07 November, 2014

Native language

Midway through my second year of medical school, I attended a holiday party at a neighborhood bar with a bunch of my classmates. The mood was festive. Exams were finished. Tequila shots were passed around. I hovered halfway between two groups, listening to both conversations but not really a part of either.

At then it struck me: Even tipsy - even steadily marching toward alcohol poisoning in a few cases - everyone continued to converse fluently about "basic science", the courses in biochemistry, anatomy, physiology, pathology, and so on that we all studied during the first two years of medical school. Their vocabularies were peppered with medical terminology. True, I would not have trusted any one of them behind the wheel of a car, much less in an emergency or operating room, and I doubt anyone would have been happy to see a standardized test, but I saw that we had passed a sort of point of no return: the point at which our subconscious minds began to belong more to medicine than to the rest of the world.

From there, it only gets worse - if our goal as physicians is to remain well equipped to relate to our patients and their families. (And our own families.)

By now, eleven years in, I must admit that medicalese is closer to my native language than my real first language, American English. Of course, it's not different enough from English to qualify as its own language, or even its own dialect. But I would venture to guess that medicalese has more unique words, and worse, more common words used in unique ways, than one would find comparing British to American English. Even the grammatical structure is subtly different, and that changes the way I think. 

I call it my native language because it's now the language that I hear in my head, when I talk to myself. The language I write first drafts in, unless I'm very deliberately trying to avoid it. The language I fall back on when I'm sleepy or flustered. When my son had a developmental evaluation, the therapists were surprised of some of the complex commands he could understand; I was not, because they fit the structure of the language of medicine, and I know he hears it often.

Doctors are justifiably criticized when they used big words and funky acronyms that most patients would never have had reason to learn: Carcinoma, for cancer. FUO, for fever of unknown origin. But I find that with a half-effort, we can avoid these fairly easily, or at least write them down for patients and explain their definitions. Saying "PRBCs" is a mouthful; "blood transfusion" is much easier.

What is much, much harder is remembering all the "normal" every day words that have been co-opted as medical jargon and the weird ways in which I've learned to construct sentences.

What I thought was: "Some types of subcutaneous mass are non-malignant and may self-resolve, without necessitating without further intervention."

What I said was: "This could resolve on its own."

But what did my patient hear?

I paused as soon as I said it, as I wracked my brain, trying to remember whether using "resolve" to refer to a symptom or illness was a normal thing to say. Would my mom have said to my sister about her cold, "It will resolve on its own." Probably not. But they would understand, even if they wouldn't say it spontaneously. On the flip side, my mom and sister both have advanced degrees and backgrounds in psychology and mental health, and talking about one's cold isn't quite on the same stress level as talking about a child's potential life-threatening illness - plenty of studies have shown that people under stress aren't functioning at the same level that they normally would - they aren't able to grasp the same concepts that they would under normal circumstances.

Back before I had an empirical basis for thinking about this, a friend (then a medical student) who had just had his first child with his wife (a general pediatrician) told me that they selected their son's pediatrician because he talked to them like they were "just like any other parents." He said his wife wanted someone who would treat her like she was "just a mom" - meaning, not like a doctor, or a pediatrician. I was a little skeptical, but I had neither kids nor a medical specialty, so I just shrugged - of course, everyone is entitled to their own opinion and reasoning when choosing a medical provider.

But ten years on, as a mother, a daughter, and a pediatric oncologist, I can't imagine wanting a physician to address me as if I didn't have a medical - and science - background. For one thing, it would feel condescending. But more importantly, it would be confusing. Sometimes medicalese is unnecessarily cumbersome, trumping our own feelings of importance in the world (as doctors) and deliberately obscuring our discussion from the comprehension of our patients (that seems to be especially the case with acronyms). That, happily, is the minority of its use. Most of the time, we use specific medical language because it's more precise. Like the oft-repeated story of the Eskimo language having dozens of words for different types of snow, I have dozens of words and descriptors to describe different types of broken bones.

When I translate my thought process - in my now-native language - into American English, details are lost. Something is always lost in translation, right? And when someone else - whether it's a patient in a clinic, or a friend at a bar, or my own doctor who thinks he's doing me a favor by speaking "plainly" - tells me a story about health, in my head, I'm trying to translate it  into medicalese, so I can better understand it. But it is imprecise - I'm often left guessing about all the information that English doesn't have words to convey, at least not succinctly. Literal translations of complex ideas from medicalese end up being tremendously wordy and almost impossible to follow.

For example:
Absolute neutrophil count (ANC) - a measurement of the amount of a specific type of white blood cell (the neutrophil) that usually fights off bacterial infections.

I thought that was not terrible, but Microsoft Word informed me that it was written on a twelfth-grade level and has a Flesh-Kincaid reading ease score of around 35 (easier is higher, up to 100). Oops. So I played around with it until I managed to write a description at a fourth-grade reading level (which is what we usually aspire to, in order to reach the lowest common denominator of patient literacy and education). It went like this: "How many of a specific kind of cell you have in your blood. This cell is called a neutrophil. It fights off infections from bacteria."

Ugh. I would have a hard time talking like that and not sounding robotic, I think.

I haven't quite figured out what this all means for me, personally, or for the ideal of the medical profession. I once considered myself somewhat unusual among my colleague-friends, because I wasn't "premed" for most of my college years, my undergraduate degree wasn't in biology or chemistry, and I imagined I could have just as easily pursued any number of other careers. Joining the foreign service or going to law school were high on the list at the time. Later, I contemplated finishing an anthropology Ph.D. or applying for an MFA in creative writing (always more school where I'm concerned) and becoming a novelist. Often, I puzzled over why I never seriously considered journalism: when I had to do a "what would you be if you weren't a doctor?" icebreaker, I picked "foreign correspondent."

Now I have a unique "best of all worlds" sort of job. I occasionally wonder if I could ever give up practicing medicine - I do really want to write that novel - but I think not. I think it's a part of my identity, my consciousness, in more ways than just my native language. Of course, language is culture, and culture is identity, no? Language shapes the very way we allow ourselves think. 

"To have another language is to possess a second soul."
- Charlemagne