To be sure we understand each other, permit me to define the word "obfuscation." Obfuscate: to obscure, confuse, bewilder. Beyond a doubt, for any practice to succeed, the meaning shared by doctor and patient must be made as clear as possible. Unfortunately, our language system fails to capture a great many of our thoughts and emotions. Words too often only approximate the meanings they were designed to convey. Connotations vary markedly from patient to patient and from doctor to doctor.
We are all familiar with the confusing language used by lawyers in contracts, agreements, wills, deeds, etc. Even more common are the warranties and guarantees that accompany practically everything we buy. Perhaps the best example of all is the gobbledygook we receive each year from the IRS. In each instance, communication breaks down because of the jargon.
Jargon is specialized language adopted by various businesses and professions because the existing language has no words that serve their needs. Notice the extent to which we have been inundated by terms spawned by the electronic revolution: bits, bytes, uplinks, network feeds, macros and modems.
Each profession has its own jargon -- its own vocabulary and way of speaking. Imagine the anxiety or even fear a dental patient might experience when being told, "Mr. Smith, you have a carious lesion requiring restoration." A sigh of relief comes only after the dentist explains what it means in simple language: decayed tooth must be filled.
Everything is fine when highly esoteric jargon is exchanged by chiropractic researchers and other specialists; sometimes it is even beneficial, since for those initiated into it, it may be precise, convenient and time-saving. One word may stand for an entire series of words or even sentences. Take the phrase, "sum of squares." In statistics, it refers to the sum of the squared deviations about the mean score. While those in the field immediately understand its meaning, outsiders haven't got the foggiest idea of what it means.
The paramount difficulty arises when specialists must communicate with the general public. A refreshing example can best be provided by the following little story:
There was once a plumber of foreign extraction who wrote to the Bureau of Standards in Washington, D.C., that he had found hydrochloric acid was fine for cleaning drains, and that it was harmless. Washington replied: "The efficacy of hydrochloric acid is indisputable, but the corrosive residue is incompatible with metallic permanence." The plumber wrote back that he was mighty glad the Bureau agreed with him. The Bureau replied with a note of alarm: "We cannot assume responsibility for the production of toxic and noxious residues with hydrochloric acid and suggest you use an alternative procedure." The plumber wrote he was happy to learn that the Bureau still agreed with him. Whereupon, Washington exploded: "Don't use hydrochloric acid, it eats the hell out of pipes!!"
It should be patently clear that, regardless of whatever one is speaking about clogged pipes, space probes, or misaligned vertebrae, the problem remains the same: a breakdown in communication traceable to how people use or abuse language.
Let us now focus on the jargon indigenous to the chiropractic profession. Not unlike our medical brethren, we too, casually use words and phrases that are unclear to our patients. Because our jargon plays such an integral part in our everyday communication, we often assume that we are being understood. Such an assumption is very unwise. Patients are notorious for misconstruing what their doctors tell them. Not only do they misunderstand the words and phrases doctors use, they also mispronounce them. To illustrate the tendency, permit me to cite two amusing examples:
The first one involves a 33-year-old woman who has just returned home after having her annual physical check-up. Her husband asked, "Well honey, how did your physical go today?" His wife replied, "The doctor said I had a fish in my canal and that if I had a baby, it would be a mackerel." It turned out that what the doctor actually told her was, "You have a deficiency in your canal, and if you have a baby, it will be a miracle."
The second story concerns a 41-year-old taxi cab driver who had been in America for only six months. One day, because he wasn't feeling well, he decided to see a doctor. When he got home, his wife asked what the doctor had said. He answered, "The doctor said I have a flucky." Convinced that this was a very serious condition, he got into bed and waited for his life to end. Terribly upset, his wife asked a neighbor to call the doctor and find out what really happened. To her surprise and amazement, she found out that the doctor didn't say her husband had a "flucky," but that he "got off lucky."
Putting aside these two facetious examples, let us now turn to some of the more common jargon used by the average chiropractic physician. With considerable confidence, I submit that our profession, on the whole, does more explaining than the medical profession. We take the time to explain how and why chiropractic works, and why we are performing a given procedure. As a result, we run a greater risk of being misunderstood. Field-specific jargon such as subluxation, fixation, spasm, musculoskeletal, biomechanical, vertebral misalignment, center of gravity, trigger points, exacerbation, palpation, scoliosis, and kyphosis are but a few of the terms we routinely use in our daily practice.
If you are a regular reader of this column, the acronym, C.O.I.K. will be familiar. It stands for Clear Only If Known. Practically all of us have been exposed to unfamiliar words and phrases when talking with an automobile mechanic, a television repair person, an accountant, or even an electrician. Convinced that you are an intelligent person, they glibly use the jargon of their trade as if you understood. Too embarrassed to ask questions, we reinforce the impression that we do understand what we are being told. Most of us fake it -- and so do our patients. While they may get the gist of what we tell them, our intended meaning may only be approximated.
What assurance do we have that our patients understand what we tell them? One way is to use familiar similes and metaphors in our descriptions and explanations. You will recall from your college days that a simile is a figure of speech in which two unlike things are compared using the words "like" or "as." Example: "Your heart is as big as your fist." A metaphor is a figure of speech in which a term is transferred from the object it ordinarily designates to an object it may designate by implicit comparison or analogy. Example: "You are all heart."
A comprehension of anything involves linking the unknown with the known. Each of our patients comes to us with a repository of knowledge in certain areas. Hence, our first step is to become aware that an understanding of what we say must find a source of correlation with what our patients already know, that is, the mental pictures they carry around in their heads. With few exceptions, people think in pictures, not words. You must, therefore generate recognizable pictures. As with the plumber mentioned earlier, describe the vertebral column using pipes and joints as similes and metaphors. With the computer programmers, use margin alignment to illustrate spinal alignment, or line spacing to depict the importance of disc height. Whatever word choice you employ, it must have some related meaning to the listener.
The pedantic practitioners among us run a special risk of obfuscating meaning through the use of sesquipedilia (polysyllabic words). Why they find it necessary to impress their patients with flowery and pretentious language is open to psychological speculation. Perhaps the etiology of such behavior is an anemic ego -- low self esteem. These individuals often equate simplicity with inadequacy when, in point of fact, the opposite appears to be the case. Communicologists repeatedly emphasize the importance of simplicity. Remember the plumber? "It eats the hell out of pipes!"
There are times, however, when jargon is appropriate. If you are testifying as an expert witness in court, you must sound like a doctor and, to sound like a doctor, you must talk like a doctor. First, answer the questions put to you using the language of your profession (technical talk). Then, if you are asked to explain what you mean in simpler terms, break it down for the jury to understand.
Inter-professional jargon is also a problem. The mere fact that medical and chiropractic doctors are both in the healing arts is no guarantee that they will employ the same jargon. Likewise, while the priest and rabbi are both members of the clergy, they also have jargon that differs. Popular opinion has it that educated people -- people with a degree or great knowledge in anything, should be able to understand one another. False. Obfuscation makes no distinction between levels of education and professional disciplines.
Here are several other linguistic factors capable of obfuscation. Audibility: If either party has difficulty hearing the other in a verbal exchange, obfuscation may result. Pronunciation: Not infrequently, the mispronunciation of a word will obscure its meaning. Take the word, "wound." Although standard pronunciation dictates that it phonetically begins with a "woo" sound, pronouncing it by beginning with a "wow" sound could easily jeopardize its comprehension. Accent: More and more patients, as well as doctors, come from other countries and pronounce English words differently. Semantics: What would be your reaction to a patient who complained of a "risin?" To the patient in question, it simply meant a bump -- a swollen area on the back of her neck which she called a "risin." Pseudoaffective behavior: where what people say and how they look do not agree. Example: A patient tells you he feels fine, but looks terrible.
In recent years, there has been a steadily growing interest in how to improve doctor-patient communication, how to minimize misunderstandings, and how to maximize patient involvement. However, despite good intentions, the problem continues. Perhaps educators in both medical and chiropractic colleges should assign greater importance to the role of doctor-patient communication. College catalogues exemplify this felt need by the conspicuous absence of adequate course offerings in professional communication. Journals follow suit by affording relatively little or no space to the subject of communication. Technology appears to dominate the health care scene, while the art of establishing a meaningful dialogue between doctors and their patients receives only marginal attention.
This column has identified some of the more common causes of obfuscation. Hopefully, readers will take the time to reflect upon their own communication skills and, by so doing, facilitate better doctor-patient relationships.
Before closing, one other point should be mentioned. Insurance carriers who provide members of our profession with malpractice coverage heavily emphasize the importance of good doctor-patient communication. Rest assured, a strong correlation exists between practice-related lawsuits and the breakdown in communication so often triggered by obfuscation.
Abne M. Eisenberg, DC, PhD
Croton on Hudson, New York
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