Tuesday, December 15, 2009

Tongue Twisiting

Every profession has its own secret code known only to acolytes, and medicine is no exception. Medical terminology seems complex, but it’s actually pretty easy one you know the scheme. The key is to recognize that most medical words come from a specific set of Greek or Latin roots, and that virtually everything is a combination thereof. So to describe just about anything, once you know the code all you have to do is mix and match the hundred or so roots to come up with what you want. So if you want to describe a blue extremity, you combine the root for extremity, “acro,” with the root for blue, which is “cyan”, to come up with acrocyanosis. If you want to talk about an enlarged extremity, you use “acro” again, but now combine it with the root “megaly,” meaning enlarged, to come up with acromegaly. The root “path” pertains to disease; a pathologist is someone who studies disease, and idiopathic means you’ve got a disease but it beats me why. It’s this flexibility that gives rise to medical puns such as dyspareunia (“dys” meaning bad, “pareunia” meaning biblical knowledge of another) is better than no pareunia at all. We can also use it to describe invented non-clinical conditions, such as hypocyanocrutiatism (“hypo” meaning low, “cyan” meaning blue, and “crutio” meaning cross…translated as “low Blue Cross”), and ainsuria (“an” meaning without, “insuria” meaning…well, insurance. I so totally made that one up).

You can also use this flexibility to play with medical students. One of the joys of the teaching of medicine, in which I was engaged for six years after residency until I rejoined the real world, is the opportunity to amuse yourself with the ignorance (of those who think they actually know something) and gullibility (for those who know nothing) of the children.

It’s especially fun with the former group. There was a particularly obnoxious student at the University of Florida, the kind who walks around with an AMA pin in his lab coat and a license plate that said “MD 2 B” and who thought he could date the ED attending’s ex-girlfriend. He was truly getting on everyone’s nerves, so the senior resident and I conspired together and formed a plan.

One day when the student was on duty, we called him over to the X-ray room to look at a chest X-ray that both the resident and I had verified was completely normal. We asked his opinion, and he said it looked fine to him as well. Then the resident pointed at the upper left part of the film. “Hey, up in the corner. Isn’t that a sign of hypocyancrutiatism?”

I peered closely at the lighted screen. “Yeah, I think so. Nice pickup.” I turned to the student. “Ever heard of that?”

You could see his mind start to work. Sometimes it’s just too easy, like shooting fish in a barrel or vegans in California.

“Yes, I did. I read an article about it. Some of the symptoms are…”

The resident lasted about 23 seconds before bursting out in hysterics, and I didn’t last but a few moments more. We told him we had made it all up, that there was no such disease, and that he should probably review his essential references (medical school-speak for “you’re a moron”) before commenting in our presence ever again. He was quiet for the rest of the month.

(This is one of the students who passed the ED rotation only because we were sure he was never actually going to do emergency medicine and those who failed had to do another month.)

Another trick you can do with medical students and terminology is to take recognized medical eponym and turn them on their heads. For example, there is something called a “Chandelier Sign.” It’s actually a pun on a clinical finding…when you do a pelvic examination on a patient with a pelvic infection and you move the cervix, the pain is so bad they want to leap towards the ceiling and grab the chandelier. That’s not, of course, what you tell the student. What they hear is:

“You know, it’s an interesting story behind this eponym. Most people think it’s something made up. But in early 19th century France, there was a pioneer gynecologist named Jean-Marie Chandelier (it’s critical to say “shaaan-deee-leee-ay” to make it sound real). He was the one who first discovered the pathologic correlate between tenderness of the cervix on exam and pelvic inflammatory disease. He was actually a first cousin to one of the leading families in the French glass-blowing industry, the family that first produced the lighting fixture we call in English the Chandelier (pronounced shan-dee-leer to emphasize your erudition).”

That being said, sometime the eponyms are funny enough without needing to make up more material. When you examine a patient’s eyes, among the things you look for is responsiveness (if the pupil contracts when exposed to bright light) and accommodation, which is normal when light shown to one causes the opposite pupil to contract as well. So the Argyll-Robertson Pupil, a sign of tertiary syphilis, is known as the Prostitute’s Pupil because it’s accommodating, but not very reactive.

One last language trick is to ask the students if they really mean what they say. One of my favorites in this category is the use of the term “appreciated.” For some reason, we are taught in medical school to “appreciate” heart murmurs and other clinical findings, as in “There was a 4/6 murmur appreciated over the lower left sternal border.” But I always ask if they just heard something, or really appreciate it? Did they gasp in astonishment? Did they call their parents to let them know? Did they send a singing telegram to the relationship de jour? And speaking of singing, we’ve also learned to describe lung sounds as “musical” in terms of pitch. (Pitch and tone are important clinical indicators. This was first noted by the French composer Louis-Nicolas Clerambault, a close friend of Rene Laennec, inventor of the stethoscope. On rounds with his friend one day at the Hotel Dieu, he is reported to have heard breath sounds and was inspired to write his very popular “Symphony for Harpsichord and Sputum in D.”) But we could go so much farther. What key are they in? G flat or A major? Does it have a beat? Can you dance to it? Best in the east, give it at least, a 75?

(For more information on the linguistic joys of the teaching life, I would also refer you to a classic 1989 JAMA article entitled, “The Art of Pimping,” by Frederick Brancati. A copy of this work can be found at http://www.neonatology.org/pearls/pimping.html.)

However, every now and then the playful use of use of medical terminology can take an alarming turn towards political correctness. The latest example is the term “psychogenic non-epileptic status epilepticus,” or PNESE, which I saw for the first time in the November 2009 issue of Critical Decisions in Emergency Medicine. Breaking this down to root words, it means a continual seizure state that is not related to seizures but has its origin in the psyche and not in the wiring of the brain. (The fact that it’s a non-seizure seizure means it’s not a seizure, right?) It turns out that, when you read the actual clinical description of the PNESE, it’s what we used to call a “pseudoseizure,” or “faking.”

As best I can tell, the change in terminology came about because the term pseudoseizure implies that the person is doing it on purpose, while the PNESE suggests that the event may not be intentional, but a result of unconscious forces driving a “somatization” disorder, where psychiatric illnesses are manifested as physical symptoms. (See “fibromyalgia.”) But the fact is that the PNESE is still not a seizure. I know this not just from analysis of the word roots, but also because I asked a neurosurgeon if he knew what a PNESE was. He said no, and so I read him the description. “That’s a (homophone for clucking) psueodseizure,” he said. “What kind of idiot needing tenure thought that one up?”

Umm, probably the same ones who spent six years in academics getting promoted and tenured before joining the real world…

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