeebled by disuse that it was already close to linguistic death. Instead my teachers were increasingly employing the vibrant languages of the biological sciences, and even at times lisping uncertainly and self-consciously in the transatlantic accents of the newer psycho-social sciences. As to the theory and practice of medicine, this was already enshrined in a classical language quite as dead as Latin and Greek. Nobody actually spoke it any more. The generalists had finally disappeared from the staff of the hospital and had taken their words and grammar with them. What scientific enquiry now demanded was highly differentiated researchers, whose neologisms created micro-Esperantos for small tribes of readers of increasingly specialised journals. The modern teaching hospital had consequently transformed itself into a Technical Tower of Babel.
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It was the poet William Blake who asserted that scientific truth resided in ‘‘minute particulars’’ — a claim that he made not only for scientific truth, but for truth in art and virtuous behaviour. Today medical thought is increasingly determined by the burgeoning of arcane technologies, by these very minute particulars, quite distant from one another. In the words of the 20th Century Irish poet WB Yeats ‘‘Things fall apart; the centre cannot hold.’’ His poem was in fact about the Second Coming of Christ, not about contemporary medicine, and he wrote ‘‘The falcon cannot hear the falconer’’. In terms of the analogy that I am drawing, the different specialists and their patient are all out of earshot of one another. Some 10 years ago in the New England Journal of Medicine, Robert Myerburg [6] noted that ‘‘Faculty members in Departments of Medicine are having increasing difficulty in communicating with each other’’. This is not, I believe, simply a problem in understanding each other’s technical jargon. The problem lies, rather, in the subtly different values embedded in what superficially may look like a common medical language. And it concerns the problems of translation. We all know that if you translate a French poem into an English poem, you do not get a faithful reproduction of the original. You get a new poem — perhaps not as good as, perhaps much better than the original, but something that is subtly and importantly different. As long ago as 1970, in my contribution to the book The Future General Practitioner [7], I compared the language of the general practice consultation with the language of poetry: ambiguous, rich in allusion and pun. Communication in what Jacob Bronowski [8] described as this ‘‘multi-valued language’’ contrasts with what he describes as ‘‘the single-valued language of natural science’’. Yet it is this second language, the language of most contemporary research, which shapes our ideas about evidence, truth and meaning in clinical medicine. If the single valued language of science limits our thinking about communication, so too does another foreign tongue: the language of lawyers. Legal language, fashioned for the purposes neither of art nor science, confuses both single- and many-valued communication. It is a language designed for the
purposes of assigning responsibility, culpability, contract, boundaries and fairness. In medicine it is manifest in the language of rationing and prioritising. And it is at its most powerful and treacherous when it speaks of rights to health and care. How should doctors communicate these ideas: how should patients respond? Last year, in a paper about health care entitlements I gave, in illustration, two real life cases which had been reported to me in a student tutorial. I called the patients, with unoriginal anonymity, Mrs Jones and Mr Smith. Mrs Jones was a 55-year old Afro-Caribbean woman who complained of swollen legs. This was an old complaint for which she had been taking diuretic tablets prescribed by her recently retired previous doctor. Her new doctor, young and well trained, could find little in the way of swelling and nothing in her records to explain or confirm any relevant diagnosis. Tactfully this is what she explained, and declined to repeat the prescription. Mrs Jones became angry. However, the doctor now noticed that on an earlier occasion her patient’s blood pressure had been rather raised. Clutching at a straw she took it again now, and perhaps because the patient was vexed, the pressure was again modestly up. She related this good news to Mrs Jones. Now, if indeed she proved to have high blood pressure, the doctor would certainly be able to prescribe her diuretic tablets: these were, after all, a recognised and legitimate treatment for hypertension. The reply was emphatic: ‘‘I don’t want to have the tablets for high blood pressure. I want to have the tablets for my swollen legs.’’ The entitlement which Mrs Jones was seeking was to be ill on her own terms. Mr Smith was in his 70s. He complained of recent pain and tenderness in the left rib cage. The doctor could find no obvious cause for this, but bearing a number of serious possibilities in mind, she ordered a battery of blood tests. It is not unusual in the face of such puzzling presentations to embark on a clinical fishing expedition. Unhappily, this time the doctor actually caught a fish. The chemical pathologist had detected a high level of alkaline phosphatase, had carried out further tests, and urged the general practitioner to refer Mr
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Smith for a bone scan to confirm his diagnosis of localised Paget’s disease. By now the patient was more than a little bewildered. The pain in his ribs had stopped, and he no longer felt ill. He now had no problem. But somewhere, outside his body, in a laboratory in the hospital miles away, there was a diagnosis and a disease to which he was being firmly wedded, but of which he wanted no part. His life was being mistranslated — expressed in the wrong language. He did not want a scan. Mr Smith was claiming the entitlement to be well on his own terms. I’m going to return in a while to a specific problem with translation. Now I want to turn to the medium of medicine. The very structure of health care and services, the context of the communication, is being transmogrified.
6. Configurations The coming developments in information technology, genomics, biometry, tele-medicine, robotics, unimaginable interfaces between body and machine, will force a massive re-invention of health services and organisations. These have scarcely changed in the UK over most of this century. Essentially the business of diagnosis and treatment is still carried out on two sites: the shop-sized general practice within a mile or two of the patient’s home, staffed by omni-potential but low-technology doctors and nurses; the hyper-market-sized general hospital within a short bus-ride, dealing with everything from child-birth to depressive illness and open heart surgery. The mapping of the human genome will usher in a radical re-structuring of the pharmaceutical and biotechnology industries. Yet the very use of the common phrase ‘the health services industry’ begs intriguing questions about the future shape and size of all our health-related organisations. I predict that these will be re-formed in the image of the new clinical science. This re-invention must begin by questioning the appropriateness of our great institutions in terms of their size, homogeneity and conformity. In place of the present hierarchical arrangements of care, we will see complex networks of location
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and people. It is from web-like images associated with the ecosystem and the internet that the new health care organisations will derive their structure and function. The drivers for this will include the democratisation of knowledge, increasingly potent software, global tele-communications, the personal bio-sensor woven into the very fabric of the body, and the patient-held medical record on a ‘read-andwrite smart card’. The institutions will change, and so also the tasks and training of health care professionals. Although the doctor may still be concerned with what Lord Cohen called the three tasks of the doctor — ‘diagnosis, diagnosis, and diagnosis’, the diagnostic task will be transformed. The outline is already clear in current practice. Problem solving at the patient’s side will be based on computer interrogated history, data from biosensing monitors, Bayesian computer analysis, and the immediate availability of a second opinion by teleconferencing (to a patient in London, from a specialist in Los Angeles). Most initial contacts will be with clinical nurses operating from small primary units located in high streets and hypermarkets, business and commercial centres, central transport terminals and schools, or communicating on-line. Such changes, when I first adumbrated them only 5 years ago, seemed somewhat exaggerated or at least far distant. Yet many elements of them are currently being introduced by the UK government as an integral part of our NHS. In terms of state-of-the art interventions, patients will wish to go to centres of excellence, and will know where they are. The quality of these centres’ performance will in part be a function of the quantity of their cases treated. One writer in a book on Clinical Futures [9] quotes a surgical colleague: ‘‘Twenty-five years of experience in paediatric cardiac surgery have convinced me that the sickest neonate with severe congenital heart defects could be safely transferred to the other side of the world to be treated in a specialised unit’’. Clinical care will first become fully industrialised (it has not quite yet) and then immediately postindustrialised. It will be essentially episodic, and what we now think of in UK general practice as a relationship — a relationship in which both doctor and patient share a biographical task — will in future
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become fragmented into a kaleidoscope of brief encounters. Remember please that I am forecasting not desiring. In the UK the traditional division of labour between general practitioners and hospital-based specialists resulted in the evolution of two quite distinct diagnostic tasks. I have described them as follows: The task of the specialist is to reduce uncertainty, to explore possibility, and to marginalise error. That of the general practitioner is to mediate between the predicament of the individual and the potential of bio-science: i.e. to tolerate uncertainty, explore probability, and marginalise danger. But the necessity for this previously crucial division must now be questioned on both technical and moral grounds. Now the patient herself will participate much more actively, and will herself fulfill many of the past roles of the generalist. The dominant mode of communication in health care, the core values, may now move from partisan advocacy to technical competence: from intimate biography to bio-mechanical possibility; from fairness to efficiency. Have I shocked you? Well, consider this. Arguably the great European humanitarian tradition in medicine was most completely developed in 20th century British general practice under the NHS. It included intellectual skills in ‘multi-paradigm’ clinical thinking, the interpretation of diverse data, the analysis of complex moral issues, a sensitivity to the patient’s social and psychological life, a sometimes passionate advocacy and partisanship. But like William Blake’s ‘invisible worm’ in his poem about the ‘sick rose’, at its heart, this humanitarian tradition harboured its own ‘dark secret love’ — a scarcely concealed if well intentioned paternalism. Perhaps in the past this was a necessary anodyne. After all, even in the second half of this century, the limited powers of medicine could never quite match the grandeur of the iatric promise. Today, however, medical technology is beginning to catch up with medicine’s rhetoric. If we are serious about the moral intentions of teaching communication to future clinicians, the agenda will shift from the enhancement of the doctor–patient relationship to the true liberation of both patient and public. It is a paradox that in pursuit
of this moral goal, we will have to retreat from the isolating consolations of evidence-based-medicine, and content ourselves with patient-based-compromise. It must be feared that with patient-based-compromise, the health outcomes will be far from the optimum that therapeutic trials would suggest. Doctors and patients together will, of course, in having changed the clinical agenda, have meanwhile radically redefined the meanings of both ‘health’ and ‘outcomes’.
7. An error of translation I promised finally to return to problems with translation. The ideal of a whole person medicine was always more or less conceived in reference to the Freudian unconscious, its manifestations in the doctor–patient relationship, and its understanding of illness as an expression of the patient’s deepest self. But for the past half century medicine, or rather the patient, may have been the dupe of an epic error of translation, with far-reaching implication for the form and content of communication in medicine. Bruno Bettelheim in his 1982 study ‘Freud and Man’s Soul’ [10], describes how the persistently inaccurate translations of Freud’s work from the original German into English, resulted in a serious misrepresentation of the intentions of psychoanalysis. This intellectual crime, Bettelheim claims, was compounded by the hijacking of psychoanalysis by American psychiatry. Freud’s writing, in what has been described as a very beautiful and poetic German, can only be precisely understood in the very specific cultural context in which he wrote. Translations traduce. The majority of Freud’s fellow professionals and academics would be expected to be familiar with the classics, for example, with the text of Sophocles’ play Oedipus Rex. They would easily recall the slow steps that led Oedipus to the dreadful truth that he was the son of Jocasta and Laius, the mother he had bedded, the father he had murdered. But they would be equally aware, generally aware as part of the culture of the Viennese intelligentsia of the day, of the part that both Laius and Jocasta had
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played in accepting what the Sphinx had told them, and so plotting to kill their child. Bettelheim suggests that this original focus in the Oedipus story — on the consequences of the unconscious murderous feelings of the parents, and not simply on the murderous impulses of the son — puts quite a different spin on the so called ‘Oedipus Complex’, from what it became in the world of anglophone psychiatry. This story is offered only in evidence of the seductions of mistranslation. There is a much deeper mistranslation of Freud that points to the heart of our concerns today. In English his translators have rendered Freud’s use of ‘Psyche’ as ‘mind’ or even ‘intellect’. But the classic picture of Psyche, the lover of Eros, is of a beautiful young woman with the wings of a butterfly. ‘Psyche’ means both butterfly and soul in classical Greek. This, Bettelheim points out, invests Psyche with connotations of ‘beauty, fragility and insubstantiality’. In many other cultures butterflies are symbols of the soul. Even the different stresses that we give in German and English to what appears to be almost the same literation, can cause the meaning to somersault. In German ‘Psychoanalyse’, and in English ‘psychoanalysis’. In English the accent on the first halfword, on analysis, suggests a Baconian experiment to determine the constituents of the mind. In German, the emphasis on the other, the first half-word, on Psyche, suggests an exploration of not of the mind, but of the soul. If Bettelheim is right in his assertion that Freud was concerned with the state of man’s soul rather than with the working of the patient’s mind, it can be argued that much of our claim to a whole person medicine is only another example of iatric flagwaving imperialism; that medical doctors are not, after all, secular soul surgeons; that they have never had the training; that they have never had the mandate. The language of doctor-mediated beneficence, empathy, holism, and the interpretation of illness, in
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fact the language that I spoke throughout the whole of my clinical lifetime, already sounds archaic, another dead or at least a dying language, in the world of genomics, robotics, and electronically democratised knowledge. We do not yet have that millennial vocabulary which will allow us to speak at once of the bewildering possibilities of biomechanics, and of our intimate biographical journeys. We have not yet constructed a grammar that will establish the rules by which we may safely trade-off our private desires in health care, and the public good. The text of our core values as doctor, patient and citizen, cannot be written in the language of 20th century medicine. With the advent of the patient as partner in the production of her own health, as architect in the design of our future health institutions, and as citizen in defending the values of a public service, we will need a different, a more robust language. This is the message that is encrypted in the unfolding medium of modern medicine.
References [1] McLuhan M. The Gutenberg galaxy. London: Routledge & Kegan Paul, 1962. [2] Morgan G. Images of organisations. London: Sage, 1986. [3] Foucault M. La naissance de la clinique. London: Tavistock, 1973. [4] Balint M, Hunt J, Joyce R, Marinker M, Woodcock J. Treatment or diagnosis. London: Tavistock, 1970. [5] Rorty R. Contingency, irony and solidarity. Cambridge: Cambridge University Press, 1989. [6] Myerburg RJ. Departments of medical specialities. New Engl J Med 1980;330:1453–5. [7] The Royal College of General Practitioners. The future general practitioner, learning and teaching. London: BMJ Publications, 1972. [8] Bronowski J. Science and human values. London: Penguin, 1956. [9] Marinker M, Peckham M, editors. Clinical futures. London: BMJ Publications, 1988. [10] Bettelheim B. Freud and man’s soul. London: Tavistock, 1982.