Remapping the Medical Metaphor

Forms that Inform Us

To live is so startling,
It leaves little time for
Anything else.

Emily Dickinson

I often feel startled by life as many physicians do; startled by the vast intricacies of life, and humbled by the almost unfathomable complexities. But these days, I am concerned that for many in my field the wonder is waning, drowning. The enchantment isn’t working like it used to, either for the doctors, or the patients, or the art. For all of its accomplishments and brilliance, modern medicine seems off, or lacking in some very essential way.

I am not referring to the crisis in health insurance or the absurd costs of medicines or other externals, but something more fundamental, internal, something lacking between the doctor and the patient. In a word, I would characterize that deficit as something to do with communication or language or maybe poetry. Modern medicine certainly isn’t deficient in technological prowess or interventional skills or diagnostics, all of which seem proportional to the advances made in basic science. But, oddly, because medicine deals with humans, it seems to lack a kind of humanity. It seems too mechanical, too rote, and too fast. Like fast food that gets the job done, but isn’t quite nourishing for either the patron, or the cook.

Many of my patients tell me that  they feel disconnected from their physicians; they frequently feel unheard. They say too many doctors are brusque; they don’t listen well. And the data bears them out. On average, doctors interrupt the patient’s narrative after twenty seconds. As a result, the patients complain that they are not heard, and this surfaces as the most common single complaint in malpractice suits.

Doctors feel the disconnect as well. Physicians used to put their ears on the patient’s chest to hear the breath sounds; they used to smell the  wounds for bacterial identification and even taste the urine for the presence of sugar. Mellitus, as in diabetes mellitus, means honey-sweet. But much of that clinical intimacy has been replaced with laboratory tests and scans and x-rays. Reassurance and watchful waiting have been replaced with pills and procedures. An encounter with today’s medical system of specialists and sub-specialists and labs and x-ray departments seems, by comparison,  oddly mechanical, perfunctory—like being rolled down an assembly line.

Modern medicine also seems to me to be overly biased towards treating and intervening rather than supporting natural healing tendencies. Most illness is self-limited. Most colds go away. Most lacerations heal fine with cleaning and simple dressing changes. The patient often just needs support because nature is already inclined towards repair. A professor I had in medical school, said to me in confidence one day, “You know Bob, the real secret of doing medicine is knowing that most things get better by themselves.” But our medical system seems bent on heavy-handed intervention as if “pushing” is the only causal tool. Further, if a little push is good, a bigger push is better. As a consequence, we often use unnecessary force—like powerful antibiotics for minor infections or, for that matter, treating minor infections at all.

In general, we justify the hasty, mechanical, overly forceful ways of medicine by claiming that this is still the best and most efficient way to apply scientific medical standards to the populace. And maybe this is factual in our present system. But let’s suppose that the goal isn’t merely the quick fix, but simply excellence. What if healing is taken in the original sense of “making whole?” What does such a medical practice look like? And how does language and poetry play a part?

A New Medical Metaphor

I want to venture into the philosophical realm for a bit in order to address these problems by putting forward a new conceptual model for medical practice, a new metaphor, a new map of the territory. I think a new model may significantly augment the healing encounter, even help recover some of the lost startle and wonder. The model is based on the premise that if we can change our language we change our medical practice. It is grounded in the emerging science of information.

So, let me take a very wide angle view and then narrow it down. Let me start by asking the question, “What is information?” since information provides the basis for this new metaphor. Oddly, interestingly, information isn’t anything. Literally, it is not a thing. It isn’t matter or stuff because it isn’t physical. Information falls into another logical class than things do. It is insubstantial, non-material.

If not a thing, what is it? At its most elementary and fundamental level it is probably best described as a difference or a distinction or a change. I hear a bird chirp. Ah, I detect a difference between the silence and the chirp. Information is derived from that juxtaposition, that relationship; it is neither the chirp, nor the silence. It is the signal generated by the difference or the change. It is more like a ratio between sound and silence, but utterly non-material. If I rub my finger along a smooth surface with equal pressure, I may not notice much, until it hits a bump, ah, suddenly I notice a change. That is information.

Notice that it takes at least two to make one difference. It is one of the central tenets of information theory. It takes two to make one because even a single punctum of information requires contrast. A zero is meaningless without a one. The concept can be expanded. The entire chirping bird, for instance, can be reconceptualized as a cluster of differences—as many as you can note. The bird can be remapped as thousands of clustered differences, like an image rendered on a computer monitor. We can speak of these clusters in terms of pattern, organization, relationships, negentropy. In fact, we needn’t stop at the bird, or computer image; every known thing from atoms to galaxies can be reconceptualized as information rather than stuff or matter. It is a different language game, a different style of thinking, a different metaphor, and it reveals a different world, one that may have utility in the healing arts.

In support of this point of view is the observation that the human nervous system and all of our sense organs, our hearing, our touch and so on only respond to differences or changes. It is our only window on the world. All the talk of matter and substantiality, things, stuff, objects, and energy, is inferred—layered on, reasoned, but not directly perceived. We live closer to the world of information than we think because that is how our nerves function. They either fire or they don’t depending on the differences to which they are exposed. If the differences fall below  threshold, then the impulses aren’t triggered, and that particular world disappears.

“Forms that inform us” is literally what information means. Gregory Bateson, one of the important early theorists of information theory, would say that “information is a difference that makes a difference.” And Bateson is properly radical about it. He would say that it doesn’t matter if it makes a difference to someone’s mind or to their body or to the wall thermostat. If a signal makes a difference to the receiver then it is information. Pills and potions, for instance, can be remapped as information rather than as chemical substances. They provide distinct signals and hopefully make a difference to the receiver.

Having a receiver is a necessary and relevant aspect of information. If there is no receiver, there is no information. This distinguishes it radically from the competing matter metaphor, namely that the things in the world are made of matter or substance. Most of us tend to regard the world as if it existed “out there,” independently, objectively, regardless of whether someone sees it or not. But from the informational perspective, a receiver is a mandatory and integral piece of the system. Viewed as pure information, the world disappears without the senses because that world and the perception of it are linked. Thus the informational map has utility in realms where connection or coming together is instrumental, realms like human behavior, communication, and healing.

In fact if we revision the body as information, re-map it, the age-old problem of body/mind duality disappears because the body and the mind are cut from the same kind of cloth. There is no disparity. Mind and matter can be regarded as information. But to see this, to think like this, we have to be willing to suspend the matter metaphor. And that’s the rub. Our habits run deep.

From Push to Pattern

Look around the room. Focus on edges or outlines where differences are readily perceived. Imagine that the so-called objects are derived, not from substance, but from relationship. Try changing your perspective or your cognitive grid, from matter to pattern, from objects to clusters of differences, from “its to bits” as one author put it. Remember to regard yourself as part of the circuit, as a necessary component, namely the perceiver of those differences. The idea is to dismantle the static objective world in favor of a participatory perception. You are inside and relevant, not outside observing. The perceptual shift can be difficult because our language tends to posit nouns in place of relationships. It posits independent objects while ignoring the fact that everything depends on something else. I see  a yellow pencil  lying here in front of me. But I  reflexively and automatically overlook the fact that  the brown desk beneath it is necessary for me to identify the pencil. The pencil depends on its background, on that relationship, to distinguish it.

One method to facilitate the awareness of an informational world is to name one of the contexts of an object. Every so-called thing has at least one context. I think of context as a background or container. It may be a different color or different texture or different sound. It may be a universe for a grain of sand. When I name the context, my habitual, language-focused attention can slip off the object for a moment and focus on the relationship or differences between the object and a context. I can identify those differences and talk about them. Some of them are meaningful. Since information is non-material, the room can suddenly take on a new texture or feel, like that of a grand idea or a very vibrant dream. Shakespeare said it aptly, “We are such stuff as dreams are made on.” Notice that comparing the world to a dream does not alter the hard reality of manifestation, it merely revisions a hard reality using a different map. Bear in mind that even in a dream you can stub your dream toe and it hurts.

Information has no more claims to ontological truth than matter; both are perhaps best regarded as abstractions, metaphors, or language maps. As with most maps, their utility depends on where you want to go or what you want to do. In this case we want the most effective map for healing. Unquestionably the matter metaphor has been useful in biological science. But matter/substance talk has an ominous dark side, namely that it posits force, or power, or the like, as the only way to cause movement or change. Newton’s first law of motion is explicit. Bodies move or they don’t due to force.

In contrast, in the realm of information, difference can be causal. Perceived signals can trigger action. When the bell sounds, I go to lunch. I am not forced. Sometimes silence is the signal—like the dog that didn’t bark in Sherlock’s case. Sometimes “not doing” can trigger action—like when you don’t send in your income tax form—things will happen.

The language of force is appropriate and useful for the world of inanimate objects, but clearly suboptimal in the realms of communication, information and describing behavior.  Speaking  more loudly or yelling (increasing force), for instance, doesn’t  necessarily improve communication, it frequently impairs it. Forcing, coercing, exhorting are usually off putting and not suitable for long term, effective interpersonal relationships.

Unfortunately, the force idea is pervasive in our society because we believe it is the only way that things get changed. It is an outgrowth of the matter metaphor. We have air force, military force, force of habit, show of force, economic force, force of nature, life force, gravitational force. But look, gravity isn’t really a force in the sense of a unilateral one-way push. Gravity is an interaction, a relationship. One body isn’t forcing the other. Our language hasn’t woken up to these ideas. We haven’t yet remapped to informational wisdom. Do you think we might live in a less violent society if we talked about communication, relationship, interaction, pattern, organization, and meaning as tools of change rather than force? What if we sought harmony which requires attention to context rather than seeking shows of force, economic power, diplomatic pressure, or advertising impact. We might enjoy a less brutish world, even adopt a new slogan, “May the pattern be with you.”

Contextual Awareness in the Clinic

Let’s return to the clinic now and see how doctors might utilize the new informational metaphor. To begin with, they would be acutely aware of context. Their style of communication, their office, their staff, the fresh flowers on the desk would all contextualize their art. Like smiles, they are signals, and usually make a difference. The doctors’ message of healing would usher from many voices.

Contextual awareness has another advantage. It engenders wholes. It creates movement to the more inclusive and comprehensive. And there is no end: contexts have contexts, until one is finally up against the limits of language. Thus the contextually oriented doctors would move towards wholing, or making whole, which is healing in its derivative sense. The wider perspective would allow them more therapeutic options and provides an antidote against the juggernaut of increasing specialization and fragmentation.

They would know and show that they are irrevocably inside an informational system. They would know that they cannot not communicate because silence and body language are signals. They would use this to their advantage rather than trying to remain outside, doubly blinded, regarding the patient like a interesting bug. They would be comfortable saying, “I don’t know” because that too is relevant and valuable information. And hopefully, some of the salubrious effects of this perspective might fold back to include the physician as well, as they reclaim the clinical intimacy and ordinary wonder that can get lost in a sterile, static, and purely objective world.

Turning the clinic table around, the new doctors see patients differently, contextually. They examine both the seed and the soil. For example, not only do they focus say on the Staphylococcus, but also the patient’s diet, cognitive hygiene and so on. They see the cause of the pneumonia as a result of the summation of various conditions that impact immunity and resistance rather than as a single unilateral, powerful, bacterial agent. They are comfortable intervening anywhere along the causal circuit where they can get the most leverage, rather than focusing exclusively on a single cause or presenting symptom. They abandon the pushiness of force in favor of action that is contextually modulated, in other words, what fits. Evidence-based science for them includes the widening gyre of tiered interdependencies like gender, ethnicity, DNA profiles, family history, and so on. A science like this is likely be more complex. But it also might be more effective and even more efficient if one were to seriously consider prevention properly within the purview of the physician.

It is not the things in the world we value, but the fulfillment they bring. It is not the stuff, but the information about the stuff we hold dear. We inhabit a world of joys, satisfactions, desires, fears, loves, ideas, feelings, disappointments, ambitions, attitudes, and the like. We might benefit if our language and our health science attended to these intangible worlds. Happiness is a kind of healthiness and yet it isn’t any thing. Sure, we can use the old map and see the world as an assemblage of separate things moved around by forces when it is necessary like when we build a locomotive or bridge. But we can also draw from a different map, an informational one. One that is woven from two, from relationship. One that seems to better fit the territory of human experience.

Notice that this language-medicine isn’t about “harnessing its power,” or “the power of positive thinking.” That’s force language. Likewise, it isn’t about using strong or powerful pills or “big guns” or “magic bullets” in cancer warfare or anti-this and anti-that. Informational medicine is derived from a different way of thinking, a different metaphor, a new poetic. It is a medicine that deals with signals, with names and forms. It is a medicine that embraces connection through context and communication, one that thrives on balance, harmony and learning. In yet a grander vision, it is a medicine that has the capacity to extend beyond the bodymind, to include our society, and the broad fabric of life itself.

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