Reconsidering the role of language in medicine

Reconsidering the role of language in medicine Background: Despite an expansive literature on communication in medicine, the role of language is dealt with mostly indirectly. Recently, narrative medicine has emerged as a strategy to improve doctor-patient communication and integrate patient perspectives. However, even in this field which is predicated on language use, scholars have not specifically reflected on how language functions in medicine. Methods: In this theoretical paper, the authors consider how different models of language use, which have been proposed in the philosophical literature, might be applied to communication in medicine. In particular, the authors contrast the traditional, indexical thesis of language with new models that focus on interpretation instead of standardization. Results: The authors demonstrate how paying close attention to the role of language in medicine provides a philosophical foundation for supporting recent changes in doctor-patient communication. In particular, interpretive models are at the foundation of new approaches such as narrative medicine, that emphasize listening to patient stories, rather than merely collecting information. Conclusion: Ultimately, debates regarding the role of language which have largely resided in non-medical literatures, have important implications for describing communication in medicine. In particular, interpretive models of language use provide an important rationale for facilitating a more robust dialogue between doctors and patients. Keywords: Language, Philosophy of medicine, Narrative medicine, Doctor-patient communication Background clinical settings are often the focus of studies in the In the field of medicine discussions of language have literature on medical encounters. been relatively rare. Many readers, at first, may object to Most recently, narrative medicine has emerged as a this claim. After all, many articles and books examine prominent technique for integrating language and litera- the communicative competence of clinicians [1, 2] Med- ture into medicine [8–10]. The main point of this ical students, for example, are constantly reminded that approach is that patients construct stories about their they must learn to interact effectively with patients. lives, including their illnesses, that are vital to under- Additionally, issues related to translation, interpretation, standing their social and bodily conditions. The claim and cultural competence are constantly discussed [3, 4]. made by narrative medicine is that physicians, due to Perhaps a better way to state the problem is that in their training and focus on physical elements, have medicine language is dealt with mostly indirectly. Many historically ignored these storylines [11]. As a result, studies focus, for example, on the physician-patient rela- physicians make diagnoses or design interventions that tionship, the need for dialogue, the proper interpretation are culturally insensitive or, at times, irrelevant. As a of clinical records, and the power dynamic that exists corrective, the framework of narrative medicine encour- between doctors and their patients [5–7]. In other ages physicians to truly listen to their patients. words, the quality and type of interaction that occurs in Given this research and recent trends, how can a legitimate claim be made that language is ignored in * Correspondence: franzb@ohio.edu medicine? The answer is that in each of these cases, in- Department of Social Medicine, Heritage College of Osteopathic Medicine, cluding narrative medicine, language is involved but is Ohio University, Grosvenor311, Athens, OH, USA Full list of author information is available at the end of the article © The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Franz and Murphy Philosophy, Ethics, and Humanities in Medicine (2018) 13:5 Page 2 of 7 not the primary focus of attention. Any explanation of properly to be treated as facts or evidence [16]. The influ- the interaction patterns of patients and physicians pre- ence of language, in other words, is unavoidable and pro- supposes the use of language, but the nature of language vides the entrée to a patient’s world that is necessary for a itself is not usually in question. Even in most treatments relevant portrayal of illness or health. of narrative medicine, the stories patients tell are pre- The key issue here is that clinicians should be con- sumed to be informative. The issue remains to be ex- cerned about language use, given that interpretation is plored, however, whether the nature of language pervasive and plays a primary role in communication. contributes to this insight. The aim of this paper, there- For these reasons, a wide range of health professionals fore, is to demonstrate why focusing on divergent theor- should be interested in language. But in the field of ies of language is a practical consideration for clinicians. medicine, discussions of communication have mostly fo- Specifically, we argue that moving beyond the traditional cused on the transmission or dissemination of informa- theory of language is necessary in order to take seriously tion [17]. Nonetheless, there is something fundamental the stories offered by patients in the clinical encounter. about language that demands the attention of clinicians. Critical to narrative medicine is that both patients and Perhaps language offers access to information that is vi- clinicians bring perspectives to the clinical encounter that tally important to proper care. are relevant to patient care. Any concern for improving communication, so that these stories can be explored and Traditional role of language better guide a care plan, is only logical. When persons In traditional portrayals, language is described as being a speak, for example, they expect others to listen, and both tool [18]. This apparatus, moreover, differentiates physicians and patients are no exception. From the per- humans from animals, and represents a huge advance in spective of patients, having physicians listen carefully to evolutionary development. With the help of language, their insights is often appreciated given the time con- humans are able to identify specific elements, such as straints of clinical practice. Evidence suggests that patients behaviors and events, and make particular differentia- feel comfortable with caregivers who are attentive, and be- tions. Everyday life, according to this scenario, is no lon- lieve that such care is effective [12]. ger murky but, through socialization and training, can In this regard, narrative medicine deals with meta- be clearly demarcated. phors, literary anecdotes, and the need to approach per- The indexical thesis is the outgrowth of describing lan- sons or clinical records openly. Additionally, empathy is guage as a tool. There are two parts to this position. The extolled but this skill presupposes language use [13]. In first is that language is tied to cognition and represents these cases, the nature of language is not the prime con- human expressions. The second is that these expressions cern. Instead scholars of narrative medicine emphasize are attached to reality. This attachment, however, is cru- sensitivity to the narratives that both clinicians and pa- cial. Specifically, the link that exists serves to distinguish tients bring to the clinical meeting. These stories are be- factors and make these elements known. lieved to supply details that are often overlooked, but The metaphor that proponents often introduce at this which are important to quality care. juncture is of language as a pointer. As sentiments or ex- But is there a more compelling reason for physicians pressions are attached to objects, language is able to iden- and other service providers to pay attention to language? tify things, highlight differences, distinguish background The guiding theme of this paper is that the nature of from foreground, illustrate context, and isolate key features. language provides such a reason, and therefore the fun- Simply put, language can make distinctions and discrimina- damental character of speech should be investigated. tions and impose order on an otherwise nebulous mass of Philosophers and some other scholars have been raising input. What is important are the connections present be- this issue for some time, but in medicine such an inquiry tween language and the referents that are identified. has been mostly missing [14]. The key benefit of this rendition of language is that The defining methodology of this discussion is phenom- clarity can be established. In order to achieve this aim, enology, particularly the anti-dualistic stance of this phil- however, a precise link has to exist between a linguistic osophy. When Husserl states that “consciousness is always expression and a particular referent. Language and refer- conscious of something,” he is undermining a ents must be clearly, unambiguously aligned. When long-standing position that diminished the influence of these connections are clear, understanding is possible. language and encouraged the pursuit of objectivity [15]. Within the framework of the indexical thesis, precision But with language thoroughly intertwined with whatever is highly valued. As much noise, or ambiguity, must be is known, interpretation is elevated in importance by Hus- eliminated as possible from the relationship between serl and others who subsequently emphasized the import- language and all referents. Language use, accordingly, is ance of interpretation. According to these proponents, assumed to be clear when the referent of an expression events or behavior must be interpreted, or contextualized, is precisely identified. Franz and Murphy Philosophy, Ethics, and Humanities in Medicine (2018) 13:5 Page 3 of 7 When a person says “house,” for example, a particular [26]. In this case, the aim is to achieve the neutrality re- phenomenon should come to mind, with all of the per- quired to provide objective descriptions of a medical tinent characteristics. At first, the link between language problem. The assumption is that in following the acqui- and this referent may not seem problematic. In the con- sition of objective data correct diagnoses can be made text of medicine, on the other hand, these linkages are and the proper interventions prescribed. With objective not so obvious. When patients say that they do not feel evidence at the foundation, medical decision-making is well or are experiencing pain, establishing clarity is not supposed to become more rational. always easy. A certain amount of interpretation is, there- Clinicians and researchers have proposed a variety of fore, inevitable [19]. tactics to achieve this goal. But only three will be dis- Clinicians, nonetheless, must try to clarify the connec- cussed at this time. The first is based on the principle of tion between an expression of pain and a physical refer- measurement. Through an increased reliance on quanti- ent. This association, however, is mired in a host of fication, some have argued that clinical practices have social and cultural considerations that make this identifi- become more reliable [27]. Numbers, after all, are not cation difficult. In some cases of chronic pain, these as- thought to be culture-bound and thus should provide a sociations are incredibly vague and thus dismissed as precise description of events. A quick glance at a clinical fantasy or as medication-seeking behavior [20, 21]. What record reveals a propensity to describe many results in weighs heavily in this decision is the degree of precision quantitative terms and clearly counting is encouraged by that can be established, while trying to navigate various the implementation of electronic patient records [28]. In competing experiences and interpretations. practice, the language of calculation is concise and read- Physicians have the difficult task of trying to overcome, ily understandable. Everyone is assumed to know the or at least neutralize, the sources of uncertainty that may meaning of a 40% solution or the bio-data derived from affect language use. The clinical setting is hardly pristine. a stress test. Issues arise, for example, related to emotion, memory, past The second method relies on standardization and is experiences, and personality that compromise clarity. premised on a basic rule of logic. In this case, clarity is How is certainty possible when language use is influenced improved when mutually exclusive categories are by those considerations? What often happens is that at- adopted to classify events and behaviors [29]. With the tempts are made to marginalize these intervening factors elimination of any overlap, standardization is possible. In so that the referents of linguistic expressions become the absence of ambiguity, patient responses should be more clear. But the clinician, due to the uncertainty asso- similar to a particular query and any variation can be as- ciated with language, might have to engage hermeneutics sumed to represent these differences. The current prolif- and seek a proper interpretation [22]. Nonetheless, clarity eration of checklists and pre-programmed, easily is sought typically in other ways. processed forms is justified by this principle. The third tactic is the computerization of clinical prac- Clarifying language use tice. Consistent with the idea of technē described by Jac- The strategies that have been followed to seek clarity are ques Ellul, computers are thought to operate according based mostly on empiricism [23]. Specifically, the focus to ineluctable rules [30]. Expert systems, for example, is on collecting objective evidence. The assumption is are now available to conduct therapy sessions, organize that misunderstanding can be avoided only if the contin- clinical data, and make diagnoses [31]. The fact that gencies that often pervade language use are overcome. computers are reliable and faithfully follow instructions An image is created suggesting that language can be sta- creates an image of regularity and uniformity. In effect, bilized to avoid ambiguity. In the end, regularity must be computers do not tolerate ambiguity, and thus discipline established. how language is used. At this point, a central proposal of Cartesian philoso- But critics may argue that in a computerized record, phy, or dualism, comes into play [24]. That is, the at- space is often allotted for the thinking of patients, or tempt is made to strip language of the uncertainty their subjectivity, to be given consideration. In the stan- linked to culture, emotion, or personality, for example, dardized SOAP format, for example, both the Subjective that may taint communication in a clinical setting. The and Objective features of a problem are documented. aim of this maneuver is to restrict the influence of these Nonetheless, given this dualistic prescription, personal and similar interpretive factors, so that assessments are insights are treated mostly as supplementing the object- improved. Clinical decisions can thus be made on ob- ive descriptions, or are downplayed as anecdotal. In ei- jective data, as proponents of evidence-based medicine ther case, clinicians give primacy to what is believed to recommend [25]. be objective evidence. At this time, medicine is struggling with this issue, In each tactic, a similar practice is employed to pro- with almost an obsession to become evidence-based mote clarity–the illusion is created that language use is Franz and Murphy Philosophy, Ethics, and Humanities in Medicine (2018) 13:5 Page 4 of 7 not situated but universal. Quantification, after all, is clinical practice. This position is non-dualistic and chal- touted to be a universal, culture-free language. And be- lenges Cartesianism. Language, in this view, does not cause the use of computers epitomizes rationality, and merely highlight elements but participates intimately in thus is uninfluenced by human foibles, language appears the identification and arrangement of everything that is to be severed from everyday speech [32]. Hence the con- known. As suggested by Merleau-Ponty, reality is catalo- nection between an expression and referent is presumed gued through language, including the lives of patients. to be as clean as possible, divorced from alternative uses This image of language is poetic, but not according to of language and competing interpretations. the usual stylistic distinction between poetry and litera- But this search for precision generates an abstract and ture. In this context, consistent with Barthes, poetic false image of language. Specifically ignored is how persons, means that language is creative, evasive, but insightful and in this context physicians and patients, use language in [36]. Rather than obvious, meanings arise from contrast- everyday life. Joseph Weizenbaum calls this usage “natural ing interpretations. A patient’s interview or medical rec- language” [33]. The language that is imposed by clinical ord, for example, thus defies formalization and forms and checklists, for example, is rigid and unrealistic, immediate comprehension. and thus insensitive to how persons interpret themselves What this shift in thinking means, in clinical practice, is and their situations. Responses maybestandardized, and that clarity is not necessarily the gold standard. Because the thus precise, but the intentions of patients may be seriously influence of language can never be cast aside, a new way is misconstrued. What they have to say is easily concealed be- needed to think about valid knowledge. In this emerging hind clear, but irrelevant language. framework, even attempts to neutralize language merely What is important at this stage in this discussion is introduce other modes of talk under the guise of calculation whether the indexical thesis adequately characterizes and standardization. But because in those examples lan- language. Indeed, this theory seems to promote a por- guage is believed to be neutralized, many erroneous classifi- trayal that obscures how persons really talk, as a conse- cations and interpretations go unnoticed. quence of emphasizing clarity. This thesis, however, has Instead of seeking clarity, therefore, clinicians have a been eclipsed by another that treats language differently. different responsibility, if one is to take interpretation Charles Taylor calls this outlook “expressive-constitu- seriously. With all knowledge mediated by language, tive” [18]. In this relatively new approach, the aim is not clinical practice becomes a hermeneutic activity [37]. In- to overcome, or neutralize the influence of language, but stead of pointing to referents, linguistic expressions con- to appreciate how language use and the worlds of pa- vey messages that must be properly deciphered. And tients are basically connected. This realization, more- rather than clarity, clinicians might focus on making over, is purported to enhance clinical practice. sure they interpret information as patients intend. This outcome, moreover, is not necessarily achieved through Language that compels precise measurements or classifications. Because the hu- Because the indexical thesis is dualistic, the opportunity man condition, like prose is fundamentally interpretive, is open for objectivity; that is, subjectivity can be over- another strategy is required. come to confront objective facts. In this regard, the de- This change in orientation, however, does not neces- scriptive that is used is problematic, that is, a pointer. sarily mean that medicine should not be evidence-based, Language merely indicates something, thereby suggest- although some critics claim that sound practice may be ing that all referents can be examined objectively be- compromised [38]. What passes for evidence, however, cause their significance is not influenced by subjectivity. must be assessed anew. No longer are objective data, A proper investigation, of course, is necessary that relies captured through experimental practices, a reliable on empirical data. source of relevant information about a patient or com- Newer theories, however, adopt a different trope, one munity. In the absence of dualism, evidence has an exist- derived from literature. As Maurice Merleau-Ponty says, ential cast, and refers to the personal, and interpersonal, language constitutes the “prose of the world” [34]. His stock of knowledge or interpretations that persons or point is that as opposed to a pointer, language envelops communities use to define themselves and their persons. As a result, language use mediates everything situations. that is known. To paraphrase Roland Barthes, there is A hermeneutically-based approach recognizes the no other side to language, where objective connections situatedness of language, since one perspective or an- and referents reside [35]. People are permeated by lan- other is always revealed [39]. Clarity, therefore, is too guage; there is no escape. Language cannot be avoided limited and sterile. A life that is linguistically mediated is or tamed, so that objectivity is possible. never clearly exposed, but is engaged gradually through The unifying feature of new theories of language is a a process of give and take that is interrupted by check- focus on interpretation, which has clear implications for lists and computer-ready forms [40]. In this Franz and Murphy Philosophy, Ethics, and Humanities in Medicine (2018) 13:5 Page 5 of 7 environment, a clinician who hopes to communicate ef- understood in their own terms [39]. A clinician, for ex- fectively with a patient must stop imposing means for ample, must reflect on a patient’s expressions, try out an achieving clarity and pursue understanding. Medical interpretation, and possibly advance another option until practice thus has a very special aim–patients must be some agreement is reached. No outside authority should allowed to speak and be heard in their own voices. stifle this search; no objective support can be consulted. Any understanding, accordingly, is always tentative, due Looking for the world to the ambiguity of language. For even agreement in- As a pointer, language merely indicates something or an- volves interpretation, as opposed to a direct encounter other. But in interpretive theories of language, expres- with an objective connection or referent. sions are not pointing but are part of a process of What clinicians are trying to do, in other words, is creating knowledge. Understanding is achieved, accord- enter the linguistically inscribed world of patients. This ingly, not through clarity but a proper interpretation. activity is not as sterile as striving for clarity. There is no Rather than attempting to neutralize language, clinicians attempt to withdraw from or overcome the elusiveness must recognize the nature of language and attempt to of language, but rather a desire to become immersed in enter the elusive realm of interpretation. In this place, the expressions of patients. A world is announced in facts are always contested by rival interpretations, in- these stories that provides important insights into the stead of objective. Plagued by the creative influence of meaning of health and illness to patients, and how they language, referents of speech are never obvious, but will respond to these considerations [8]. must be disclosed through proper interpretation [41]. Focusing on these stories, however, can be problematic Accurate classification and standardization are no [45]. Not everyone tells the truth. Furthermore, some guarantee that mutual understanding will be reached. persons are reluctant to talk or exaggerate, and a class While adhering to what Gabriel Marcel calls the “spirit bias may be at the root of these differences [46]. But if of abstraction,” both processes rely on the imposition of the conditions for dialogue are created, these issues can strategies to foster clarity [42]. But such tactics, rather be addressed. There is a bigger issue, however, related to than culture-free, simply introduce interpretations that power and the resulting structural inequalities [47]. In- may occlude the situational effects of language. True un- deed, persons must have access to treatment before they derstanding cannot occur through this modus operandi. can tell their stories and be correctly heard. Narrative Instead of trying to neutralize language, how patients use medicine seems to skirt around this political issue. language must be unpacked [43]. Clinicians, for example, But in clinical practice, and community work, dialogue can learn to contextualize patient expressions and treat allows language use to be unpacked instead of avoided. them as testimonials that should be addressed in the way What this change signals for clinical practice is that cli- that they are intended. Accordingly, the intended signifi- nicians view themselves as communicating with rather cance of these meanings can be exposed by clinicians and than gathering data about patients. If a device, such as a corroborated through continued and iterative discourse checklist, violates this principle, other attempts should [44]. In fact, only through interpretation is on-going ex- be made at world entry. Follow-up questions can be change possible that allows a doctor and patient to interact asked, along with further discussion to flesh out a re- competently. At this point is where the importance of dia- sponse; more intimate consultations should be pursued. logue is revealed. Simply following rules, or step-wise instructions, may But dialogue goes beyond merely an exchange of foster precision but inhibit dialogue. But when the in- words. As a result, it is important that both a patient dexical thesis is dismissed, the best alternative is to enter and doctor try and enter each other’s worlds. In this re- language and the accompanying ambiguity. After all, the gard, the creative nature of language is fundamental, and significance of patients’ expressions is not found in ab- is the focal point of encountering someone. How per- stractions but in their worldly significance. sons interpret themselves and others is not something that occurs after their experiences but mediates the Conclusion process of knowing and interacting. Physician and pa- The main point is that clinicians must listen to their pa- tient, accordingly, must reflect and wade through a myr- tients [48]. But this message has been given priority in iad of interpretations to reach a common understanding, the past. Viewing language differently, however, makes which can always be reinterpreted and changed. Dia- this idea more compelling. With this different portrayal logue is thus always a fully interpretive and contested of language in mind, the rationale for listening extends exchange. beyond politeness or because patients expect this cour- Again, clarity is not the thrust of dialogue. After all, as tesy. Even a more serious appeal to acquire facts about a suggested above, dialogue is not neat but a process patient’s history is not very convincing. But now some- whereby assumptions are challenged until patients are thing more important is revealed by language that Franz and Murphy Philosophy, Ethics, and Humanities in Medicine (2018) 13:5 Page 6 of 7 compels listening [49]. That is, language use is basic to 2. Schmidt E, Schopf AC, Farin E. 2017. What is competent communication behaviour of patients in physician consultations? – chronically-ill patients creating and acquiring valid knowledge about a patient’s answer in focus groups. Psychol Health Med. 2017;22(8):987–1000. medical concerns. 3. 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From method to hermeneutics: which epistemological framework for narrative medicine. Theor Med Bioeth. 2017;38(3):179–93. 48. Frank AW. Letting stories breathe. Chicago: University of Chicago Press; 2010. 49. Zaner R. The context of self: a phenomenological inquiry using medicine as a clue. Athens, OH: Ohio University Press; 1981. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Philosophy, Ethics, and Humanities in Medicine Springer Journals

Reconsidering the role of language in medicine

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Abstract

Background: Despite an expansive literature on communication in medicine, the role of language is dealt with mostly indirectly. Recently, narrative medicine has emerged as a strategy to improve doctor-patient communication and integrate patient perspectives. However, even in this field which is predicated on language use, scholars have not specifically reflected on how language functions in medicine. Methods: In this theoretical paper, the authors consider how different models of language use, which have been proposed in the philosophical literature, might be applied to communication in medicine. In particular, the authors contrast the traditional, indexical thesis of language with new models that focus on interpretation instead of standardization. Results: The authors demonstrate how paying close attention to the role of language in medicine provides a philosophical foundation for supporting recent changes in doctor-patient communication. In particular, interpretive models are at the foundation of new approaches such as narrative medicine, that emphasize listening to patient stories, rather than merely collecting information. Conclusion: Ultimately, debates regarding the role of language which have largely resided in non-medical literatures, have important implications for describing communication in medicine. In particular, interpretive models of language use provide an important rationale for facilitating a more robust dialogue between doctors and patients. Keywords: Language, Philosophy of medicine, Narrative medicine, Doctor-patient communication Background clinical settings are often the focus of studies in the In the field of medicine discussions of language have literature on medical encounters. been relatively rare. Many readers, at first, may object to Most recently, narrative medicine has emerged as a this claim. After all, many articles and books examine prominent technique for integrating language and litera- the communicative competence of clinicians [1, 2] Med- ture into medicine [8–10]. The main point of this ical students, for example, are constantly reminded that approach is that patients construct stories about their they must learn to interact effectively with patients. lives, including their illnesses, that are vital to under- Additionally, issues related to translation, interpretation, standing their social and bodily conditions. The claim and cultural competence are constantly discussed [3, 4]. made by narrative medicine is that physicians, due to Perhaps a better way to state the problem is that in their training and focus on physical elements, have medicine language is dealt with mostly indirectly. Many historically ignored these storylines [11]. As a result, studies focus, for example, on the physician-patient rela- physicians make diagnoses or design interventions that tionship, the need for dialogue, the proper interpretation are culturally insensitive or, at times, irrelevant. As a of clinical records, and the power dynamic that exists corrective, the framework of narrative medicine encour- between doctors and their patients [5–7]. In other ages physicians to truly listen to their patients. words, the quality and type of interaction that occurs in Given this research and recent trends, how can a legitimate claim be made that language is ignored in * Correspondence: franzb@ohio.edu medicine? The answer is that in each of these cases, in- Department of Social Medicine, Heritage College of Osteopathic Medicine, cluding narrative medicine, language is involved but is Ohio University, Grosvenor311, Athens, OH, USA Full list of author information is available at the end of the article © The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Franz and Murphy Philosophy, Ethics, and Humanities in Medicine (2018) 13:5 Page 2 of 7 not the primary focus of attention. Any explanation of properly to be treated as facts or evidence [16]. The influ- the interaction patterns of patients and physicians pre- ence of language, in other words, is unavoidable and pro- supposes the use of language, but the nature of language vides the entrée to a patient’s world that is necessary for a itself is not usually in question. Even in most treatments relevant portrayal of illness or health. of narrative medicine, the stories patients tell are pre- The key issue here is that clinicians should be con- sumed to be informative. The issue remains to be ex- cerned about language use, given that interpretation is plored, however, whether the nature of language pervasive and plays a primary role in communication. contributes to this insight. The aim of this paper, there- For these reasons, a wide range of health professionals fore, is to demonstrate why focusing on divergent theor- should be interested in language. But in the field of ies of language is a practical consideration for clinicians. medicine, discussions of communication have mostly fo- Specifically, we argue that moving beyond the traditional cused on the transmission or dissemination of informa- theory of language is necessary in order to take seriously tion [17]. Nonetheless, there is something fundamental the stories offered by patients in the clinical encounter. about language that demands the attention of clinicians. Critical to narrative medicine is that both patients and Perhaps language offers access to information that is vi- clinicians bring perspectives to the clinical encounter that tally important to proper care. are relevant to patient care. Any concern for improving communication, so that these stories can be explored and Traditional role of language better guide a care plan, is only logical. When persons In traditional portrayals, language is described as being a speak, for example, they expect others to listen, and both tool [18]. This apparatus, moreover, differentiates physicians and patients are no exception. From the per- humans from animals, and represents a huge advance in spective of patients, having physicians listen carefully to evolutionary development. With the help of language, their insights is often appreciated given the time con- humans are able to identify specific elements, such as straints of clinical practice. Evidence suggests that patients behaviors and events, and make particular differentia- feel comfortable with caregivers who are attentive, and be- tions. Everyday life, according to this scenario, is no lon- lieve that such care is effective [12]. ger murky but, through socialization and training, can In this regard, narrative medicine deals with meta- be clearly demarcated. phors, literary anecdotes, and the need to approach per- The indexical thesis is the outgrowth of describing lan- sons or clinical records openly. Additionally, empathy is guage as a tool. There are two parts to this position. The extolled but this skill presupposes language use [13]. In first is that language is tied to cognition and represents these cases, the nature of language is not the prime con- human expressions. The second is that these expressions cern. Instead scholars of narrative medicine emphasize are attached to reality. This attachment, however, is cru- sensitivity to the narratives that both clinicians and pa- cial. Specifically, the link that exists serves to distinguish tients bring to the clinical meeting. These stories are be- factors and make these elements known. lieved to supply details that are often overlooked, but The metaphor that proponents often introduce at this which are important to quality care. juncture is of language as a pointer. As sentiments or ex- But is there a more compelling reason for physicians pressions are attached to objects, language is able to iden- and other service providers to pay attention to language? tify things, highlight differences, distinguish background The guiding theme of this paper is that the nature of from foreground, illustrate context, and isolate key features. language provides such a reason, and therefore the fun- Simply put, language can make distinctions and discrimina- damental character of speech should be investigated. tions and impose order on an otherwise nebulous mass of Philosophers and some other scholars have been raising input. What is important are the connections present be- this issue for some time, but in medicine such an inquiry tween language and the referents that are identified. has been mostly missing [14]. The key benefit of this rendition of language is that The defining methodology of this discussion is phenom- clarity can be established. In order to achieve this aim, enology, particularly the anti-dualistic stance of this phil- however, a precise link has to exist between a linguistic osophy. When Husserl states that “consciousness is always expression and a particular referent. Language and refer- conscious of something,” he is undermining a ents must be clearly, unambiguously aligned. When long-standing position that diminished the influence of these connections are clear, understanding is possible. language and encouraged the pursuit of objectivity [15]. Within the framework of the indexical thesis, precision But with language thoroughly intertwined with whatever is highly valued. As much noise, or ambiguity, must be is known, interpretation is elevated in importance by Hus- eliminated as possible from the relationship between serl and others who subsequently emphasized the import- language and all referents. Language use, accordingly, is ance of interpretation. According to these proponents, assumed to be clear when the referent of an expression events or behavior must be interpreted, or contextualized, is precisely identified. Franz and Murphy Philosophy, Ethics, and Humanities in Medicine (2018) 13:5 Page 3 of 7 When a person says “house,” for example, a particular [26]. In this case, the aim is to achieve the neutrality re- phenomenon should come to mind, with all of the per- quired to provide objective descriptions of a medical tinent characteristics. At first, the link between language problem. The assumption is that in following the acqui- and this referent may not seem problematic. In the con- sition of objective data correct diagnoses can be made text of medicine, on the other hand, these linkages are and the proper interventions prescribed. With objective not so obvious. When patients say that they do not feel evidence at the foundation, medical decision-making is well or are experiencing pain, establishing clarity is not supposed to become more rational. always easy. A certain amount of interpretation is, there- Clinicians and researchers have proposed a variety of fore, inevitable [19]. tactics to achieve this goal. But only three will be dis- Clinicians, nonetheless, must try to clarify the connec- cussed at this time. The first is based on the principle of tion between an expression of pain and a physical refer- measurement. Through an increased reliance on quanti- ent. This association, however, is mired in a host of fication, some have argued that clinical practices have social and cultural considerations that make this identifi- become more reliable [27]. Numbers, after all, are not cation difficult. In some cases of chronic pain, these as- thought to be culture-bound and thus should provide a sociations are incredibly vague and thus dismissed as precise description of events. A quick glance at a clinical fantasy or as medication-seeking behavior [20, 21]. What record reveals a propensity to describe many results in weighs heavily in this decision is the degree of precision quantitative terms and clearly counting is encouraged by that can be established, while trying to navigate various the implementation of electronic patient records [28]. In competing experiences and interpretations. practice, the language of calculation is concise and read- Physicians have the difficult task of trying to overcome, ily understandable. Everyone is assumed to know the or at least neutralize, the sources of uncertainty that may meaning of a 40% solution or the bio-data derived from affect language use. The clinical setting is hardly pristine. a stress test. Issues arise, for example, related to emotion, memory, past The second method relies on standardization and is experiences, and personality that compromise clarity. premised on a basic rule of logic. In this case, clarity is How is certainty possible when language use is influenced improved when mutually exclusive categories are by those considerations? What often happens is that at- adopted to classify events and behaviors [29]. With the tempts are made to marginalize these intervening factors elimination of any overlap, standardization is possible. In so that the referents of linguistic expressions become the absence of ambiguity, patient responses should be more clear. But the clinician, due to the uncertainty asso- similar to a particular query and any variation can be as- ciated with language, might have to engage hermeneutics sumed to represent these differences. The current prolif- and seek a proper interpretation [22]. Nonetheless, clarity eration of checklists and pre-programmed, easily is sought typically in other ways. processed forms is justified by this principle. The third tactic is the computerization of clinical prac- Clarifying language use tice. Consistent with the idea of technē described by Jac- The strategies that have been followed to seek clarity are ques Ellul, computers are thought to operate according based mostly on empiricism [23]. Specifically, the focus to ineluctable rules [30]. Expert systems, for example, is on collecting objective evidence. The assumption is are now available to conduct therapy sessions, organize that misunderstanding can be avoided only if the contin- clinical data, and make diagnoses [31]. The fact that gencies that often pervade language use are overcome. computers are reliable and faithfully follow instructions An image is created suggesting that language can be sta- creates an image of regularity and uniformity. In effect, bilized to avoid ambiguity. In the end, regularity must be computers do not tolerate ambiguity, and thus discipline established. how language is used. At this point, a central proposal of Cartesian philoso- But critics may argue that in a computerized record, phy, or dualism, comes into play [24]. That is, the at- space is often allotted for the thinking of patients, or tempt is made to strip language of the uncertainty their subjectivity, to be given consideration. In the stan- linked to culture, emotion, or personality, for example, dardized SOAP format, for example, both the Subjective that may taint communication in a clinical setting. The and Objective features of a problem are documented. aim of this maneuver is to restrict the influence of these Nonetheless, given this dualistic prescription, personal and similar interpretive factors, so that assessments are insights are treated mostly as supplementing the object- improved. Clinical decisions can thus be made on ob- ive descriptions, or are downplayed as anecdotal. In ei- jective data, as proponents of evidence-based medicine ther case, clinicians give primacy to what is believed to recommend [25]. be objective evidence. At this time, medicine is struggling with this issue, In each tactic, a similar practice is employed to pro- with almost an obsession to become evidence-based mote clarity–the illusion is created that language use is Franz and Murphy Philosophy, Ethics, and Humanities in Medicine (2018) 13:5 Page 4 of 7 not situated but universal. Quantification, after all, is clinical practice. This position is non-dualistic and chal- touted to be a universal, culture-free language. And be- lenges Cartesianism. Language, in this view, does not cause the use of computers epitomizes rationality, and merely highlight elements but participates intimately in thus is uninfluenced by human foibles, language appears the identification and arrangement of everything that is to be severed from everyday speech [32]. Hence the con- known. As suggested by Merleau-Ponty, reality is catalo- nection between an expression and referent is presumed gued through language, including the lives of patients. to be as clean as possible, divorced from alternative uses This image of language is poetic, but not according to of language and competing interpretations. the usual stylistic distinction between poetry and litera- But this search for precision generates an abstract and ture. In this context, consistent with Barthes, poetic false image of language. Specifically ignored is how persons, means that language is creative, evasive, but insightful and in this context physicians and patients, use language in [36]. Rather than obvious, meanings arise from contrast- everyday life. Joseph Weizenbaum calls this usage “natural ing interpretations. A patient’s interview or medical rec- language” [33]. The language that is imposed by clinical ord, for example, thus defies formalization and forms and checklists, for example, is rigid and unrealistic, immediate comprehension. and thus insensitive to how persons interpret themselves What this shift in thinking means, in clinical practice, is and their situations. Responses maybestandardized, and that clarity is not necessarily the gold standard. Because the thus precise, but the intentions of patients may be seriously influence of language can never be cast aside, a new way is misconstrued. What they have to say is easily concealed be- needed to think about valid knowledge. In this emerging hind clear, but irrelevant language. framework, even attempts to neutralize language merely What is important at this stage in this discussion is introduce other modes of talk under the guise of calculation whether the indexical thesis adequately characterizes and standardization. But because in those examples lan- language. Indeed, this theory seems to promote a por- guage is believed to be neutralized, many erroneous classifi- trayal that obscures how persons really talk, as a conse- cations and interpretations go unnoticed. quence of emphasizing clarity. This thesis, however, has Instead of seeking clarity, therefore, clinicians have a been eclipsed by another that treats language differently. different responsibility, if one is to take interpretation Charles Taylor calls this outlook “expressive-constitu- seriously. With all knowledge mediated by language, tive” [18]. In this relatively new approach, the aim is not clinical practice becomes a hermeneutic activity [37]. In- to overcome, or neutralize the influence of language, but stead of pointing to referents, linguistic expressions con- to appreciate how language use and the worlds of pa- vey messages that must be properly deciphered. And tients are basically connected. This realization, more- rather than clarity, clinicians might focus on making over, is purported to enhance clinical practice. sure they interpret information as patients intend. This outcome, moreover, is not necessarily achieved through Language that compels precise measurements or classifications. Because the hu- Because the indexical thesis is dualistic, the opportunity man condition, like prose is fundamentally interpretive, is open for objectivity; that is, subjectivity can be over- another strategy is required. come to confront objective facts. In this regard, the de- This change in orientation, however, does not neces- scriptive that is used is problematic, that is, a pointer. sarily mean that medicine should not be evidence-based, Language merely indicates something, thereby suggest- although some critics claim that sound practice may be ing that all referents can be examined objectively be- compromised [38]. What passes for evidence, however, cause their significance is not influenced by subjectivity. must be assessed anew. No longer are objective data, A proper investigation, of course, is necessary that relies captured through experimental practices, a reliable on empirical data. source of relevant information about a patient or com- Newer theories, however, adopt a different trope, one munity. In the absence of dualism, evidence has an exist- derived from literature. As Maurice Merleau-Ponty says, ential cast, and refers to the personal, and interpersonal, language constitutes the “prose of the world” [34]. His stock of knowledge or interpretations that persons or point is that as opposed to a pointer, language envelops communities use to define themselves and their persons. As a result, language use mediates everything situations. that is known. To paraphrase Roland Barthes, there is A hermeneutically-based approach recognizes the no other side to language, where objective connections situatedness of language, since one perspective or an- and referents reside [35]. People are permeated by lan- other is always revealed [39]. Clarity, therefore, is too guage; there is no escape. Language cannot be avoided limited and sterile. A life that is linguistically mediated is or tamed, so that objectivity is possible. never clearly exposed, but is engaged gradually through The unifying feature of new theories of language is a a process of give and take that is interrupted by check- focus on interpretation, which has clear implications for lists and computer-ready forms [40]. In this Franz and Murphy Philosophy, Ethics, and Humanities in Medicine (2018) 13:5 Page 5 of 7 environment, a clinician who hopes to communicate ef- understood in their own terms [39]. A clinician, for ex- fectively with a patient must stop imposing means for ample, must reflect on a patient’s expressions, try out an achieving clarity and pursue understanding. Medical interpretation, and possibly advance another option until practice thus has a very special aim–patients must be some agreement is reached. No outside authority should allowed to speak and be heard in their own voices. stifle this search; no objective support can be consulted. Any understanding, accordingly, is always tentative, due Looking for the world to the ambiguity of language. For even agreement in- As a pointer, language merely indicates something or an- volves interpretation, as opposed to a direct encounter other. But in interpretive theories of language, expres- with an objective connection or referent. sions are not pointing but are part of a process of What clinicians are trying to do, in other words, is creating knowledge. Understanding is achieved, accord- enter the linguistically inscribed world of patients. This ingly, not through clarity but a proper interpretation. activity is not as sterile as striving for clarity. There is no Rather than attempting to neutralize language, clinicians attempt to withdraw from or overcome the elusiveness must recognize the nature of language and attempt to of language, but rather a desire to become immersed in enter the elusive realm of interpretation. In this place, the expressions of patients. A world is announced in facts are always contested by rival interpretations, in- these stories that provides important insights into the stead of objective. Plagued by the creative influence of meaning of health and illness to patients, and how they language, referents of speech are never obvious, but will respond to these considerations [8]. must be disclosed through proper interpretation [41]. Focusing on these stories, however, can be problematic Accurate classification and standardization are no [45]. Not everyone tells the truth. Furthermore, some guarantee that mutual understanding will be reached. persons are reluctant to talk or exaggerate, and a class While adhering to what Gabriel Marcel calls the “spirit bias may be at the root of these differences [46]. But if of abstraction,” both processes rely on the imposition of the conditions for dialogue are created, these issues can strategies to foster clarity [42]. But such tactics, rather be addressed. There is a bigger issue, however, related to than culture-free, simply introduce interpretations that power and the resulting structural inequalities [47]. In- may occlude the situational effects of language. True un- deed, persons must have access to treatment before they derstanding cannot occur through this modus operandi. can tell their stories and be correctly heard. Narrative Instead of trying to neutralize language, how patients use medicine seems to skirt around this political issue. language must be unpacked [43]. Clinicians, for example, But in clinical practice, and community work, dialogue can learn to contextualize patient expressions and treat allows language use to be unpacked instead of avoided. them as testimonials that should be addressed in the way What this change signals for clinical practice is that cli- that they are intended. Accordingly, the intended signifi- nicians view themselves as communicating with rather cance of these meanings can be exposed by clinicians and than gathering data about patients. If a device, such as a corroborated through continued and iterative discourse checklist, violates this principle, other attempts should [44]. In fact, only through interpretation is on-going ex- be made at world entry. Follow-up questions can be change possible that allows a doctor and patient to interact asked, along with further discussion to flesh out a re- competently. At this point is where the importance of dia- sponse; more intimate consultations should be pursued. logue is revealed. Simply following rules, or step-wise instructions, may But dialogue goes beyond merely an exchange of foster precision but inhibit dialogue. But when the in- words. As a result, it is important that both a patient dexical thesis is dismissed, the best alternative is to enter and doctor try and enter each other’s worlds. In this re- language and the accompanying ambiguity. After all, the gard, the creative nature of language is fundamental, and significance of patients’ expressions is not found in ab- is the focal point of encountering someone. How per- stractions but in their worldly significance. sons interpret themselves and others is not something that occurs after their experiences but mediates the Conclusion process of knowing and interacting. Physician and pa- The main point is that clinicians must listen to their pa- tient, accordingly, must reflect and wade through a myr- tients [48]. But this message has been given priority in iad of interpretations to reach a common understanding, the past. Viewing language differently, however, makes which can always be reinterpreted and changed. Dia- this idea more compelling. With this different portrayal logue is thus always a fully interpretive and contested of language in mind, the rationale for listening extends exchange. beyond politeness or because patients expect this cour- Again, clarity is not the thrust of dialogue. After all, as tesy. Even a more serious appeal to acquire facts about a suggested above, dialogue is not neat but a process patient’s history is not very convincing. But now some- whereby assumptions are challenged until patients are thing more important is revealed by language that Franz and Murphy Philosophy, Ethics, and Humanities in Medicine (2018) 13:5 Page 6 of 7 compels listening [49]. That is, language use is basic to 2. Schmidt E, Schopf AC, Farin E. 2017. What is competent communication behaviour of patients in physician consultations? – chronically-ill patients creating and acquiring valid knowledge about a patient’s answer in focus groups. Psychol Health Med. 2017;22(8):987–1000. medical concerns. 3. 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