Computers and informatics have become central to NHS healthcare. All experience and activity are now subject to official technical designations. This changes our communications: language becomes increasingly lackeyed to the computer’s requirements.
Much else is lost. What?
My first mentors in general practice and psychiatry – galvanised by the just departed 1960s – were all nourished, enlivened, then enlightened by literature and philosophy. Such proclivities were not ponderous or self-conscious postures, but pursuits that were shared with a mien of quiet and unaffected pleasure. I remember many conversations where, in order to understand others better, we made wefts of contemporary pragmatic practice with illuminated threads from drama, philosophy, literature or mythology.
The then-fresh Balint movement encouraged us to step up and out from our scientific base of standard diagnoses and treatments; while we recognised that these certainly helped us, they could do so only with generalities. So grounded, we were spurred to thoughtful experiment: to engage with the humanly speculative and imaginative – for these could help us, instead, with the individual: this person and this situation. To do any of this we needed to draw from a panoply of human thought and testament. Imaginative understanding of others is a kind of ‘play’, and for any successful foray into play we must encourage an expanded, rather than
constricted, language. For sometimes it is an unusual word, simile or metaphor that catalyses greater understanding and then rapport.
Even at the most pragmatic levels of service this previous broader and richer language was more likely to capture and convey the uncodifiable untidiness of real life, the crucial vicissitudes of Practice. I recently had an unexpected reminder of this, and it is a good example. While seeing Matthew, an amiably direct, stalwart and un-nervously jocular 35-year-old, I rummaged through his old manual records, where I found a mechanically typed letter from a hospital casualty
department. It was written to me in 1980 about a toddler, Matthew. Here it is:
Matthew P, age 2 years
This delightful little boy was brought here on Sunday morning by his very anxious and solicitous mother. Mother was worried by an alleged fever and cough of two days’ duration. Matthew himself was alert, bright-eyed, active and playful. He had no signs apart from a very mild catarrhal cough, which he didn’t seem to notice!
Mother seems a sensible and intelligent woman, but inordinately anxious about Matthew’s minor symptom. In talking to her it came to light that her own sister has recently been diagnosed with acute leukaemia. Understandably this has shocked and shaken the family. I had a long discussion with Mrs P in which I told her that Matthew is perfectly well apart from having a slight cold, and that her very real anxieties about her sister have unintentionally spilled over onto Matthew. I hope I have been able reassure her. I have taken the liberty of asking her to see you for follow-up.
Dr TS, CSO
All these years later I remember a couple of phone conversations I had with Dr TS – a warm, friendly, bantering northern voice that conveyed intelligent pleasure in his work, its people and their welfare. Reading this letter, more than 30 years later, brought me both joy and sorrow.
The joy was humble though clear; it was the memory of such quiet, subtle suffusions of personal interconnectedness: here Dr TS had shared with me his brief
connection with – but growing understanding of – Matthew, Mrs P and all her family. Matthew’s slight catarrhal cough was thus given much greater human –
and thus healing – meaning. This sent a gentle benign ripple across the whole matrix: we all felt better about ourselves, one another and our work. This is well-fared welfare.
But then came my sorrow, for the massive yet littlevoiced loss of such things. For it is almost impossible that I would receive such a letter now. Both because of, and in spite of, the endless blizzard of electronic, data-particled emails transmitted from my local airport-like hospital, I have with them almost no conversations enlarging my understanding of people. Dr TS’s personally sentient letter would now be replaced by an anonymised electronic, templated format. This would machine gun me didactically with tabulated impersonal data itemising myriad aspects of the (normal) physical examination; the healthy child’s
measurements of oximetry, temperature and respiratory rate; the immunisation status; the social status of the child and whether social services’ involvement has been triggered …. This surfeit of (usually) unedifying administrative detail would have neither space nor vocabulary for the brief glimpse of the importantly
unobvious; the human story that gives this (non) medical scenario significant and compassionate meaning. We have lost both the personal language of healthcare and its colleagueial discourses.
Such losses coalesce, then anchor. Eventually a restricted language and format will not merely confine description, it will – hypnotically – limit our thinking and
actions too. Language, thought and action are often less divisible than our analyses of them. Expansion or contraction, encouragement or proscription, nourishment or impoverishment – influence one and the others will probably change in a parallel way.
The more complex the human activity, the more this matters. We have seen, with Matthew, how language can service or disservice a relatively simple, yet humanlycomplexed, medical problem. Let us take a more intricate and chronic problem. Geoff is a troubled diseased man in his mid-30s. Here are two accounts from an encounter he has with a psychiatrist.
A: patient as object. Language as designation
G has a long history of agitated depressive illnesses with marked anxiety/panic components. Although his questionnaired depression scores were high, they were discrepant from the multi-disciplinary team staff ’s assessment. He has a poor record of maintaining work and long-term relationships. He also has problems with anger management: this was evident to the clinic staff when I was unavoidably delayed. This inconvenience was clearly explained to G, who nevertheless was unacceptably angry and rude to the staff in response. It is thus likely that G also has a personality disorder.
B: patient as person. Language as understanding
G has never recovered from the childhood terror and sorrow from his experience of father’s raging cruelty, brutality, and then final desertion. G’s life has been spent yearning for, but mistrusting, male support, esteem, affection and affiliation. He wants comfort from others, but fears betrayal, so disguises his needs. My lateness for his appointment seems to stir in him ancient residues of imperilled dependency, uncertainly and abandonment. His response to my greeting is staccato, flushed and tense: he seems both angry and afraid. I sense in him a conflation of fight and flight, and I think again of his wounded, early childhood.
If it were you that was distressed, which doctor would you wish to tend you?
One definition of the success of a specialty is that it replaces vernacular language with its own vocabulary. Thus specialisation both colonises and shortcircuits common speech, replacing this with its own distillate. The losses involved vary greatly: the dehumanising potential of ‘megaloblastic anaemia’ is negligible, that of ‘depression’ considerable. Archimedes’ notion of displacement is instructive far beyond the physical world: it often operates in the realms of human culture and language. The overgrowth of the technical and the schematic can all too easily – without malign design – extinguish the organic and the human. Our world of ever-increasing mass production has many hidden taxes. There are hungry conundrums, too: how do we safeguard literature in our language, art in our
(medical) science and heart in our practice?
A man is hid under his tongue’ Ali Ibn-Ali-Tabib, Sentences, (7th century)