A Reflection on Language, Epistemology, and Medicine
One of my favourite physicians, Dr. Viktor Frankl, once wrote that an individual’s freedom is found between a stimulus and that individual’s response.
Let me illustrate the triangular conceptual map with a personal, real world example:
I ended up with a very nervous patient in the Emergency Department the other day.
It’s not uncommon to see people come in worried about the onset of new, sometimes never before experienced symptoms, and bring up other health concerns that have been on their minds for years. Their bodies are in a state of hightened stress that is only aggravated by the ER’s frenzied environment, and their minds follow suit and devise a list of problems to be fixed.
“Doctor, may I ask you one more question?”
The patient, in this case, was the stimulus who would automatically garner a response from me.
My initial, verbally unexpressed response?
This is the third time you’ve asked to ask one more question. The previous two were related to long-term issues that are not emergent and which you ought to be tackling with your family physician. Furthermore, they’re unrelated to your chief complaint, which might not even be emergent, in the first place. I have seven other people waiting to see me, and I still have to order a number of tests to ensure that you’re OK.
I could have chosen freely to vocalize my impassioned response, which probably would have left the patient feeling even worse than before.
But instead, I freely chose to take a deep breath, and recall the time I asked a doctor a lot of questions only to be later deemed “a difficult patient.” I attempted to empathize with the patient and realized that these recent manifestations of illness were far more than pathophysiological processes; they were earthquakes that shook this patient’s sense of identity and self-worth. I realized that spending a few extra seconds to address those concerns now could prevent additional and unnecesary visits to the ER later.
So I would smile, nod my head, and respond with an emphatic, “Of course!”
Sometimes I’d even throw a joke in to lighten the mood a little.
A few hours later, while frantically typing in orders and reading through a chart to prepare for my next patient, I felt a hand softly land on my right shoulder.
I turned, saw my concerned patient, and anticipated answering “one more question.”
“Doctor, I just wanted to thank you for taking the time to answer my questions, and I really appreciated your sense of humour. You really helped me, today.”
I share this story not to brag, but to share my genuine shock and amazement. When I had initially felt rushed and agitated, I was convinced that my patient was picking up on it.
But that wasn’t the case. The only thing my patient had picked up on was the result of my effort to elevate my mind beyond a base and rash reaction. The stimulus was reacting not to my own automatic response, but to the response that I had filtered and molded with my freedom.
I also share this story to draw a parallel between Frankl’s tripartite map and another philosophical model that I’ve been pondering as of late.
Medicine is a science-heavy field that requires diagnostic precision in order to ensure the best possible outcomes.
It’s also a socially conscious one that relentlessly strives for the public’s betterment.
Advocacy groups in medical schools defend every possible cause, and doctors are always making their opinions known when it comes to hot public topics. Just take the gun debate, for example.
Which is why I’m so surprised that we use the word pimp so much.
To put it into context, hospital-based physicians will round on their patients in the mornings, often accompanied by other healthcare professionals, residents and medical students. The traditional practice has been to walk from bed to bed and discuss each patient’s most responsible diagnosis and corresponding treatment plan, while taking the opportunity to teach the residents and students present.
We were prepared for this practice in medical school, being advised to read amply prior to our different rotations. But we weren’t told to be ready to be quizzed, questioned, challenged, or even taught.
Instead, we had to be ready to get pimped.
“The doctors’ll pimp you for answers”, they would say.
The term never sat well with me.
Psychiatrists had told me not to call their patients crazy and family physicians had told me not to call their patients fat, so there clearly existed an awareness of the fact that the language we used influenced the way we thought about the objects we described.
But for some reason, there seemed to exist a comfort in ignorantly likening doctors to pimps.
Merriam-Webster defines the term in three ways:
- Noun: “A criminal who is associated with, usually exerts control over, and lives off the earnings of one or more prostitutes.”
- Transitive verb: “To make use of often dishonorably for one’s own gain or benefit.”
- Intransitive verb: “To work as a pimp.”
A fourth, informal definition is “to make showy or ostentatious.” Hence, pimping my ride.
When I look at these four definitions, there’s really no discernible way to redeem the word’s use in medical education. As a physician, I don’t see myself as a criminal who exerts control over learners. The doctors who did treat me this way as a learner only inspired me all the more to break the chain and ensure that I would empower – not crush – the students that would be entrusted to my care. The students that are training with me are eager to learn, so I will not dishonourably ask questions for the sake of public humiliation and the superficial inflation of my own ego – answering a question during rounds shouldn’t feel like a disgusting blowjob in a dirty pickup truck behind a liquor store.
Much less will I be trying to ostentatiously display my knowledge, only to foster greater envy, resentment, and secluded individualism among my colleagues. If there’s something we need more of in medicine, it’s collegial teamwork. Pimps never work in teams. Doctors are supposed to. So let’s stop being pimps, and start being doctors.
And as a first step, let’s stop calling ourselves pimps.
Freedom was the tool that I used to build a bridge between a stimulus and a response in a therapeutic encounter with a worried patient in the Emergency Department.
And language is the tool we use to build a bridge between being (the world as such) and thought (the perceived world). The way we speak about someone or something will influence the way we think about someone or something, and vice versa. I don’t think of myself as a pimp, and I don’t think of my successors in the medical field as prostitutes, so I won’t be using those words to talk about us.
I’m not vouching for social campaigns or policy changes. It’s not how I wish to propel the cultural change that I’d like to witness in medical education.
Not to sound cliché, but I’d rather be the change that I’d like to see.
1.) If I hear someone use the word pimp in the context of medical education, and I have the opportunity to do so, I’ll ask the speaker what she thinks it means and why she chooses to use it. I’ll try to spark a collective conversation, one encounter at a time.
2.) I will continue honing my Socratic teaching method by identifying what the learners ought to know for their level of training. For example, if I’m keen on quizzing a third year medical student about the liver, I’ll ask about the potential complications that can stem from cirrhosis, rather than oblige him to ramble off the criteria that comprise the Child-Pugh Score for Cirrhosis Mortality.
I’ll save the criteria for the third year internal medicine resident who wants to subspecialize in gastroenterology.
3.) I will ask specific students and I will throw questions out to the entire crowd, leaving them open to whomever wishes to answer. When a student answers incorrectly, rather than vaguely instructing him to “read more” about the subject when he gets home after his long and exhausting shift, I will offer a succinct explanation, and at least try to offer one or two specific references for additional reading.
I did come across a comment written in response to a post on the use of the word pimp, in which the writer clarified that in medical culture, it’s an acronym that stands for “put in my place.” Again, do I view myself as an authoritarian disciplinarian who reigns over her worthless minions? No. No I don’t.
I see myself as an agent who encourages and empowers.
It’s actually the more scientifically sound way to view myself, others, and education, since research has shown that “focusing people on their shortcomings or gaps doesn’t enable learning. It impairs it.” (“The Feedback Fallacy“, Harvard Business Review, Mar-Apr 2019)
(C) Laughsatives ’19