Copyright © 2014 by Eva Berger and Isaac Berger

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www.generalsemantics.org

First printing

Cover & Interior Book Design by Scribe Freelance

ISBN: 978-0-9860764-8-0

Published in the United States of America

Library of Congress Cataloging-in-Publication Data

Berger, Eva, Dr., author.

The communication panacea : pediatrics and general semantics / Eva Berger, Isaac Berger.

p. ; cm. -- (New non-Aristotelian library series)

Includes bibliographical references and index.

ISBN 978-0-9860764-8-0 (pbk. : alk. paper)

I. Berger, Isaac, 1938-, author. II. Institute of General Semantics, publisher. III.

Title. IV. Series: New non-Aristotelian library series.

[DNLM: 1. Pediatrics. 2. Semantics. 3. Communication. 4. Physician-Patient Relations. WS 100]

R727.3

610.69'6--dc23

2014041410

For Zlate

Other titles included in

The New Non-Aristotelian Library
Series

Corey Anton, Series Editor

Korzybski, Alfred (2010). Selections from Science and Sanity.
2nd Ed. Edited by Lance Strate, with a Foreword by Bruce I. Kodish. Fort Worth, TX: Institute of General Semantics.

Strate, Lance (2011). On the Binding Biases of Time and Other Essays on General Semantics and Media Ecology
. Fort Worth, TX: Institute of General Semantics.

Anton, Corey (2011). Communication Uncovered: General Semantics and Media Ecology
. Fort Worth, TX: Institute of General Semantics.

Levinson, Martin H. (2012). More Sensible Thinking
. New York, NY: Institute of General Semantics.

Anton, Corey & Strate, Lance (2012). Korzybski And …
(Eds.) New York, NY: Institute of General Semantics.

Levinson, Martin H. (2014). Continuing Education Teaching Guide to General Semantics
. New York, NY: Institute of General Semantics.

CONTENTS

Foreword

Introduction

PART I

Chapter 1--Semantic Iatrogenesis

Chapter 2--The Semantic Environment of Pediatrics

Chapter 3--The Communication Panacea: Pediatrics and General Semantics

Bibliography

FOREWORD

I
N 1963, WHILE living in Chicago for his residency with his wife Zlate and one year old daughter Eva (his co-author of this book), Zlate told Isaac that her sister would be coming for a short visit from Mexico. In a solemn tone, she asked him to sit down with her in the living room, as she needed to talk to him. Not knowing what to expect and getting ready for some dramatic news, he heard from his wife for the first time that her sister was diabetic. She was diagnosed years before but had been prohibited by her mother to tell anyone, as was everyone else in the house. Zlate had been told not to tell Isaac, in spite of the fact that he was a physician, for fear that the news would prompt him to leave her. And the sister herself was not allowed to mention it because if she did, nobody would want to marry her. But there was no choice now. Mina would be arriving in a few weeks with her medicine and her syringes, so there would be no way of hiding the disease from him and, besides, he was a doctor and he needed to know so that he could help if there were any problems.

Mina was diagnosed with Type 1 diabetes (formerly called juvenile-onset or insulin-dependent diabetes) at the age of 12 at a time when treatment was much more complex and the chances of surviving beyond a certain age were much slimmer than today. The diagnosis was thus a terrifying label that put great psychological pressure on children in addition to the difficulties that came with the measuring of sugar levels, injecting insulin a few times a day, and abstaining from eating many of the foods loved by children. And there was the cultural context, too: A Jewish family of European immigrants to Mexico for whom marriage was very important.

Mina died at the age of 30, survived by her loving sisters, her husband and her daughter.

Diagnoses are the names doctors give to combinations of symptoms. They are the labels given to illnesses, guiding much more than just treatments and decisions about medication. Depending on the social and cultural norms, as well as a patient’s personal psychology, an illness, its diagnosis, can mean, in addition to the objective physical symptoms of the disease, the degradation of a person’s identity and a permanent stigma. Diagnoses can be iatrogenic labels. In other words, they may intensify stress, define incapacity, impose inactivity, and focus on uncertainty which leads to the loss of autonomy for self-definition. They often isolate people in their role as patients, separating them from the normal and healthy, and requiring submission to the authority of doctors and nurses.

Awareness of the language of medicine and its implications on health care, including diagnoses, especially in the context of pediatrics, is at the heart of this book and it brings together the professional fields of its authors. Isaac is a retired pediatrician with over 50 years of experience and Eva, his daughter, is a professor of Communication.

At some point it became clear to us that our conversations throughout the years always revolved around the semantic environment of medicine and that we shared our passion for thinking of ways to make that environment as pollution free as possible. The book was born at the Eureka moment when we realized that the principles of General Semantics provide the most coherent framework for thinking about the subject, and that without being aware of the specific principles during his career, Isaac had intuitively acted based on them in the treatment of his patients.

We would like to acknowledge a number of people whose help and support made this book possible. First we would like to thank Corey Anton, General Editor of the New Non-Aristotelian Library; Marty Levinson, President of the Board of Trustees of the Institute of General Semantics; and Lance Strate, Professor of Communication and Media Studies at Fordham University and old friend.

We would also like to thank Yuval, Eva’s husband for his patience, support and encouragement as well as his smart criticism, his suggestions and his love. We thank Etai and Jonathan, Eva’s sons and Isaac’s grandsons, for so naturally talking to their mother for months with the back of a laptop covering half of her face. And we thank Zlate, Isaac’s wife and Eva’s mom, for her enthusiastic participation in all of our conversations and her aid to Isaac in recalling the stories of his patients. We dedicate the book to her.

Finally, Isaac wishes to express his gratitude to all of his patients and their parents throughout the years for their lessons of courage, of gratitude and of love.

INTRODUCTION

Doctors will have more lives to answer for in the next

world than even we generals.

—Napoleon Bonaparte

T
HE PAST 50 YEARS or so have been characterized by an increasing dissatisfaction with the relationships between doctors and patients. To paraphrase Wildavsky (1977), people seem to be doing better but they are feeling worse.

Developments in medicine, along with improved diet and public health measures have reduced deaths from infection and extended life. Doctors are saving people who would have died only a generation ago. But alongside the scientific progress and new cures available, clinical practice keeps getting increasingly impersonal, commercialized and technological. Patients are more doubtful about how genuine doctors’ concern for them are as people, and doctors feel that patients are becoming less compliant and are more challenging to their authority.

The dissatisfaction stems, at least in part, from patients’ conception of the historical ideal of the personal or family physician that had trusting and long-term relationships with their patients. Doctors still see patients, of course, and some even have long term relationships with them, especially in the realm of primary care. But the environment in which these encounters take place has changed. The relationships take place now in impersonal settings such as hospitals, emergency rooms or clinics and they are usually hurried, mediated by technology, and paid for by third parties.

The cultural conception of doctors at around the end of the nineteenth century was, as Shorter (1991) explains, of wise and observant men, as can be learned from art of the era such as Luke Fildes’ 1891 painting, The Doctor
. They relied less on instruments and more on compassion and good judgment and they were almost exclusively male.

By 1920, public health measures had reduced the incidence and in some cases entirely eliminated many diseases such as smallpox, yellow fever, cholera or typhus, and over the course of the twentieth century, patients began to visit doctors more often for less serious conditions such as colds or skin problems. But in spite of the increased scientific knowledge, some infectious diseases such as tuberculosis, diphtheria or scarlet fever remained lethal until the 1940’s and 50’s.

The modern doctor-patient relationship developed against this background. It was very common for doctors to make house calls to patients suffering of these diseases, and the house calls entailed a careful physical examination. Patients did not expect to be cured, but they did expect to be cared for and comforted, which was believed to have healing powers in itself.

These encounters were, however, not entirely tension-free, as even then the doctor’s livelihood depended on the fees paid for his services, so he had to satisfy the expectations of his patients which wasn’t always an easy task. As George Bernard Shaw put it in The Doctor’s Dilemma
(1911):

The doctor who has to live by pleasing his patients in competition with everybody, who has walked the hospitals, scraped through the examinations and bought a brass plate, soon finds himself prescribing water to teetotalers and brandy or champagne jelly to drunkards; beefsteaks and stout in one house, and uric acid free vegetarian diet over the way. (p.1xxxi)

To this tension between the self-interest of the physician and the best interests of the patient, a new one was added between the increasingly technological and biomedical focus on disease and the care of the patient.

Major diagnostic technologies developed such as the microscope, X-rays, the sphygmomanometer (to measure blood pressure), and electrocardiographs among others. These transformed the measurement as well as the perception of disease and paradoxically, as the technologies made their way into offices of family doctors and hospitals, the personal relationship between physicians and patients began to weaken. As medicine became increasingly scientific, it also became more impersonal, mechanistic and remote. The emphasis moved from patients to disease, doctors began to be more and more specialized, and the availability of family doctors and primary care physicians who knew their patients as a whole person and who had lasting relationships with them decreased. As the humanist physician Sir William Osler explained (as quoted by Cushing, 1925), the new scientific medicine of diagnostic precision was endangering the old medicine of care and compassion. Osler advised doctors to stay away from what he called “the many useless drugs” and to stay focused on the patient as a person. “The good physician,” he said, “treats the disease, but the great physician treats the patient.” And along the same lines, Harvard Professor of Medicine Francis W. Peabody (1927), pointed out that patients in advanced university hospitals were sometimes passed from one specialist to another, submitted to multiple tests, and treated for unimportant conditions. He added that with the exception of the relationship that one may have with a member of one’s family, or with the priest, there is no human bond like the one between physician and patient (or the patient’s family). Nevertheless, these bonds were constantly weakened and the house calls, which had allowed physicians to understand patients in the context of their families, began to disappear. Among other reasons for their disappearance was doctors’ increasing realization that house calls were keeping their income down because they limited the number of patients they could see in a day.

Developments in non-medical technologies were affecting the process of distancing between physicians and patients, too. For example, with the growth of the suburbs and the use of cars, doctors’ practices started to move beyond their own communities. The growth of private insurance payments and the introduction of Medicare and Medicaid in 1972 generated new sources of income and introduced another impersonal actor that undercut the personal qualities of traditional fee-for-service medicine. This turned patients more apprehensive of doctors who were suspected as being motivated by greed. And revelations in the media about the abuse of human subjects in medical research further shook the public’s faith in physicians. The insistence on informed consent and the right to refuse treatment marked an important shift in the power and center of focus of decision-making that was moving from the physician to the autonomous patient. The reign of benevolent paternalism was coming to an end.

But one of the key forces in the downfall of the modern doctor-patient relationship was the corporate transformation of American medicine that began in the 1980s. Independent professional doctors became employees of hospitals, insurance companies and health care corporations. And pharmaceutical companies played an important role, too, as they found themselves increasingly under financial pressures to find new diseases among healthy people, and to satisfy the security analysts. They began to lobby for the reclassification of conditions by, for example, constantly moving the line that marks what is regarded as normal blood pressure so that someone who was once in the upper part of the range and defined as “normotensive” is now “pre-hypertensive,” even if there are no symptoms to justify this. This new definition of normal blood pressure allows pharmaceutical companies, of course, to adjust and refine their sales to get doctors to overprescribe. No wonder the Greek term “pharmakon” is ambiguous, and it can mean both “cure” and “poison.”

In short, medicine has become more and more dominated by bureaucratic authority and motivated by commercial gain; doctors are seeing more and more patients per day, and it has become more and more difficult for them to advocate for their patients. And this has obviously led to patient dissatisfaction but also to growing rates of doctor burnout and depression.

As a response to this state of affairs, a host of theories and movements aimed at humanizing the relationship between doctors and patients and improving communication between them have been developed. These include the fields of Bioethics, the Medical Humanities, Narrative Medicine, Spirituality in Medicine, Patient-Centered Care, and Health Communication.

Scholars in the field of Health Communication study physician-patient communication from a variety of perspectives and approaches. Over the past three decades, numerous models of the physician-patient relationship have been developed and advocated with varying degrees of enthusiasm (e.g., Emanuel & Emanuel, 1992; Leopold, Cooper, & Clancy, 1996). Many of the models were developed and offered as alternatives to paternalistic approaches to the physician-patient relationship (Emanuel & Emanuel, 1992). Other models were influenced by ideas consistent with bio-psychosocial approaches to health care. But as Cegala and Street (2009) explain, much remains to be done with respect to providing meaningful, theoretical accounts of processes affecting communication and outcomes, as well as creating measures that integrate behavioral and perceptual features of communication.

This book’s purpose is to make a contribution in that direction on the basis of the field called General Semantics that allows us to understand medicine as a semantic environment and not only as a profession or as a service.

General semantics is a practical discipline that applies modern scientific thinking to the solution of personal and professional problems. The application of its principles allows for clearer thinking, more effective and accurate communication and interactions, as well as more appropriate responses to what happens. It helps avoid prejudice, stereotyping, and generalizations and to understand and evaluate the underlying assumptions of other people’s assumptions as well as one’s own. And to modify them based on observation.

If adopted, the principles of General Semantics lead, generally, to greater sanity in life. Thus, we find them to be the panacea or medicine to cure or at least alleviate the symptoms of the illnesses of modern day medicine and to reduce the number of cases afflicted with what we shall later call “Semantic Iatrogenic Disease.”

Chapter 1
of the book is devoted to the idea of “semantic iatrogenesis” – harm inflicted by physicians through doctor-talk and communication patterns that intensify and even induce illness. After defining what we mean by semantic iatrogenesis we introduce the concept of a semantic environment, and explain in general terms, the usefulness of General Semantics in keeping the medical sematic environment clean and free of sematic pollution.

Chapter 2
of the book is devoted to the specific semantic environment of pediatrics. We encourage doctors and patients to look at pediatrics not only as a medical specialty, but as a special semantic environment due to its triadic nature and the ages of the patients.

In Chapter 3
we go into the specific tools that General Semantics provides pediatricians to fight Semantic Iatrogenic Disease, beginning with an understanding of the difference and connections between the context and the content of semantic environments: both the physical and emotional aspects of the medical encounter, doctors diagnoses and definitions of illness, as well as the metaphors employed throughout history when thinking of pediatrics – pediatrics as exploration and pediatrics as veterinary medicine.

After establishing the context and explaining our central terminology, in Part II
of the book we move on to illustrate sematic iatrogenesis as well as the use of General Semantics to counter it. Beginning with a distinction between curing, healing and doctoring, in Chapter 4
we tell the stories of eight of the patients of the medical doctor among us and parallel to the relatively new term of Personalized Genetic Medicine, we propose the development and practice of what we call “Personalized Semantic Medicine.”

We tell of Ami and the triumph of his metaphor of “having sickness” over the common metaphor of “being sick.” Hassan’s story is one about Isaac’s refusal to be governed by the Chief of Pediatrics’ definitions and policies, for the good of the patient. Dalia’s mom’s story revolves around the need for doctors to ask good questions, and the next story tells of the lesson a patient taught Isaac about the dangers of mystifying patients and the importance of avoiding role fixation. At the center of the following story is Dani who was having recurring nightmares that sent the parents into a self-reflexive spiral. And the next story is all about time-binding – when patients stick around and their pediatrician becomes their own children’s pediatrician. The story about the quintuplets born at Isaac’s hospital is about children’s individuality and the need for indexing. And Jack’s story is about the difficulty of inferring experience from behavior.

Chapter 5
discusses the latest trends in medicine stemming from policy and economics as well as from the technological innovations of the past few years and illustrates how the problems encountered by Isaac have been further exasperated, bringing us to the brink of a semantic iatrogenic epidemic, creating the need for doctors who are general semanticists and for a new kind of doctoring that we call Subversive Doctoring.

Our conclusion chapter summarizes the thesis presented throughout the book that the principles of General Semantics provide a most useful tool for more effective communication in the medical environment; that General Semantics is the panacea that can act as both remedy and preventive medicine against Semantic Iatrogenic Disease. In this final chapter we also suggest that not only doctors need to be subversive but so must patients whose role is also key in making the semantic environment pollution free. And that the way to achieve this is by replacing the metaphor of medicine as war with that of medicine as art.

PART I

CHAPTER
1

Semantic Iatrogenesis

A doctor is the conjunction of a white coat,

a stethoscope, and a jargon.

—Adolfo Bioy Casares

I
LANA HAD BEEN experiencing excruciating pain in her elbow for almost a year. She had gotten a few shots, had taken part in an experimental study, and nothing seemed to work. At the dinner table one night, she told us the story of her latest visit to the doctor. He never examined her. He just wanted to talk to her. So she sat across the desk from him telling him of how it was getting harder and harder to do even the most daily chores. He never picked his eyes up from the computer screen and still typing, he said: “You are simply hitting your backhand wrong.”

He must have noticed the word “tennis” somewhere in Ilana’s Electronic Health Record, and purely on its basis diagnosed what was wrong with her elbow – and her game. It was, of course, tennis elbow. But had the doctor taken a moment to really listen to Ilana, he would have found out that she was a professional tennis player for about 20 years, Israel’s champ five years in a row, and famous for her killer backhand. He would have also found out that she was now a coach, that the pain was interfering with her livelihood, with her income, and that she was worried about the future.

Ilana experienced first-hand the implications of an increasingly technological and bureaucratic health system in Israel. She was a victim of the EHR, of the 8-minute appointment, and of the over-scheduled doctor. The computer screens and EHR’s that doctors look at while talking to us these days is only one of the newest in a series of technologies that have mediated between doctors and patients throughout history. Each new medical technology, each new screen in the clinic or the hospital, has brought us closer to an apparently accurate representation of our bodies, in sickness and in health, or at least to the illusion thereof. As Reiser (1978) explains:

[The invention of the stethoscope] helped to create the objective physician, who could move away from involvement with the patient’s experiences and sensations, to a more detached relation, less with the patient but more with the sounds from within the body. Undistracted by the motives and beliefs of the patient, the auscultator could make a diagnosis from sounds that he alone heard emanating from body organs, sounds that he believed to be objective, bias-free representations of the disease process. (p. 38)

This detachment and illusion of objectivity became even truer with visual medical imaging technologies that enable the physician to further disregard the patient’s motives and feelings, or worse, regard them as “wrong” and the picture as “true.” With these technologies the detachment from patients increased and the art of listening began to falter. Instead of performing as aids in the process of diagnosis, the stethoscope, X-rays, the electrocardiograph, ultrasound, MRIs, and other technologies almost entirely replaced conversation. . . .

CHAPTER
2

The Semantic Environment of Pediatrics

Children are the living messages we send

to a time we will not see

—Neil Postman

T
HE ILLNESS OF A child requires the re-organization not only of the parent’s life-story but of the child’s life-story in the minds of parents, too. The loss of the previously taken-for-granted continuity of life in chronically ill people is regarded as especially tragic in the case of children. Pediatrics presents a special challenge. As Kleinman and Seeman (2000) explain, the experience of illness is not bounded by the bodies or consciousness of those who are ill. It reaches out to encompass a household, a family, or a social network. And this is especially true when the patient is a child. . . .

CHAPTER
3

The Communication Panacea:

Pediatrics and General Semantics

For each illness that doctors cure with medicine, they

provoke ten in healthy people by inoculating them with

the virus that is a thousand times more powerful than

any microbe:

the idea that one is ill.

—Marcel Proust

T
HE MAP IS NOT the territory” is perhaps the most central idea of General Semantics. In Science and Sanity
, Korzybski (1958) explains: “A map is not the territory it represents, but, if correct, it has a similar structure to the territory, which accounts for its usefulness.” And he continues: “If we reflect upon our languages, we find that at best they must be considered only as maps; a word is not the object it represents” (p. 58). Or, as Hayakawa (1963) puts it, “Words, and whatever words may suggest, are not the things they stand for” (p. 22). And, in discussing this idea, Korzybski distinguishes between the structure and the content of a language:

If words are not things, or maps are not the actual territory, then, obviously, the only possible link between the objective world and the linguistic world is found in structure and structure alone. The only usefulness of map or a language depends on the similarity of structure between the empirical world and the map-languages. (p. 61)

Connecting General Semantics and Media Ecology, semantic and media environments, Korzybski and McLuhan, Strate (2011) discusses the relationship between the inner environment of the map, and the outer environment of the territory. And he explains that it is along this relationship that Korzybski made reference to verbal and semantic environments, and Neil Postman to media as environments. The relationship between the map and the territory is the relationship between the medium and the message, between the structure or context of the semantic environment and its content. . . .

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EVA
BERGER
is a Professor of Communication at the School of Media Studies of COMAS (College of Management Academic Studies) in Israel where she was Dean (2006-2012). Dr. Berger is member of the Board of Trustees of the Institute of General Semantics (since 2009) and of ETC.: A Review of General Semantics
(since 2008). She is member of the Editorial Board of Giluy Daat: A Multidisciplinary Journal on Education, Society and Culture
(since 2011) and was member of the Editorial Board of EME: Explorations in Media Ecology
(2005-2014). She has held many public positions and is active in numerous organizations in Israel: She was member of the search committee for candidates for the position of Chair of the Council for Cable and Satellite Communications (appointed in 2013 by the Minister of Communication); Chair of the Board of Women in the Picture
(an organization for the advancement of women in the visual arts); member of the Israel Press Council (2011-2013) and of the Israeli Film Board (2000-2006). She is member of the board of IPI (Israel Peace Initiative, since 2011). Eva is periodically invited as guest commentator on Israel’s newspapers and public and private radio and television stations; she is the author of programs for the teaching of media in Israel’s high schools; and has published numerous academic articles and book chapters on varying topics including war photojournalism; advertising; language, metaphor and narrative; and media and technology. Eva is married and has two sons.

ISAAC
BERGER
studied medicine at UNAM--National University of Mexico in Mexico City (1955-1961). He did his internship as well as his residency in Pediatrics at Michael Reese Hospital in Chicago and was research fellow in neonatology there. In 1965, he returned to his country of origin—Mexico—where along with his private practice throughout the years, he was instructor of postgraduate courses in Pediatrics at Juarez Hospital; assistant lecturer in Pediatrics at UNAM (National University of Mexico); lecturer in Pediatrics at the School of Nursing as well as at the residency program of American British Cowdray Hospital in Mexico City; and he taught neonatology at Hospital Infantil Privado where he was physician in charge of Medical Education. In 1977 Dr. Berger moved with his family to Israel where he became Head of the Pediatric Outpatient Department of Meir General Hospital in the city of Kfar Saba, and later Head of Pediatric Ambulatory Services (including Emergency Room, Clinics, Day Hospital Unit, and Child Development Unit). Isaac co-authored numerous articles and chapters in books. He retired from the hospital in 2003 and aside from his still active private practice he is medical advisor to a large child development center in Israel. Isaac is married and has five daughters and nine grandchildren.