Linguistic Iatrogenesis

Iatrogenic disease refers to any disease resulting from the treatment administered by a doctor. In this article, however, the causal emphasis has been shifted away from what doctors do to what they say and how they say it.

Doctor-talk is a sub-language -- a language that only doctors understand. While there are certainly some nonprofessionals who possess a limited understanding of medical or chiropractic jargon, the majority of people do not. Hence, a potential language barrier continues to exist between doctor and patient. Not only is such a verbal barrier capable of creating feelings of alienation, it also is capable of producing actual dis-ease. In support of this hypothesis, may I offer a rather amusing anecdote:

A man of 52 returns home from having a routine physical examination. His wife asks what the doctor said, and he replies, "I have a 'flucky.'" Because the diagnosis had such an ominous sound he interpreted it as being fatal and took to his bed. Their son and daughter, away at college, were immediately called to his bedside. Shocked and confused by such a strange-sounding diagnosis, the son called the doctor for clarification. The doctor replied, "I did not say your father had a 'flucky,' I said he got off lucky."

Whereas such a facetious event is highly improbable, it serves to illustrate how vulnerable some people are to unfamiliar language, i.e., how easily doctor-talk can be misinterpreted. This is doubly true where English is not a patient's native language. While phrases such as vertebral subluxation complex, brachial neuritis, idiopathic hypertension, and scoliosis are familiar to the physician, they are totally incomprehensible to most patients. Furthermore, in the susceptible patient, such terms can cause downright fear and anxiety.

Superadded to the iatrogenic impact certain words can have on a patient is the way a doctor delivers them. Because so many patients come to a doctor's office harboring varying degrees of apprehension, they incline to be excessively sensitive to paralinguistic as well as linguistic messages. Paralinguistics, put simply, deals with how things are said. The variables it entails are such things as the pitch, volume, emphasis, and speech-speed of the human voice. An oncologist could say the word "cancer" in a variety of ways. Each, in turn, could affect a frightened patient differently. The chiropractic physician, likewise, could instill similar uneasiness with a word like "spondylolisthesis."

Students of health care history are well aware of how certain words, phrases, or incantations can evoke dire physical and/or mental changes in an impressionable subject. Voodoo is a classic example among true believers. Since time immemorial, diverse groups have capitalized upon the fear people have of the unknown. Every profession seems to have its own jargon designed to keep out the uninitiated. Medicine and chiropractic are no exceptions.

Words do not exist in a vacuum, but in a context. For instance, subluxation to the chiropractic physician is richly integrated with a host of neurological and biomechanical theory. To the inexperienced lay person, however, its concomitant nomenclature is meaningless. What then is the practical significance of linguistic iatrogenesis? To what extent should members of the healing arts address the impact their words have upon their patients? Obviously, this writer senses a compelling need for a heightened awareness among members of the chiropractic profession.

Diagnoses, like styles in clothing, go in and out of fashion. For instance, films in the '40s and '50s often portrayed high level executives with gastric ulcers. Back then, an ulcer was considered a status symbol -- a sign of success. Consequently, whenever an executive complained of stomach pain to a doctor, the diagnosis of an ulcer often followed.

Times have not changed that much. Some of today's fashionable diagnoses include: muscle spasm, subluxation, disc disease, breast cancer, hypertension, virus, sciatica, arthritis, hypoglycemia, et cetera. In effect, the public mind tends to expect certain diagnoses popularized by the media, and the professional mind delivers them. These forerunners, or precursors, contribute to the perpetuation of iatrogenic disease in health care. Ironically, doctors (as well as their patients) often succumb to the temptation of making these diagnoses when definitive objective results are not readily available or forthcoming. Not infrequently, patients come to their doctors suspecting they have a particular condition. The doctor then either confirms or denies that suspicion.

Where does one begin? A reasonable and rational starting point should be with unanimous consent; our profession must collectively agree, as the subtitle of this column suggests, that words have consequences. Language is the currency of exchange.

Let us now consider the doctor's voice. What overall reaction does it elicit in patients? Is it soft, gentle, and reassuring, or is it coarse, abrupt, and somewhat disquieting? It is common knowledge that the human voice is not a solitary entity, but rather a reflection and expression of someone's character, temperament, personality, and emotional disposition. The unsure doctor's voice, for instance, might be somewhat halting, tentative, or quavering, while the confident doctor's voice is strong, steady, controlled, and calming. Any treatment rendered should factor in the impact a doctor's voice has on a patient. Is the doctor's voice high or low-pitched? Field studies have equated the high pitched voice with emotions such as helplessness, tenseness, and nervousness; the low-pitched voice with strength and maturity. While these observations lack the exactitude of pure science, they do warrant some probationary attention.

The majority of doctors reading this column have only a vague notion of how they sound to their patients, or do they fully appreciate the fact that their voice can be re-trained. To find out the effect your voice is having on your patients, ask a few regulars this question, "Aside from what I say, how does the sound of my voice make you feel?" Some, of course, will be disinclined to say anything unkind, whereas the more direct and outspoken patient might tell you the truth. Not unlike the temptation to tell a dentist with bad breath to try some mouthwash, patients are reluctant to say anything negative. Not withstanding such reluctance, it is essential that all doctors discover their "vocal persona."

For some curious reason, members of the healing arts have placed more importance on what they say, rather than upon how they say it. This is not the case however with stage and screen actors. The way they deliver their lines could impact on an audience in a variety of ways. But theater-goers are not patients. Being shaken up by a compelling performance cannot compare with the shock a doctor can deliver with an ominous-sounding diagnosis. An innocent statement such as, "I think we should run some tests," could in itself be very unnerving to an already uptight patient. Such a statement could be delivered in a calm and casual manner, or slowly, solemnly, and with emphasis on the words "think" and "tests."

Become sensitive to the sound of your own voice. Record it on a good tape recorder. Practice saying these three simple statements in different ways to communicate different meanings. Each time, stress different words. For instance, "How are YOU feeling today?" or "How are you feeling TODAY?" or "How are you FEELING today?" Do this with all three statements and speculate how their meanings differ:

"How are you feeling today?"
"This area feels much more relaxed."
"What seems to be the problem?"

Do the same with any other phrase you use in everyday practice. Then, using a tape recorder, say them in different ways by changing pitch, emphasis, speech speed, and volume. Then, have your nurse or chiropractic assistant listen to the tapes and give you some feedback.

More than any other channel of communications, the human voice is the most revealing. The inclination of patients to regard their doctor as kind and caring frequently can be traced to how the doctor sounds when talking.

Linguistic iatrogenesis, therefore, should be taken seriously. Every patient coming into your office comes with a lifetime of experience (attitudes, values, and beliefs) with which your words, and the sound of your voice are punctuated. The word "punctuate" refers to how patients intellectually, culturally, and emotionally interpret your message. Assign the words you use and the way you say them a very high priority.

In a bygone era, something called a bedside manner was held in very high esteem. I strongly suspect that the curriculum in contemporary chiropractic and medical colleges fails to include a course titled "Bedside Manner 101." Legend has it that the most potent therapeutic agent in health care is the doctor. Would it, then not behoove each of us to pay significantly more attention to how we come across to our patients paralinguistically, as well as linguistically? Without question, "the doctor is the message." And the message could deliver either a curse or a cure.

Abne Eisenberg, DC, PhD
Croton-on-Hudson, New York

Editor's Note: As a professor of communication, Dr. Eisenberg is frequently asked to speak at meetings and conventions. You may write to him at 2 Wells Avenue, Croton-on-Hudson, NY 10520 or call (914) 271-4441.