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Metaphors and ambiguity in health care

Most people who teach doctors and health professionals about communication with patients emphasise the importance of being very clear in everything they say. The Australian physician Paul Komesaroff has a different view. While science usually seeks certainty, Komesaroff suggests, clinical communication often requires ‘the deliberate preservation of uncertainty.’ Drawing on different sources including the philosopher Levinas, Komesaroff argues the case for respecting ambiguity in the use of language. He is not suggesting that we should deliberately use muddled expression and miscommunication. Instead, he sets out to challenge the view of language that dominates medical thinking, where one word or phrase is generally believed to represent only a single thing or idea. He points out how all effective communication has to start with a search for a way ‘to break through the curtain of mutual unintelligibility.’ This means opening oneself to ‘suggestiveness and allusiveness.’ It involves the careful, tentative use of ‘the same devices, rhetorical forms, figures and tropes generally eschewed by philosophers and scientists, but embraced by poets and creative writers.’ Speech, he reminds us, ‘is not a solitary or impersonal exercise or a thought, it is not a process of mediation among contested propositions; it is a shared adventure of creation and discovery.’

Thinking about this has prompted me to remember occasions when my own interactions as a family physician succeeded not because of medical knowledge, but through subtle exchanges of language, of the kind that Komesaroff is describing. For example, I remember a patient who came in saying: ‘There are three things I want to see you about.’ Something about her emphasis on the word ‘three’ led me to ask immediately: ‘What’s the fourth?’ She told me. It was the most important problem in her mind, and we never needed to return to the others. Another patient, angry at something I had said to challenge him, called me a ‘fat lot of use’ and stormed out of the room. His comment drew attention to the fact I was overweight at the time, but it turned out to be accurate in other ways as well. Two weeks later, he returned to say he had thought about what I said and decided it was true and useful. More recently, a patient came to see me with a chronic skin condition, saying she felt like Job in the Bible, who was afflicted with incurable boils. I asked why she chose that comparison, and she listed a catalogue of disasters in her life recently, including the loss of her job and home. We were then able to discuss how the Book of Job ends, with its hero restored to health and prosperity, and how ‘the Lord blessed the latter end of Job more than his beginning.’

Such consultations do not take place every day. As Komesaroff suggests, they can happen at critical moments, or when the mismatch between the discourse brought by the patient and the standard one offered by doctors is so great that we are compelled to explore radical alternatives. I would certainly encourage health professionals to look out for the times they manage to go beyond the banal formulas of everyday medical conversations, and find themselves moving into similes, metaphors, allusions, puns, humour, paradox or other imaginative forms of speech. If they did so, they would discover that medicine can be poetic, in the true meaning of the word.

Further reading: Komesaroff P. Uses and misuses of ambiguity: Uses of ambiguity. Internal Medicine Journal 2005; 35: 632–3.

 

 

John Launer,

Member of the Editorial Board of ‘Chronicle of Narrative Medicine’

Honorary  consultant at the Tavistock Clinic, London, 

Honorary president of the Association of Narrative Practice in Healthcare

 

[This article has been adapted by the author from his essay entitled “Medicine as Poetry” that appeared in the Postgraduate Medical Journal in May 2014 - Picture by William Blake]
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Member of the Editorial Board of ‘Chronicle of Narrative Medicine’, Honorary consultant at the Tavistock Clinic, London, Honorary president of the Association of Narrative Practice in Healthcare

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