"Language is the cake with the file in it."

Photo by Tim Ellis

The title of this post is a quote by  B. Blanton sent to me by my ever-clever father-in-law with the byline "a quote to get us through the day." And it did just that.  It also got me thinking about language and how it tricks us, often without our even knowing it. So I thought I'd apply this idea to the area of medicine with which I am most familiar by laying out a few of the phrases I would like to expunge from the obstetric lexicon. So, here goes nothing:

1. Incompetent cervix
- There is nothing incompetent about any part of woman's pregnant body. Period.

2. Low pain tolerance / low pain threshold
- First, why is pain, especially labor pain, not inherently valuable? Why is it an experience that needs to be tolerated? Why is it a problem for a person to have a physical or emotional reaction when the intensity of pain has exceeded a certain magnitude? And if a woman wants pain relief at this juncture, isn't there some serious paternalistic behavior being exhibited if she doesn't get it? Finally, how in the hell can we objectively judge what the patient is experiencing? But all of this is yesterday's news.

3. Terrible pusher
- What can I say about this? Really nothing except that our patients aren't freshman linebackers.... or novice drug dealers.

4. Dysfunctional uterus / dysfunctional contraction pattern 
- Dysfunction implies impairment, something that is flawed, decayed, defective - a deviation from the norm.  So we should ask, who is defining the normal?

5.  Failure to progress
- Failure: collapse, defeat, fiasco. As in "I'm sorry Ma'am, but your labor has failed.  Now you get a cesarean section. And all because you made no progress."

6. Elderly primigravida / Advanced maternal age
- Up until the 1960s, women were often having children well into their 40s.  Modernity does not necessarily equate with progress. And I think even my teenage son will agree that thirty-five is certainly not elderly even if he categorizes The Smiths as "classic rock".

7. Stalled labor 
- The body is not a '64 Impala.

8. Late to care 
- I am pretty sure that most of these women care.  They may have been late to medical oversight, late to obstetric assistance, but they are not late to care.

9. Failed homebirth
- Again with the failure.  It's a homebirth transfer.  Let's say it aloud: no one is a failure in this scenario.

... and, for the all time most heinous of our many articulations:

10. Give the woman a tubal, already! (or) Please tell me she's signed her tubal papers.
- This is one for future scrutiny in the form of an academic paper. And I am totally on it. All I can say for now is that I know Americans are terrible with history, but our collective memory cannot possibly be that short-term.  Ever heard of sterilzation? If not, follow the link for an easy primer.  We need to think about these not-so-distant days of yore, and think hard, before uttering these words ever again.


So, as the good Mr. Blanton says, language is indeed the cake with the file in it.  The question is, does that file set us free or does it cut our throats?  You decide.

The Problem of Pain

Pain.  Pain is something that, as health care providers, we learn is subjective.  Subjective: meaning belonging to the subject (patient) rather than the object (the “objective” practitioner).  Subjective pain: pain that is perceived by the patient and not by the provider.  Pain: an area of healthcare where the objective practitioner can have the ability to, and often does, perhaps unconsciously, objectify his or her subject.  This may be doubly true in assessing laboring women who all present differently at different stages and who may or may not meet certain clinical expectations in response to the pain of childbirth.

I won’t talk about patriarchy and women’s experiences of their bodies.  I won’t talk about how women punish one another into utilizing or forgoing modern pain relief methods for some weird feminist ideal of woman/motherhood.  I won’t even talk about language such as “low pain threshold” or “no pain tolerance” in discussing another person's pain.  No. Just for today, I won’t. Instead, I will give you this anecdote.

A patient is admitted for intractable pain, not in labor.  This intractable pain is accompanied by some intermittent vomiting… and a suspicion by providers that this patient might be drug seeking. It is never totally clear why. She is poor.  She is a minority.  So there are two strikes against her from the get go.  She is perceived as something before she is anything in the clinical realm... before she is even a patient. “What makes you think that? About the drug seeking?” someone asks in team meeting.  “Well,” responds the attending provider, “Her pain seems very out of proportion to her early labor status and no one has ever witnessed her vomiting.  Also, we were going to perform a tox screen but she can’t seem to void, which I find very suspicious.”  Suspicious.  Not concerning but suspicious. A good practitioner should, right about now, have counted at least five symptoms that could be used to rule out a host of issues other than drug seeking behavior. But this is where we are.  So a wise doctor seated beside me addresses the pain issue by asking, “And have you given her anything for this pain?”  “No,” responds his colleague, “Nothing but an antiemetic for the supposed vomiting.” 

The inquiring doctor rolls his eyes and turns to me, sotto voce, “Drug seeking for ondansetron. Now that’s a problem.”

*The Problem of Pain is a very brief and worthy little book written by C.S. Lewis and Virginia Woolf touches on the subject in her essay On Being Ill.  For a little non-medical perspective to inform practice, you can also read some Heidegger and Nietzsche among others.