JAC Volume 4

Medical writing is a venerable field, relatively unknown in English and composition studies. Because so specialized, it obviously presents difficulties to humanists trying to influence it. In fact, we will never, I believe, effectively enter this area until we fully appreciate the structure and function of the medical model and its relationship to language.

To begin understanding these matters, we need first to recognize that a health care crisis now faces us, a crisis that seems to have many ramifications and many roots. Inaccessible or fragmented, inhumane or depersonalized care all seem to be both cause and effect of the problem, as does the seemingly vast difference between the efficacy of medical treatment and its cost. So grave has the crisis become that at least one U. S. organization (the National Fund for Medical Education) has decided to support programs that help increase communication and “otherwise enhance relationships between patients and their physicians.”² Another of its priorities for the 1980’s is to encourage programs that deal with the cost problems of health care.

Whatever the scope and cause of the medical crisis, many critics believe that much of the problem stems from an outdated world-view based on mechanistic, Cartesian-Newtonian science.³ Current medical practice is firmly embedded in this conceptual universe, which divides mind from matter, body from mind. The reasons for the development of this view and its adoption by medicine are fairly clear. For one thing, the Cartesian model initially fit well with the division imposed by the early Church on the mutable body and the immutable soul; the model could allow medical science to move forward, relatively unscathed by attacks from orthodox Christianity. The dualism at the model’s base had another practical benefit as well. It fostered a clarity in scientific investigations that a monistic approach would have muddied. Thus medical science began approaching disease “by focusing in a fractional-analytic way on biological (somatic) processes and ignoring the behavioral and psycho-social.”⁴ Medicine then and now has been, at heart, an empirical science. Though people in the field may want to change it, they have trouble doing so, partly because of its current size, partly because of its history,⁵ partly because of the real complexity of the problem that I make seem so simple.

A not entirely surprising concomittant of scientific dualism has been a lack of consciousness about the role language plays or can play in research and the healing arts. Medical language was originally highly metaphorical, its characteristic feature being the “application of names of familiar objects to bodily structures of similar form.”⁶ A quick thumbing through Gray’s Anatomy⁷ illustrates the point. There we find abdomen (perhaps from abdere omen, to hide an augury), possibly reflecting the ancient practice of reading the future in entrails;⁸ bursa, medieval Latin for “purse,” signifying the pouch lined with synovium near a joint; caverna—"caves”—referring to the various caverns of the body; coccyx, the Greek word for “cuckoo,” possibly referring either to the bird’s beak and its likeness to our tail bone or to the bird’s cry, which may resemble the sound of expelled flatus.⁹ We also find iris, Creek for “rainbow,” and mons veneris, the mount of Venis, commemorating the goddess of love and beauty; testes are also there, the “witnesses” to manhood, perhaps alluding to the Roman custom of allowing only uncastrated males to testify in court.¹⁰ Or look at Stedman’s Medical Dictionary,¹¹ where we find various metaphors for a number of diseases, everything from “angina,” the Latin for “quinsy” or the constriction produced from inflamed tonsils, to “diabetes” (“syphon”) to “priapism,” a chronic state of erection named for Priapus, the Roman god of the phallus.

All these terms reflect a commonality of experience, an attempt to give meaning to observed phenomena by relating them to the world in which we live. But we live in a different world now, and the language of medicine is one measure of how far we have come since the seventeenth century, since, in T. S. Eliot’s now discredited phrase, the “dissociation of sensibility.” “Caring units,” for example, can now describe loved ones, primarily, as one document put it, “in the form of spouse and/or children.” Or we find “emergent cases” instead of “emergency patients”; doctors come well-equipped nowadays with a medical “armamentarium” as they “interface” with society, trying to determine how trauma or disease has “impacted” on patients. Some medical metaphors are deliberately inaccessible now or sometimes even cruel. A doctor might describe an obese patient as having an “excess of signet ring cells”¹² or might allude to a patient’s "supratentorial lesion,” a malady existing only in the head. This term describes a lesion above the tentorium cerebelli, “the membrane separating the cerebral hemispheres of the brain above from the cerebellum below.”¹³ Whole sentences, paragraphs, and articles can be similarly filled with a “meta-language,” often with unintentionally amusing results. This sentence, for example, graces one article on how to improve doctor-patient communication and, thereby, a patient’s compliance with a prescribed regimen: “Finally a set of findings has emerged supporting the efficacy, relative to increasing appointment keeping compliance, of information provision in the form of reminding the individual at some point in time near the appointment date.” This means, I assume, that simply phoning or writing to a patient can help her or him show up for an appointment.

Modern medical literature abounds with such opaque structures, which far outnumber the illuminating metaphors that we find in earlier stages of the field’s development. In losing the sense of the metaphorical basis of their language, a sense of commonality of experience with other people, scientists have truly started developing sub-languages (“discipline-specific” languages, you might say). Some recent investigators, themselves steeped in Cartesian dualism, describe the development of such sub-languages as follows:

Occipital condyles rotate, thumbs oppose hands, and medicalese differentiates itself from its primitive mammalian forbears.

There may be some truth, however, in the Darwinian scheme, for medical language has always been primarily utilitarian, differing substantially, its modern practitioners more and more insist, from belletristic writing: it does not depend on rhetorical, metaphorical, or other “poetic” effects. This notion is endemic to scientific and humanistic disciplines and stems from two different ways of viewing language: as a tool for conveying facts directly to the intellect and as a phenomenon that encompasses affective, emotive, as well as intellectual realms. This polarization has usually made both camps fail to see some common ground. In the humanities it has fostered some disrespect for technical and scientific writing. In scientific writing, it has caused writers as eminent as Robert Day to claim that preparing a scientific paper has little to do with writing, per se¹⁵ and has produced hundreds of articles filled with well-organized but incomprehensible data.¹⁶ It has also produced floods of complaints from readers, complaints going back to 1848, when the American Medical Association appointed committees to review the state of medical literature. They all found it repetitive, usually too mundane, and almost always abominably written.¹⁷

Obviously, if complaints have been consistently lodged and consistently ignored, writing itself must stand on the periphery of science, the last painful, but not painstaking, stage in publishing research. Our task, it seems to me, is simply to recognize the role language and writing have traditionally played in medicine and then radically change that role. The Cartesian dualism affecting medicine affects all academic disciplines, dividing the sciences from the humanities just as arbitrarily as the body from the mind. We need a holistic approach to cognition and research. We need, to mix metaphors a moment, to push medical writing from the outskirts of town right into the center of town square, into the living room of Martin Heidegger’s “House of Being.” Or at least into his front yard. It’s for everybody’s own good.

“Lightly spoken,” you must be thinking. But not necessarily, for fortunately, the medical profession itself is starting to help us both theoretically and practically. On the theoretical plane, it has begun taking notice of the revolution in the other sciences and what that revolution means for our traditional concepts of reality, especially as they relate to the biological mechanism of disease.¹⁸ Consciousness changing theorems, such as Godel’s in mathematics (1931) and Bell’s in physics (1964) have called into question the whole notion of objective reality or even of the possibility of consistency within any logical system. The scientific model, in other words, the Cartesian dualistic model of mind and matter based on objective phenomena, is a myth. The “hard sciences” recognize daily that we cannot fully codify the laws of nature, and the medical sciences will, or should, follow suit. Programmatic changes in biomedical research have already been proposed in England, based on “a view of body, mind and spirit derived from general systems theory, developed first in theoretical biology and now applied in diverse disciplines from physics to physiology.”¹⁹ More and more scientists now recognize that the idea of an objective world unaffected by human consciousness is itself our subjective projection, an attempt to create God in our own image. Mankind’s spirituality, then—and with it, all the potential of the affective and emotive levels of language—has begun entering the world of science.

Niels Bohr, the father of quantum physics, is a prime mover behind what I hope is a continuing trend. He asserts that the world is so complex, the nature of a “thing” so multiple, that to describe it fully, we not only can, but must, use the language of poetry.²⁰ David Bohm, another physicist, goes still farther, proposing a whole new language called the rheomode, which comes from the Greek word meaning “to flow.” This new language would give primacy to verbs instead of nouns and reduce the emphasis on the dualism implicit in dividing subject from object.²¹ Theory has recently even affected practice. At MIT between 1972 and 1975, for instance, an art historian taught full courses on the aesthetic dimensions of science and technology, finally producing a book on the subject.²² Flux in language, as in “reality,” has thus been recognized as something useful in science, and the role language plays in acts of discovery is also starting to be taken seriously. We have moved from an amused and marvelling view of such mystical events as Kekule’s discovering the structure of the benzene ring via the image of a snake biting its own tail or of the Bohr-Rutherford model of the atom as an infinitesimal solar system to a recognition of how central metaphor is to discovery of any kind. Research at Harvard and within industry since the 1940’s on “synectics”—"the joining together of different and apparently irrelevant elements”²³—has focused partly on the role of metaphor in creative thinking, showing that deliberate use of metaphor is essential even in scientific thought. Analytical thinking alone usually becomes sterile and superficial, but the deliberate stimulation of new metaphors can raise analytical thought to a higher level.²⁴

Well, how does all this really relate to us, Ph.D.s in literature? “Scientists must teach scientists,” many people still insist,²⁵ so as humanists unaccustomed to the rigors of the scientific method, we would seem left out in the cold. We may not fully comprehend what the trends in medicine and the other sciences mean, or even how they began. But we can appreciate that our technological world is undergoing what Thomas Kuhn would call a paradigm shift,²⁶ and we can use our literary expertise to help repair the rift that Cartesian dualism has created, help release scientists from what some recognize as the imprisonment of their own language.²⁷ And we can do these things because actual practice in hiring writing instructors directly contradicts what a few authorities say should be done in a properly designed course in scientific writing. This is the practical sphere in which medicine is helping us out.

In 1981, a colleague and I surveyed American medical schools to find out how much writing instruction was going on and where.²⁸ Of the 101 schools responding to the survey—a remarkable 82% response rate, by the way—only fifteen offered writing courses. There is a paucity of courses, to be sure, but two things about the survey should encourage us. First of all, medical schools throughout the country show considerable interest in medical writing even if they do not themselves all offer courses in the subject. The majority of the respondents saw a real need for writing instruction of some kind in medical school but cited lack of curricular time or lack of qualified faculty as the major reasons for not offering such instruction. We can, I think, solve both problems relatively easily. When at UCLA, I, for example, made my courses integral parts of the students’ routines so that the writing course actually helps them with their other courses.²⁹ A full term course can be offered in conjunction with other courses requiring writing, such as a research methodology course, or the instructor can offer short seminars attached to such courses. I have also developed a videotape that condenses a course-worth of wisdom into a twenty-minute format.³⁰ There are certainly more tapes to be made and more uses that television and film can be put to.

We can solve the second problem almost as easily, for most schools offering medical writing courses use instructors with considerable scientific editing experience and backgrounds in literature or journalism, not professors of medicine. In fact, only one school in the country actually has a writing course taught by a regular faculty member holding an M.D. degree. This fact contradicts the long-standing prejudice against non­physicians teaching physicians and should reassure medical schools that may want, but do not yet have, writing courses.

And it should reassure us, too. If we are interested in this field, we must recognize that a genuine respect for it and a willingness to acquire professional editing experience are the two most important additional qualifications we can get beyond our graduate degrees. Beginning a medical writing course is in many ways a task of reassurance and reawakening—reassuring ourselves that the traditional cleavage between the humanities and the sciences may in fact be arbitrary, and reawakening ourselves and the sciences to the power of language, rhetoric, and metaphor in analytical thought. We have begun moving towards a holistic view of the individual; we must now move towards a holistic view of the intellect as well.