His writing can be found at www.gilesdawnay.com and he is on Twitter: @gilesdawnay
‘The limits of my language mean the limits of my world.’ wrote the philosopher Ludwig Wittgenstein.1
It is easy to assume that when people share the same language, that they are in agreement on what they are talking about. Never is this more pertinent to the doctor-patient conversation where in a short space of time issues of potentially high importance are discussed, agreed upon (hopefully) and then acted out.
One of medicine’s great strengths is the precise use of language it employs to describe what and where it is diagnosing the issue in hand. The use of a Latin and Greek based vocabulary provide an outwardly neutral and objective framework by which we can describe the body and processes that are happening. It allows such a high level of abstract precision that if done well, another professional who is not in the room is able to picture, understand and engage with what it is we are talking about.
There is little room for nuance. Unlike in the arts, our scientific words have one meaning and one meaning only. The aim is for everyone to be in agreement of what they signify. Once we have learnt how to use this medical vocabulary, then our professional lives invariably become infinitely easier. How many of us have been that flailing medical student/junior doctor simply unable to express what it is we want to say under the unforgiving gaze of that gnarled yet fluent consultant. It is perhaps the closest we’ll ever come to re-experiencing the throes of a pre-verbal childhood that took place long before we can even remember.
This, of course, would be fine if we only spoke amongst ourselves in a professional capacity. And herein lies the challenge hidden in plain sight. How do we adequately communicate our understanding of what is happening to the patient who arrives in our professional space with a potentially completely different sense of language and understanding? Wittgenstein in his ‘Tractatus’2 hypothesizes that the origin of all confusion is the fundamental inability to agree upon the meaning of the words used.
I remember sitting in a clinic when I was training. The consultant was discussing a scan with a patient that had, in his words, ‘benign tumors, and so nothing to worry about.’ The patient came back to the word tumor again and again. The conversation became frantic and circular. The patient left with the consultant visibly irritated about this reaction. ‘What’s the problem? I said it was benign.’
There are also countless examples in the earnest medical lexicon of how confusing or even inadvertently hilarious our wording must sound. I remember when I first heard about a cardiac insult, I couldn’t help but wonder who had said something rude to the heart? Or that even we talk about ‘positive findings’ that normally mean we have found something concerning.3
Language is the beginnings of our understanding of the world. The words we use form the building blocks or ‘picture of the reality’4 that we perceive. But do we truly ever agree on the meaning of them. For example, when you think of the color ‘red,’ is it the same red I am thinking of. What memories does that word provoke, how does it make you even feel to think about it? Imagine then words like health, sickness, disease, pain or death. We might all be sharing a similar space and using the same language, but are we all describing the world in exactly the same way? Language has a unique paradox, it can both deeply connect but also alienate us depending on how we perceive the words used.
One of the great criticisms that has been levelled at the medical profession over the years is the impenetrable language that we conduct our work in. Similar to the high priests in the middle ages who preserved the word of God in Latin so that the common man of the congregation had no agency to interpret it, they kept themselves both powerful and in a position of vital authority. Perhaps in today’s post-enlightenment landscape of the rational biophysical, the body is now our modern Bible.
If this has some truth in it then to truly connect with our patients (and other human beings in general), we need to try and understand the words they are using, and to tailor our own language accordingly. Their world is unique and often very different to ours, and unless we strive to cross the divide, much of our work will be repeatedly lost to the seemingly invisible air in which our meeting takes place.
- Ludwig Wittgenstein Tractatus Logico-Philosophicus.6 (1921)
- Ludwig Wittgenstein Tractatus Logico-Philosophicus 3.223, 3.2
- Emily Smith, What a patient with a learning disability would like you to know, BMJ. 2016; 355: i5296. Published online 2016 Oct 5. doi: 10.1136/bmj.i5296
- Ludwig Wittgenstein Tractatus Logico-PhilosophicuTractatus 4.01
Featured image: ‘Door carving’ taken by Andrew Papanikitas, 2021