M edical slang in Rio de Janeiro, Brazil
Tramb ic línic as, p ilantró p ic o s, e mulamb ulató rio s
1 Departam en to de Ciên cias Sociais, Escola N acion al d e Saú d e Pú blica, Fiocru z . Ru a Leop old o Bu lh ões 1480, M an gu in h os, Rio d e Jan eiro, RJ, 21041, Braz il. cp eterson @altern ex .com .br
Ch ristop h er Peterson 1
Abst ract Th e au th or an alyzes m ed ical slan g in Rio d e Jan eiro based on th e view of in teractive or live m etap h or p rop osed by su ch au th ors as Black an d Ricoeu r, ap p lied to p u n s an d oth er jok es from m ed ical w ork , w ith th e goal of u n veilin g w h at p h ysician s m ean by th is lin gu istic register. Th e article classifies m ed ical slan g in th ree broad areas, p ertain in g to th e p h ysician’s relation s w ith p rofession al train in g an d k n ow led ge, p atien ts, an d h ealth care services. Com p arin g h is em -p irical m aterial w ith -p reviou s stu d ies focu sin g on h os-p ital slan g for -p atien ts, th e au th or id en ti-fies, in ad d ition , a ran ge of slan g term s for h ealth care services th em selves. Th e article p oin ts to in terfaces betw een m ed ical slan g an d th e Brazilian “h ealth h yp ercrisis”id en tified by Sch ram m .
Key words Med ical Lan gu age; Med ical Slan g; Med ical Eth ics
Resumo O au tor an alisa a gíria m éd ica carioca a p artir d a visão d e m etáfora in terativa ou viva p rop osta p or au tores com o Black e Ricoeu r, ap licad a a trocad ilh os e ou tros ch istes d o cotid ian o m éd ico, com o ob jet iv o d e d esv en d a r o q u e os m éd icos sign ifica m ou “q u erem d iz er” com esse registro lin gü ístico. O artigo ad ota u m a classificação d a gíria em três áreas tem áticas, i.é., n a relação d o m éd ico com a form ação p rofission al, com os p acien tes e com os serviços d e saú d e. Com p a ra n d o seu m a t eria l em p írico com o d e est u d os a m erica n os q u e en foca m ch ist es p a ra p a -cien t es, o a u t or id en t ifica , a lém d est es, u m a série d e t roca d ilh os p a ra os p róp rios serv iços d e saú d e, levan d o-o a su gerir in terfaces en tre a gíria m éd ica e a “h ip ercrise san itária”id en tificad a p or Sch ram m .
Apertura
“Clavicle?...”
On e h esitan t w ord from a m ore d arin g m ed sch ool fresh m an break s th e n ervou s silen ce an d bou n ces off w h ite tile w alls in th e am ph ith eater of th e m u sty In stitu to An a tôm ico, in respon se to th e first qu estion of w h at prom ises to be a gru el-in g six-year cou rse. On th e eve of th is el-in au gu ral class, th e sly professor left a h u m an bon e on th e stain less steel table as part of th e sam e ritu al h e h as perform ed for th e last th irty years to lau n ch h is cou rse, Hu m an An atom y I, alon g w ith th e qu estion , “Wou ld som eon e please care to iden ti-fy th is?”
“Clavicle,”th e fresh m an blu rts ou t for a sec-on d tim e, by n ow m ore su re of h im self.
“Clavicle, in deed. In Latin : ‘little key’. Wou ld on e of you d octors care to tell m e w h y? Migh t it be th e sim ilarity in sh ape?...”
From a d istan ce, six ty fu tu re p h ysician s search an x iou sly for a form al sim ilarity be-t w een be-t h is solibe-t a ry bon e a n d som e k ey – a n y k ey – from th eir daily rou tin es. W ith a gen erou s, cerem on ial gestu re, th e p rofessor m arch es over to th e fron t row of th e am ph ith eater an d h an ds th e bon e to th e you n g stu d en ts, w h o p ass it arou n d, stealin g sk eptical, em barrassed glan ces at each oth er.
“...Perh ap s. Yet th e an cien t an atom ists also believed th at th e ‘cla vicle’is th e first bon e to be form ed in th e fetu s, an d th e last to die in th e ca-d aver. Th u s, th e clavicle is th e lit t le ke yth at open s an d closes life itself.”
Silen ce falls over th e am p h ith eater. Som e of th e fresh m en h ave tears in th eir eyes. Bu t it’s on -ly th e sm ell of form ald eh yd e on th e w alls. Th ey’ll soon get u sed to it...
Introduction
In h is in a u gu ra l c la ss, t h e p r o fe sso r give s h is stu den ts a lesson in both an atom y an d m etap h or b y p rovo kin g t h e m wit h t h e cla ssica l q u e st io n o f th e d istin ctio n b e twe e n sim ilarity in th e d i-rect, n arrow sen se (b etween ob jects th em selves, in t h is ca se a b o n e a n d a ke y) a n d an alogy, o r relation al sim ilarity (b etween open in g an d clos-in glife a n d o p e n in g a n d c lo sin g so m e t h in g wit h a ke y). Fo r a b e t t e r u n d e r st a n d in g o f t h e p ro fe sso r’s m e t a p h o r, we c o u ld t u r n t o o t h e r m e ta p h o rs (so m e wo u ld sa y th is is o n ly n a tu r-a l, sin c e in o rd e r t o t r-a lk r-a b o u t lr-a n gu r-a ge , we h a ve t o u se it ). Th a t is, in a n e t ym o lo gic a l, arch eologicale xe rc ise, t h e p r o fe sso r swe e p s t h e d u st o f t h e ce n t u rie s fro m a h u m a n b o n e, e vo kin g t h e a n c ie n t a n a t o m ist wh o fir st e m
-p loye d a ll h is cla ssifica t o r y ge n iu s t o co in t h e m e t a p h o r clavicle– ‘lit t le ke y’. Th e p r o fe sso r h a s t a ke n t h a t in e r t b o n e , wh o se n a m e h a s lo n g sin c e b e c o m e a d e a d m e t a p h o r (t h a t is , t h e figu ra t ive m e a n in g h a s b e c o m e it s lit e r a l sen se) a n d given it life.
Wit h o u t b e ggin g p o e t ic lic e n se fr o m o u r a n a to m y tea ch er, we h a ve u sed th e little k ey to o p e n o u r d iscu ssio n o n a n o t h e r m e t a p h o r ica l fie ld in m e d ic in e , wh ic h we will c a ll m e d ic a l slan g, th e ob ject of th is essay. Before closin g th is d iscu ssio n , we will re t u r n t o q u e st io n s r a ise d b y th e cla vicle d u rin g th a t in a u gu ra l cla ss.
M edical slang: metaphor as the basis for a paradoxical discourse
-m o r, like jo ke s a b o u t se x a n d c o n ve r sa t io n a b o u t fo o t b a ll, m o n e y, e t c., n o t t o m e n t io n o t h e r, n o n ve r b a l fo r m s o f t e n sio n re lie f e n -joyed by p h ysicia n s). We in ten d to d em on stra te th a t m ed ica l sla n g crea tes n ew m ea n in gs in th e rela tio n sh ip o f p h ysicia n s n o t o n ly to p a tien ts, b u t a lso t o t h e ir own a c q u isit io n o f c lin ic a l kn owle d ge a n d e xp e r t ise a n d a b ove a ll t o t h e h ea lth ca re system itself.
As we will see over th e cou rse of th is a r ticle, Ca r io ca m e d ica l sla n g re fle ct s a n d cre a t e s in -t e rfa ce s wi-t h wh a -t Sch ra m m (1995) h a s ca lle d th e “th e Brazilian h ealth care h ypercrisis”, with co m p le x a n d o ft e n co n flict in g ch a r a ct e r ist ics. A su r ve y o f ove r 3,000 m e d ic a l d o c t o r s b y Ma ch a d o (1996) refers to a stea d y “deprofessio-n alizatio“deprofessio-n”o f Bra zilia n p h ysicia n s, ch a ra ct e rize d b y t h e re le n t le ss (b u t u n e ve n ly d ist r ib u ted ) in va sio n o f clin ica l p ra ctice by tech n o lo -gy, a lo n g with th e d ism a n tlin g o f p u b lic h ea lth ca re services (u n d er th e a egis o f th e n eo lib era l, m a rke t o r ie n t e d wa ve a n d b e t ra yin g t h e cu r -ren t govern m en t’s p ro m ise th a t fu n d s fro m th e p r iva t iza t io n o f ke y se c t o r s o f t h e Bra zilia n econ om y wou ld b e u sed to im p rove h ea lth ca re a n d e d u ca tio n ), p h ysicia n ove r-sp e cia liza tio n , a n d t e ch n ica l a n d p ro fe ssio n a l su b ju ga t io n t o m o d e r n h e a lt h c a re p la n s wit h t h e ir va r io u s form a ts. Pra ta (1992) d escrib es Bra zil’s “in com -p lete e-p idem iological tran sition”, in wh ich d is-ea ses ch a ra cteristic of ‘b a ckwa rd n ess’ occu r si-m u lt a n e o u sly wit h t h o se o f ‘si-m o d e r n it y’, wit h sp ecia l em p h a sis o n em ergin g a n d reem ergin g in fe c t io u s d ise a se s (Ma r q u e s, 1995) a n d ‘e p id em ic’ so cia l vio len ce (Min a yo, 1994). Acco rid -in g t o o fficia l Wo rld Ba n k st a t ist ics, Bra zil h a s t h e gre a t e st d isp a r it y in t h e wo r ld in t e r m s o f we a lt h a n d in c o m e, a n d t h is gro ss in e q u a lit y is re fle ct e d in t h e d ist r ib u t io n o f re so u rce s fo r h e a lt h , in clu d in g re m u n e ra t io n o f p h ysicia n s. Wit h u n ive r s a l h e a lt h c a re fo r m a lly gu a r a n -t e e d b y -t h e 1 9 8 8 Co n s -t i-t u -t io n , -t h e c o u n -t r y is t h u s a p a r a d igm fo r t h e u n re s o lve d m o ra l d ile m m a b e t we e n t h e go a l o f e q u it a b le c a r e versu s th e fin itu d e o f m a teria l a n d p o litica l re-s o u rc e re-s t o p r o vid e it (En ge lh a rd t , 1996:375-410). In t e ra c t in g wit h a ll o f t h e a b o ve is wh a t Alm eid a & Sch ra m m (1998) d escrib e a s a p a ra d igm a tic tra n sition , or m eta m orp h osis of m ed -ica l eth ics.
Th e m a in th eoretica l referen ces for a n a lysis o f o u r t a p e d in t e r vie ws we re t h e h ist o r ica l re -vie ws o f m e t a p h o r b y Bla c k (1962:25- 47) a n d Rico e u r (1972), b a se d o n wh ich we id e n t ifie d t h e livin g m etap h ora s t h e p r im e in st r u m e n t for crea tion of n ew m ea n in gs b y m ed ica l sla n g, e st a b lish in g in t e r fa ce s b e t we e n t h e fo llowin g: (1) m e t a p h o r a s wo rd (t ro p e ); (2) m e t a p h o r a s
e n u n c ia t io n (o r m e t a p h o r a t t h e c o re o f t h e p h ra se ), a n d (3) m e t a p h o r ic a l d isc o u r se (in th is ca se, sla n g).
Substitutive and comparative explanations of metaphor and their limitations
We b e gin o u r d isc u ssio n o f m e d ic a l sla n g b y b r ie fly illu st ra t in g t h e d iffe re n ce b e t we e n t h e t h re e h ist o r ic a l vie ws o f m e t a p h o r, n a m e ly su b stitu tio n , co m p a riso n , a n d in te ra ctio n , u s-in g a p h ra se fro m o n e o f o u r s-in te r vie we e s (th e en tire excerp t is p rovid ed in Ap p en d ix II). Du r-in g th e cou rse of th e r-in ter view, th e p h ysicia n , a 34ye a ro ld m a le a n e sth e sio lo gist fro m a p u b -lic h o sp it a l in Rio, st a t e s: “Th e ICU is a tortu re room.” Th e listen er ten d s to fo cu s h is a tten tio n on th e termtortu re room, wh ich Black (1962:28) t h u s ca lls t h e focu so f t h e m e t a p h o r, wh ile t h e re st o f t h e p h r a se se r ve s a s t h e fram e. If t h e p h ra se is in t e r p re t e d a s su b st it u t io n (i.e ., a c co rd in g to th e cla ssica l vie w o f m e ta p h o r, p re -va ilin g sin ce Ar ist o t le, wh e re b y a t e r m ’s lit e ra l o r p ro p e r se n se is re p la c e d b y a figu ra t ive m ea n in g), it wo u ld m ea n ‘Th e ICU is a p la ce o f p a in , iso la t io n , e t c.’. In t e r p re t e d a s c o m p a r i-so n , o r sim ile, it wo u ld m e a n ‘An ICU is lik ea t o r t u re ro o m (wit h re ga rd t o p a in , iso la t io n , etc.)’. Bo th su b stitu tio n a n d co m p a riso n im p ly t h a t in o rd e r t o u n d e rst a n d t h e m e t a p h o r, lis-ten ers n eed on ly tra n sla te b a ckwa rd s u n til th ey rea ch th e p rop er m ea n in g of th e m eta p h or’s fo-cu s. Acco rd in g to th e su b stitu tive a n d co m p a r-a t ive vie ws, m e t r-a p h o r se r ve s t o e m b e llish d is-co u rse, a s a so u rce o f su rp rise a n d d eligh t, b u t d o es n o t crea te a n y n ew m ea n in g.
M etaphor as interaction
of you r sou l...” ( Va in fa s, 1997:202). Th is e xa m p le wa s ta ken from th e In q u isition in la te16th -c e n t u r y n o r t h e a st e r n Bra zil, b u t re a d e r s m a y re c a ll a sim ila r t h e ra p e u t ic a p p r o a c h b y In -q u isit o r Be r n a rd o Gu i in Um b e r t o Ec o’s Th e Nam e of th e Rose. In o th e r wo rd s, wh ile ca llin g a n In te n sive Ca re Un it a to rtu re ro o m p o rtra ys it in a c r u e l ligh t , t h e sa m e m e t a p h o r m a ke s t h e t o r t u re r o o m a p p e a r m o re t h e ra p e u t ic. Su c h in t e ra c t ive m o d ific a t io n is a ll t h e m o re a p p a re n t in o u r in t e r vie we e’s lit t le slip , wh e n h e u se s t h e t e rm ‘t o r t u re ro o m ’ (sala d e tortu -ra) ra t h e r t h a n t h e c u st o m a r y ‘t o r t u re c h a m -b er’ (câm ara de tortu ra). By ad op tin g m eta p h or a s t h e b a sis fo r sla n g a n d in t e r a c t io n a s t h e co n cep t th a t b est exp resses th e sem a n tic p ow-er o f m eta p h o r, we a ffirm th a t m ed ica l sla n g is irre p la ce a b le a s a sign ifica n t o f m e d ica l e th o s, e ve n t h o u gh it m a y in t e r a c t wit h o t h e r re fe r en ces fo r th is eth o s, like scien tific a n d d eo n to lo gica l d isco u rse. Me d ica l sla n g is t h u s e sse n -tia lly co n n o ta tive (Du cro t & To d o rov, 1979:23), to th e exten t th a t th e sign ifica n t elem en t is th e u se o f t h e lin gu ist ic re gist e r p e r se . Ove r t h e co u rse o f th is a rticle, a lth o u gh th e ch a llen ge o f in ve st iga t io n d e m a n d s t h a t we ‘t ra n sla t e’ o r dissect su ch m ed ica l m eta p h o rs a s tram biclín i-ca, p ilan tróp ico, Em brom ed, e t c., we a t t e m p t n o t t o lo se sigh t o f t h e lim it s o f t h is ‘t ra n sla t io n’. Th e n o t io n o f lo ss o f m e a n in g in t h e a t te m p t to tra n sla te m e ta p h o r in to lite ra l m e a n -in g is e xp re sse d b y Ro b e r t Fro st (Br it t o, 1989: 111) wh en h e d efin es p oetr y a s “th at w h ich gets lost in th e tran slation” a n d Fre u d (1905:86), wh o ca u t io n s t h a t “...if w e u n d o th e tech n iqu e of a jok e it disappears.”
Be ca u se o f it s ce n t ra l ro le in Ca r io ca m e d -ic a l sla n g, we fo c u s e sp e c ia lly o n t h e p u n (o r trocadilh oin Po rtu gu ese), a sp ecia l fo rm o f in -teractive m etap h or. By way of exam p le, a sp ea k-e r a t a rk-e c k-e n t c o n fk-e rk-e n c k-e in Rio d k-e Ja n k-e ir o o n p ed ia tric resp ira to ry d isea ses sh owed a slid e o f a n in fa n t wit h a p e r fo ra t in g wo u n d in t h e ce r -vic a l re gio n a n d p u n n e d , “W h ile oth er cou n -tries h ave th e Ebola viru s, w e h ere in Brazil h ave th e ‘É bala!’[‘It ’s a bu llet!’] viru s.” Th e wo u n d h a d b e e n c a u se d b y a st ra y b u lle t , a c o m m o n a ccid en t fo r a m etro p o lita n p o p u la tio n ca u gh t in h igh -p owe re d cro ssfire b e t we e n p o lice a n d d r u g ga n gs. Th e in t e ra ct ivit y o f t h e t wo t e r m s le a d s t h e list e n e r t o sim u lt a n e o u sly a sso cia t e a n e m e r gin g in fe c t io u s a ge n t a n d e p id e m ic s o c ia l vio le n c e , a sc e n a r io o f h o r r o r e xp e r i-e n c i-e d b y Rio d i-e Ja n i-e iro p h ysic ia n s ri-e c i-e ivin g p a t ie n t s “at th e d oor to th e em ergen cy w ard” (Pin h e iro, 1994). No t e t h a t fro m 1985 t o 1995, th e two Bra zilia n cities wh ose in com e d isp a r ity wo rse n e d t h e m o st , Rio d e Ja n e iro a n d Re cife,
we re t h e sa m e o n e s t h a t su ffe re d t h e gre a t e st in c re a se in so c ia l vio le n c e (So u za & Min a yo, 1995). Ac c o rd in g t o figu re s fo r 1995- 96, t h e h o m icid e ra t e in Gre a t e r Me t ro p o lit a n Rio d e Ja n e ir o is 4.7 t im e s t h a t o f Ch ic a go a n d 9.1 t im e s t h a t o f Ne w Yo rk Cit y (Mo re ira , 1998). An d p h ysicia n s in Rio a re a wa re of th e p rob lem n o t o n ly b eca u se th ey d ea l with it in th e em er-ge n c y wa rd . In t h e la st five ye a r s t h e lo c a l p h ysic ia n s’ u n io n h a s file d 20 c o m p la in t s o f t h re a t s a ga in st h o sp it a l a d m in ist r a t o r s a n d p h ysic ia n s wo r kin g in p u b lic h o sp it a ls a n d clin ics, a ll o f wh o m we re a t t e m p t in g t o e lim in a te co rru p tio in fro m b id d iin g o in m e d ica l su p -p lie s (Co n t i, 1998:19). Th re e o f t h e se -p h ysi-c ia n / a d m in ist ra t o r s we re m u rd e re d , a n d a fo u r t h , a su r ge o n , wa s p e r m a n e n t ly d isa b le d b y a gu n sh o t wo u n d in t h e h a n d . Th u s, p u n s su c h a s Ebola/É bala a re se m a n t ic a lly a gile , sin ce a sin gle term co n veys b o th th e fo cu s a n d fra m e o f th e m eta p h o r.
Ec o (1974:83- 84) d e fin e s p u n a s “a forced con tigu ity betw een tw o or m ore w ords...m ade of reciprocal elision s, th e resu lt of w h ich is an am -bigu ou s d eform ation ...[re le a sin g] a series of p ossible read in gs...[wh ic h b e c o m e ] m u tu ally su bstitu table.” Th e Portu gu ese-lan gu age eq u iv-a le n t o f p u n , t h e trocad ilh o, d e r ive s fro m tro-car(‘t o t ra d e’) a n d c o u ld b e t r a n slit e ra t e d a s ‘tra d elet’. It is th u s etym o lo gica lly m eta lin gu is-t ic, sin ce iis-t d e n o is-t e s is-t h is p ro ce ss o f re cip ro ca l elision a n d m u tu a l su b stitu tion . As a m eta p h or co n ce n tra te d in a sin gle wo rd , p u n /trocad ilh o fa cilita tes its own in co rp o ra tio n in to sla n g, cir-cu la t in g a n d ‘t ra d in g’ a ro u n d sim u lt a n e o u sly a s co n d en sed jo ke a n d n ew lexem e. To d a te we h a ve fo u n d n o t h e o re t ica l re fe re n ce t o t h e u se o f th e trocadilh oin Po rtu gu ese, d esp ite its rich p re se n ce in t h e sp o ke n a n d writ t e n la n gu a ge. Fo r b ro a d se gm e n t s o f t h e Bra zilia n p o p u la -t io n , -t h e trocad ilh op la ys a fo u n d in g r o le : fa -t h e r s a n d m o -t h e r s c o m b in e sylla b le s fr o m t h e ir own n a m e s t o n a m e t h e ir n e wb o r n , a s if to sign ify th e gen etic recrea tio n la u n ch ed n in e m o n t h s p re vio u sly (m irr o r in g se m a n t ic p ra c-tice in th e field o f gen etics, wh ich is freq u en tly p ortrayed as lan gu age, wh ere gen etic seq u en ces a re w ords, ch ro m o so m e s a re a book of in stru c-tion st o b e read, t h e c o m p le x m o ve m e n t s o c -cu rrin g d u r in g re d ist r ib u t io n o f ge n e t ic in for-m ation a re tran slation , d eletion , ed itin g, e t c.) (e xa m p le s t a ke n fr o m e d it o r ia l in Scien ceb y Ga ll, 1995:1551).
le xica l fo rm . Th e se a re a s a re : 1) m e d ica l tra in -in g a n d t h e re la t io n sh ip b e t we e n kn owle d ge a n d th e va riou s field s of m ed icin e (u sin g m a in -ly p r ove r b s wit h a n im p e r a t ive a n d re a list ic b a se – (Du cro t & To d o rov, 1979:155) co n stru ct-e d in t h ct-e fo rm o f ch ia sm a s (Du cro t & To d o rov, 1979:277), wh ose p oin t of in flection is th e m ed -ic a l sp e c ia lt y it se lf; 2) p a t ie n t s, o r t h e p h ysic ia n p a t ie n t re la t io n sh ip (u sin g m a in ly o n o -m a to p o eic a cro n y-m s a n d n o n sen se wo rd s, b u t a lso p u n s); a n d 3) h e a lt h ca re se r vice s (wh e re p u n s p re va il). Fo r e co n o m y o f sp a ce, t h e cu r -re n t p a p e r m a ke s o n ly b r ie f -re fe -re n c e t o t h e first grou p, con cen tra tin g on th e oth er two, d u e t o t h e ir gre a t e r re le va n c e fo r t h e “Braz ilian h ealth care h ypercrisis”.
M etaphor and medical knowledge
Th is first gro u p o f tro p es sh ows h ow m eta p h o r a ccom p a n ies p h ysicia n s’ rela tion sh ip to a cq u i-sitio n o f kn owled ge a n d ch o ice o f p ro fessio n a l sp e cia lty, illu stra tin g th e n o tio n o f ca ta ch re sis a s a d e a d m e t a p h o r, i.e., t h e re p e t it io n o f o ld , wo r n -o u t jo ke s, t h e t a rge t p u b lic o f wh ich a re m e d ic a l st u d e n t s, kn own a s Acad es vu lgaris, a n d in t e r n s, o r bagrin h os (‘b u llh e a d s’). Th e p rove r b s c o n st it u t in g t h e m a in t h r u st o f t h is gro u p o f jo kes, like“Th e clin ician k n ow s every-th in g, bu t solves n oevery-th in g, w h ile every-th e su rgeon k n ow s n oth in g, bu t solves everyth in g,”p rovid e a m o ck re in t e r p re t a t io n o f t h e ro o t s o f p ro t o m o d e r n (19t h ce n t u r y) m e d icin e, wit h a b u r -le sq u e c o r re la t io n t o t h e h ist o r ic a l lit e ra t u re (Sta rr, 1982; Fried so n , 1988; Rego, 1996), in a d d it io n t o se r vin g a s a fo r m o f p rovo ca t io n b e -tween th e d ifferen t m ed ica l sp ecia lties.
Oth er jokes from th is grou p reflect th e p ro b -le m o f d ia gn o stic a n d th e ra p eu tic u n cer ta in ty, d isgu ise d b y t h e m e d st u d e n t wit h a n a ir o f b ra va d o kn own to su p erio rs a s dou torite(‘d o c-t o r ic-t is’) a n d b e c-t ra ye d b y m o re e xp e r ie n c e d p h ysic ia n s wh e n t h e ir p arecer(‘e xp e r t o p in -io n’) is t ra n sfo r m e d p a ro n o m a st ica lly b y t h e ir su b ord in a tes in to a h esita n t parece ser...(‘it a p -p ea rs to b e...’). Prin ce et a l. [1982] focu s on th is issu e o f h e d gin g in p h ysic ia n p h ysic ia n d is -co u r se. Me d ica l sla n g le xi-co n ize s su ch d o u b t b o t h ve r t ic a lly in t h e h ie r a rc h ic a l c h a in o f m e d ic a l wo r k a n d h o r izo n t a lly b e t we e n sp e -cia ltie s. Howe ve r, th e e n tire sta ff is so m e tim e s forced to b ow to th e effects of a u n iq u e en zym e ca lle d escu lh am bin a, n e ve r m e n t io n e d in t h e scie n t ific lit e ra t u re, b u t t o wh ich is fre q u e n t ly a scr ib e d t h e u n e xp e ct e d re cove r y o f a p a t ie n t with a p a rticu la rly so m b er p ro gn o sis, esp ecia l-ly if h e is p o o r a n d / o r b la c k. Th e e n zym e’s
n am e d erives from cu lh ão, or ‘testicle’ an d con n o te s th e m e d ica l sta ff’s ‘e m a scu la tio n’ o r ‘d e -m ora liza tion’.
M etaphor in the physician-patient relationship
It h a s b e c o m e c o m m o n se n se t h a t t h e p h ysi-cia n -p a t ie n t re la t io n sh ip is t h e m a in lo cu s fo r jo kes fro m th e m e d ica l fie ld , d u e in p a rt to th e p o p u la riza tio n o f Au stria n p h ysicia n Sigm u n d Fre u d ’s Jok es an d Th eir Relation to th e Un con -sciou s(1905), wh ich in clu d e s se ve ra l jo ke s o n d isea se, a ll o f wh ich fo cu s o n th is rela tio n sh ip . A n ovel by Crich to n (1968) a n d a stu d y b y Go r-d o n (1983) o n h o sp it a l sla n g in Ca lifo r n ia a lso refer to term s fo r p a tien ts, with o u t m en tio n in g o th er p o ssib le ta rgets o f m ed ica l h u m o r.
It h a s a lso b ecom e a com m on -sen se n otion t h a t m e d ic a l wo r k is a so u rc e o f t e n sio n (o r e ve n ‘stress’) fo r it s p ra c t it io n e r s, va r yin g n o t o n ly fr o m o n e in d ivid u a l t o a n o t h e r b u t a lso a cco rd in g t o t h e sp e cia l fie ld (m o re fo r e m e r-ge n cy ca re p h ysicia n s, le ss fo r d e rm a to lo gists, e t c.), o r in p a ra lle l, a c c o rd in g t o t h e t yp e o f p ro ce d u re (m o re fo r em ergen cy in ter ven tio n s, le ss fo r se le ct ive p ro ce d u re s, e t c.). Ph ysicia n s ve r b a lize t h is t e n sio n t h r o u gh m e t a p h o r s b y wh ich th ey d efin e th em selves, u sin g su ch term s a s t h e fo llo w in g fr o m o u r in t e r vie we e s : Boe-in g p ilot, football goalk eep er, cru cified , on th e tigh trop e, firefigh ter, e t c.
b e sid e s b e in g u se d a s a n o n o m a t o p o e ic in t e r -je c t io n o f su r p r ise, re fe r r in g t o o n e o b -je c t b o u n c in g o ff a n o t h e r (in t h is c a se , a h u m a n b o d y t h a t h a s b o u n c e d o ff a sp e e d in g m o t o r veh icle – pim ba!). Estropício(‘jeo p a rd y’) refers to a p oor ob stetric p a tien t, d efin ed b y a n in ter-vie we e a s “a n u n k em p t w om a n”. An d t ru bu -fu (‘fa t , u gly b la c k wo m a n’) m a y b e u se d fo r Africa n Bra zilia n o b stetric p a tien ts.
Ye t t h e p a t ie n t ’s so c io e c o n o m ic st a t u s is n o t t h e e xclu sive d e t e r m in a n t o f sla n g. Be fo re a cesa rea n section of a n ob ese ob stetr ic p a tien t o f a n y so cia l o r eth n ic o r igin , th e su rgeo n m a y re q u e st t h a t t h e in st ru m e n t t ra y in clu d e m eat h ook s. A p a t ie n t o f a n y so c io e c o n o m ic c la ss wit h m u lt ip le t ra u m a m a y b e re fe r re d t o a s p oliescu lh am bad o, a s wit n e sse d b y t h e fre -q u e n t cr y in t h e e m e rge n cy wa rd : “Hey, w e got a p oliescu lh am bad o h ere!” (ro u gh ly t ra n sla t -a b le -a s “m u lt i- fu cke d - u p”, t h e t e r m h -a s -a vu l-ga r e t ym o lo gy, fro m t h e ro o t cu lh ão, o r “t e st i-cle”, co n n o tin g th e p a tien t’s em a scu la tio n ).
Alt h o u gh t h e p o ssib le re je c t io n o f c e r t a in p a t ie n t s b y so m e h e a lt h c a re p r o fe ssio n a ls is n o t t h e fo cu s o f t h is st u d y, in t e re st e d re a d e r s a re re fe rre d t o t h e re vie w b y Ga lizzi (1997) o n ch ro n ic p a t ie n t s, e sp e cia lly t h o se d isp la yin g wh at in Brazil is referred to as h ospitalism o(i.e., t h e revolvin g-d oor p atien tsre fe rre d t o b y U S a u th o rs). Brie fly, se ve ra l te rm s e xp re ss th e im p a t ie n ce e xp e r ie n ce d b y so m e p h ysicia n s t o -wa rd s severe, term in a l, a n d / o r freq u en tly h o s-p ita lized s-p a tien ts. Fo r exa m s-p le, th e m eto n ym i-ca l u se o f th e verb en gessar(‘to p la ce in a ca st’, in th e p ro p er o rth o p ed ic sen se) ca n a lso m ea n t o o r ie n t t re a t m e n t in su ch a wa y t h a t t h e p a -tien t d o es n o t co m p la in . Fo r term in a l p a -tien ts, t h e c yn ic a l t e r m sín d rom e JEC (wh e re t h e a cron ym sta n d s for Jesu s Está Ch am an door ‘Je-su s is callin g’) rep laces th e m ore literal a cron ym fro m m e d ic a l ja r go n , FPT(Fora d e Possibili-dade Terapêu ticaor “b eyon d p ossib ility of treat-m e n t”, sitreat-m ila r t o t h e U S a cr o n ytreat-m DNR, o r “d o n o t re su scit a t e”). On e p h ysicia n re p o r t e d t h a t t h e fo llowin g co m m e n t is co m m o n : “No, th at p atien t sh ou ld n ot h ave gon e to th e OR. He sh ou ld h ave gon e directly to Path ology. Th ey sen t th e p atien t to th e w ron g w ard!”. Th e a cro n ym DPP, o r igin a lly Descolam en to Prem atu ro d a Placen ta(or abru ptio placen tae), u sed cyn ically m ean s Deixa para o Próxim o Plan tão(or “leave h er for th e n ext sh ift”), wh en a p atien t is in late-sta ge la b o r n ea r a ch a n ge in sh ifts.
Sla n g fo r p a tien ts is n o t exclu sive to Bra zil-ia n p h ysic zil-ia n s. Mic h a e l Cr ic h t o n , gra d u a t e d fro m t h e Ha r va rd Sch o o l o f Me d icin e a n d b e t-t e r kn own t-t o Bra zilia n s a s scr ip t-t wr it-t e r fo r t-t h e televisio n series ER, rep o rts exa m p les o f Am
er-ic a n m e d er-ic a l sla n g like t h e c r yp t o gr a p h er-ic d i-a gn o s is SH A, o r “Sh ip H is As s”, fo r p a t ie n t s wh o a vo id o r re fu se t o b e re le a se d fr o m t h e h o sp it a l, a n d FLK, o r “Fu n n y-Lo o kin g Kid ”, a n a cron ym u sed b y th e p ed ia tric sta ff in th e p res-e n c res-e o f t h res-e p a rres-e n t s o f a n a res-e st h res-e t ic a lly c h a l-len ged p a tien t (Crich to n , 1968:406-407).
A stu d y b y Go rd o n (1983) a n a lyzes h o sp ita l sla n g in Ca lifo rn ia , d isp la yin g n o tewo rth y sim -ila rities to Ca rio ca m ed ica l sla n g fo r th e p h ysi-cia n -p a tie n t re la tio n sh ip. Go rd o n d e fin e s fo u r ca t e go r ie s, a n d we in clu d e t h e ir a p p r o xim a t e eq u ivalen ts in Portu gu ese (after wh ich we com -m en t on th e au th or’s con clu sion s): (1) “patien ts w h o dem an d m ore atten tion th an is w arran ted by th eir ph ysical con dition”,su ch a s“goldbrick”, (e q u iva le n t t o p itiático in Bra zilia n sla n g, d e -r ive d f-ro m p etit m al, su gge st in g t h a t su ch p a -t ie n -t s a re fe ign in g a “le sse r ill”): (2) “p atien ts w ho are m em bers of socially stigm atized grou ps”, like ‘d ir t b a ll’, (se e m u lam boo r ‘ra g’ in Bra zil); (3) “patien ts w h o are ph ysically u n respon sive or com atose”, like ‘p re - st iff’ (t h e ‘Je su s- is- ca llin g syn d r o m e’ in Bra zil); a n d (4) “p atien ts w h ose con dition s are referred to by descriptive term s or are view ed p ositively”, like ‘go o d p a t ie n t s’ (o r ‘p la ced -in -a -ca st’ in Bra zil).
Go rd o n d ra ws se vera l cu rio u s co n clu sio n s. Th e fir st is t h a t c a t e go r ie s 1 t o 3 in c lu d e p a -tie n ts “w h o claim m ore atten tion for th eir con -d ition s th an is w arran te-d” (1983:179), a va lu e ju d gm en t th a t d efies b o th co m m o n sen se (o n e wou ld h ave to ask, for exam p le, h ow a com a tose p a tie n t ca n cla im a n yth in g, e xce p t in th e figu -ra tive sen se) a n d m ed ica l eth ics. Th e seco n d is t h a t c a t e go r y 4 re p re se n t s p a t ie n t s se e n in a p o sit ive ligh t b y t h e p h ysicia n , a n a ffir m a t io n b e lie d b y t h e ve r y e xa m p le s q u o t e d b y t h e a u -t h o r : ‘p a le fa ce’ fo r a ch ild wi-t h le u ke m ia a n d severe a n em ia , ‘Zorro b elly’, for a p a tien t with a h isto r y o f m u ltip le la p a ro to m ie s, e tc., in a d d i-t io n i-t o i-t h e p o i-t e n i-t ia lly a m b igu o u s u se o f ‘go o d p a tien t’, m o re a kin to th e Bra zilia n ‘p a tien tin -a -c-a st’.
stu d y (1997) on th e rejection of certa in p a tien ts m a kes th is a rea of m ed ica l h u m or m ore u n d er-s t a n d a b le in ligh t o f t h e fo llo win g er-s t a t e m e n t b y Fre u d : “Bru tal h ostility, forbid d en by law, h as been rep laced by verbal in vective...By m ak -in g ou r en em y sm all, d esp icable, or com ic, w e ach ieve in a rou n d abou t w ay th e en joym en t of overcom in g h im ...” (Freu d , 1905:122).
Go rd o n m e n t io n s in p a ssin g t h a t h o sp it a l sla n g is n o t u sed in th e p resen ce o f p a tien ts o r t h e ir fa m ilie s, ye t fa ils t o se e t h e h o sp it a l a s a m u lt ip le, h e t e ro ge n e o u s lin gu ist ic se t t in g. In fa c t , wh a t a llows p h ysic ia n s t o e m p loy sla n g wit h o u t o p e n ly b e t ra yin g e t h ic s in t h e p h ysi-cia n -p a tien t rela tio n sh ip is a ch a n ge o f style in th e sp eech a ct, a p h en o m en o n kn own a s “situ a t io n a l sh ift”, b a se d o n wh e t h e r t h e co n ve rsa -t io n -t a ke s p la c e s in -t h e p re se n c e o f p a -t ie n -t s a n d t h e ir fa m ilie s, in t h e p r iva t e o ffice o r h o s-p ita l wa rd , e tc. Situ a tio n a l sh ift wa s d efin ed a s follows (Blom & Gu m p erz, 1968 a p u d Fish m a n , 1972:49): “Mem bers of social n etw ork s sh arin g a lin gu istic rep ertoire m u st (an d d o) k n ow w h en to sh ift from on e variety to an oth er... A sh ift in situ ation m a yrequ ire a sh ift in lan gu age vari-ety. A sh ift in lan gu age variety m a ysign al a sh ift in th e relation sh ip betw een co-m em bers of a so-cial n etw ork , or a sh ift in th e topic an d pu rpose of th eir in teraction , or a sh ift in th e p rivacy or locale of th eir in teraction .”
Wit h o u t u sin g t h e a ct u a l t e r m ‘sit u a t io n a l sh ift’, on e of ou r in ter viewees exp la in s th e p h e -n o m e -n o -n a s fo llo ws: “...jok es are u su ally ju st betw een doctors...am on gst th e h ealth care staff. An d p atien ts are n ot in on th e jok e. Patien ts com e in sick , an d th ey n eed to be treated! In th e office you deal directly w ith th e p atien t. It’s ju st you an d th e patien t. You can’t jok e arou n d w ith th e patien t. Bu t in th e h ospital it’s differen t, you h ave th e grou p, you h ave th e p atien t (...). W ith th e patien t you h ave to k eep th at ph ysician -pa-tien t relation sh ip. It ’s d ifferen t w h en it ’s on e d octor w ith an oth er, you can jok e, cu rse, say w h atever you w an t. Bu t n ot w ith th e p atien t. You h ave to treat th e p atien t accordin g to th ose n orm s that w e learn ed...” (an esth etist, m ale, 54). In t h e o p e ra t in g ro o m , e ve n wit h t h e p a -t ie n -t p h ysica lly p re se n -t , a si-t u a -t io n a l sh if-t o ccu rs d e p e n d in g o n wh e t h e r t h e p a t ie n t is u n -d er sp in a l b lock (‘a wa ke’) or gen era l a n esth esia (‘a sle e p’). Du r in g a c e sa re a n se c t io n , t h e t wo d ifferen t sta ges in th e sa m e su rgica l a ct (b efore a n d a ft e r t h e d e live r y) a re a c c o m p a n ie d b y d iffe re n t sp e e ch st yle s, wh e re b y t h e t o n e a n d co n t e n t o f t h e jo ke s va r y: “...an an esth etist in obstetrics sh ou ld n ot u se sedative dru gs, becau se of th e fetu s, so h e h as to u se p a p o t e ra p ia [fro m p ap o,o r ‘ch itch a t’, a n d terap ia, o r ‘th e ra p y’] to
calm th e p atien t, tellin g h er little jok es, givin g h er a lot of atten tion , tryin g to relieve th at ten -sion , becau se all p regn an t w om en are very n er-vou s, very an x iou s, you k n ow, th ey’re feelin g p ain . Bu t after th e baby is born , th en ...th en w e’re free...” (a n esth etist, m a le, 33).
An oth er a n esth etist exp la in s th e situ a tion a l sh ift in t h e t wo st a ge s o f a c e sa re a n : “...you rarely p u t th e p atien t to sleep. You ju st give h er a sp in al block . So you can talk , bu t in a d iffer-en t w ay. You can’t ju st go an d say to th e su rgeon , ‘Hey m an , sh e’s dyin g! Sh e’s... I don’t k n ow w h at all! Sh e’s bleedin g!’You h ave to talk m ore su btly. You lim it th e jok es, an d th ere’s som e th in gs you can’t say. Bu t w ith th e p atien t sleep in g, you can tu rn to th e su rgeon an d say, ‘Sh it!’If you w an t to give h im a h ard tim e, you say, ‘Hold on m an , w e’re losin g h er!’ Bu t if t h e p a t ien t is a w a k e, you h ave to k eep u p a m ore p rofession al d ia-logu e...”(a n esth etist, m a le, 54).
Go rd o n’s n o t io n o f t h e ‘so c ia l fu n c t io n’ o f sla n g a s a n a d ju va n t t o t h e p ro fe ssio n a l re la t io n sh ip (b y p ro m o t in g gr o u p ra p p o r t , m a in ta in in g in d ivid u a l d ista n ce ) e n ta ils a su b stitu -t ive vie w o f m e d ica l m e -t a p h o rs -t h a -t ove rlo o ks t h e ir p o t e n t ia l fo r c re a t in g n e w m e a n in g. In t h e ca se o f Ca r io ca m e d ica l sla n g, it wo u ld b e a s if ca llin g a p a t ie n t a m u lam boco u ld b e re -d u ce-d to a litera l tra n sla tio n ‘ra gge-d , p o o r, a n -d b la ck’ skirtin g th e in te ra ctio n o f th e m e ta p h o r wit h t h e p h ysic ia n’s own so c io e c o n o m ic a n d c u lt u ra l wo r ld (a c c o rd in g t o t h e in t e r a c t ive view, m eta p h o r d o es n o t m erely exp ress a n ex-istin g m e a n in g; o n th e co n tra r y, it cre a te s n e w m e a n in g). Th u s, t h e m e t a p h o r m u lam bod o e s n o t m e re ly exp ressso cia l e xclu sio n ; it h e lp s t o createit.
Th e a b ove m a y h e lp e xp la in wh y Go rd o n fa iled to id en tify oth er sem a n tic field s for m ed -ic a l sla n g, i.e ., wh y h e lim it e d h is a n a lysis t o h ospital slan g for patien ts, overlookin g m edical slan g for h osp itals. As we will se e in t h e n e xt se c t io n , t h e r ic h e st m e t a p h o r s e m e r ge wh e n d octors lexicon ize th eir own rela tion sh ip to th e h ea lth ca re system .
Puns for health care services
“Not all are free w h o m ock th eir ch ain s.” (Less-in g, q u o ted b y Freu d , 1905:109).
Bra zilia n co n t e xt b y Ma ch a d o (1996:191- 193) a s a n exp la n a to r y p a ra d igm fo r th e co n tem p o -ra r y cr isis in t h e B-ra zilia n m e d ica l p ro fe ssio n : “Th e m edical profession h as becom e m ark ed by its depen den ce on differen t types of h ealth plan s an d by u n certain ty, pessim ism , an d a black an d discou ragin g fu tu re. Ph ysician s-in -train in g w ill soon be treatin g p atien ts in in stitu tion s gov-ern ed by ru les, n orm s, an d regu lation s follow in g a m an agem en t ration ale in d irect con flict w ith th e profession’s prin ciples” (Ma ch a d o, 1996).
On c e a ga in , Fre u d (1905:129) s h e d s ligh t o n t h e u s e o f m e d ic a l s la n g a s a r e s p o n s e t o t h is c o n t e xt o f c r is is in h e a lt h c a re s e r vic e s : “...in th e exam p les w e h ave con sid ered h ith er-to, th e disgu ised aggressiven ess h as been direct-ed again st p eop le [rea d ‘p a tien ts’],...bu t th e object of th e jok e’s attack m ay equ ally w ell be in -stitu tion s (...) w h ich en joy so m u ch resp ect th at objection s to th em can on ly be m ad e u n d er th e m ask of a jok e an d in deed of a jok e con cealed by its façad e.” Fre u d c a lls su c h jo ke s cyn ical o r sk ep tical, a t t r ib u t in g t o t h e m t h e p owe r o f e x-p osé: “A jok e is n ow seen to be a psych ical factor p ossessed of p ow er: its w eigh t, th row n in to on e scale or th e oth er, can be d ecisive... [wh e n ] it sh atters resp ect for in stitu tion s an d tru th s in w h ich th e h earer h as believed” (1905: 162-163). We a re n ow re a d y fo r a clo se r lo o k a t so m e m e d ic a l jo ke s re fe r r in g t o va r io u s se r vic e s in th e Bra zilia n h ea lth ca re system .
Ma n y m e d st u d e n t s (Acad es vu lgaris) a n d in t e r n s (ca lle d bagrin h os, o r ‘b u llh e a d s’, sin ce t h e y’re a n u isa n ce t o t h e re a l fish in g a n d co n -sta n tly h a ve th eir wh iskers in th e wa y) get th eir first h a n d s-on exp erien ce with clin ica l p ra ctice in wh a t is ca lle d a tram biclín ica(a t ro p e we ll-kn own t o a ll o f o u r in t e r vie we e s). Th is p u n’s p olysem y is p a rticu la rly rich , sin ce it com b in es tram biqu e,o r “trick ; frau du len t bu sin ess” (Fer-re ira , 1986:1698) a n d clín ica, “p lace of rest”, “m edical practice” (Cu n h a , 1986:189), wh ile th e word tram biqu ein tu rn stem s from tram polim, a ‘sp rin gb o a rd ’, b o th litera lly a n d figu ra tively a “...th in g w h ich lau n ch es som eon e; a step” (Fer-re ira , 1986:1698), t h u s co n n o t in g p ro fe ssio n a l in it ia t io n . How d o e s t h is m e t a p h o r fu n c t io n ? To t ra n sla t e it lit e ra lly a s ‘a fra u d u le n t c lin ic’ (accord in g to th e su b stitu tive view of m eta p h or) wo u ld im p ove r ish it s m e a n in g. Th e re is a n in -t e ra c-t io n b e -t we e n tram biqu e, tram p olim, a n d clín icawh ereb y th e term s o rga n ize ea ch o th er, a s we ca n see from th e exp la n a tion p rovid ed by a p h ysic ia n : “Tram biclín ica is a k in d of clin ic w h ich , in stead of h avin g a train ed ph ysician on w ard d u ty, h as m ed stu d en ts w ork in g for it, in ord er to p ay less, to get h igh er p rofits, n ot to m en tion th at th ese p h ysician s [sic] th em selves
are forced ...n o...o r ie n t e d...to ord er all k in d s of tests, u n n ecessarily, in ord er for th e clin ic to earn m ore profit” (a n esth etist, m a le, 33).
Th e d efin ition sh ows h ow th e tram biclín ica a ct s a s kin d o f sp r in gb o a rd fo r p h ysicia n s in -t ra in in g, a n d h ow e ve n b e fo re gra d u a -t in g -t h e la t t e r a re e n t a n gle d in t h e kin d s o f fin a n c ia l a n d m a n a gem en t p ro ced u res a d o p ted b y su ch in stitu tio n s, th u s a n ticip a tin g th e ir fu tu re la ck o f p r o fe ssio n a l a u t o n o m y. In t h e m e t a p h o r’s in t e ra ct ivit y, t h is t yp e o f clín ica(clin ic) o rga -n izes th e tram biqu e(fra u d ), wh ich in tu rn con -d it io n s c lin ic a l p ra c t ic e, wh ile se r vin g a s t h e ca reer tram polim (sp rin gb o a rd ).
An o t h e r c o m m o n t r o p e d e r ive s fro m t h e figu ra t ive u se o f a c o m m o n d e sc r ip t ive t e r m fro m c lin ic a l p ra c t ic e : d ren ar(‘t o d ra in’) b e -co m e s th e fo cu s o f ‘to d ra in a p a tie n t’, d e fin e d a s fo llows: “...a p erson w h o h as an ou tsid e p ri-vate clin ical p ractice tak es a p atien t w h o’s in a given h osp ital an d m oves h im arou n d to w h ere h e h as h is private practice. Th is term ‘to drain’is u sed , becau se a d rain rem oves...an d elim in ates thin gs, u n derstan d? So he m oves the patien t from on e place to an oth er” (a n esth etist, m a le, 54).
Mu lam bu latório is a p u n fo r m e d b y m u -lam bo, m e a n in g ‘ra g’, in c o r p o ra t e d in t o t h e Po rtu gu ese la n gu a ge fro m Qu im b o n d o, a Ba n -t u la n gu a ge, a n d u se d h e re m e -t a p h o r ica lly a s ‘b e gga r’ (Fe rre ira , 1986:1149), p lu s am bu lató-rio, o r ‘o u t p a t ie n t d e p a r t m e n t’ (Cu n h a , 1986: 39). An in t e ra ct ive in t e rp re t a t io n o f t h is p u n / m e t a p h o r su gge st s t h a t su c h a n o u t p a t ie n t c lin ic n o t o n ly treatst h e m u lam bos, b u t a lso h e lp s t o createt h e m . On e p h ysicia n id e n t ifie d m u lam bu latórioa s a syn o n ym fo r p u b lic h o s-p it a l, t re a t in g b o t h t h e h o m e le ss a n d t h e s-p o o r a n d / o r wo rkers in gen era l: “Mu la m b u la tó rio is a p lace th at treats th em u la m b o in th ea m b u -la tório. Th ey u se th is term for people – poor dev-ils! – let’s say th ey exten d th e term to people w h o go to th e p u blic h osp ital becau se th ey h ave to, an d am on gst th is grou p are som e p eop le w h o really h ave n oth in g to eat, w h ile th ere are oth ers w h o are sligh tly better off. So p eop le gen eralize th is term to in clu d e everybod y w h o’s treated in th e pu blic ou tpatien t clin ic – bu t n ot all of th em are reallym u la m b o s” (a n esth etist, m a le, 54).
Bra zilia n versio n o f th e Am erica n ca rto o n strip Brin gin g Up Fath er, o t h e r wise kn own a s Jiggs an d Molly): “Th is plan in volves procedu res per-form ed in a pu blic h ospital onp a ren tes d e fu n -cio n á r io (“re la t ive s o f e m p loye e s”),an d sin ce th e p atien ts are relatives of h osp ital em p loyees, th ey are treated better an d qu ick er. So th at’s w h y w e say, jok in gly, th at th e h ealth plan is PAFÚN -CIO... PAren te d e FUN CIOn ário!!” (a n e sth e tist, m a le, 33).
Th e Pafú n cio p u n re la t e s d ire c t ly t o t h e p h ysicia n s’ su r vey b y Ma ch a d o (1996:161):
“Th e n u m ber of patien ts w h o depen d on free govern m en t h ealth care services is h u ge an d h as grow n stead ily in recen t years, d u e to th e d ire socioecon om ic con dition s in w h ich th e m ajori-ty of t h e Bra z ilia n p op u la t ion live. Th e m ost valu able cu rren cy in su ch cases is traffick in g of in flu en ce am on g frien d s,p a re n t e s (re la t ive s), p h ysician s, d ep artm en t h ead s, h osp ital d irec-tors, etc. Th e w h o-k n ow s-w h om ap p roach , ex-ch an gin g favors, agreem en ts, an d bribes all
be-com e be-com m on place.”
An o th er p u n refers to th e so-ca lled h ospital p ilan tróp ico, a n oxym o ro n b a se d o n t h e wo rd filan trópico, “in spired by ph ilan tropy, w ith love for h u m an ity” (Ferreira, 1986:777) an d pilan tra, o r ‘cro o k’ (Fe rre ira , 1986:1328). On e p h ysicia n d efin ed su ch d u b iou s ch a r ita b le in stitu tion s a s fo llows: “...in th e en d, th ey say th at th eh o sp ita l p ila n t ró p ico is n ot-for-p rofit, bu t it really is, righ t? Th eir ‘n ot-for-p rofit’ lin e is p retty lam e. W h at th ey’re really w orried abou t is th e bottom lin e” (a n esth etist, m a le, 54).
It is im p ortan t to n ote th at th e p rivate office a p p e a rs t o b e e xe m p t fro m m e d ica l jo ke s, re -m a in in g u n t o u ch e d a s t h e id e a l fo r e xe rcisin g clin ical p ractice, as clearly in d icated b y Mach a-d o (1996:147). Bra zilia n p h ysicia n s ge n e rica lly a sso cia te p ro fessio n a l a u to n o m y with th e co n -cep t of ‘lib eral p rofession’ (in th e gen eric sen se) ra t h e r t h a n wit h m e d ica l p ra ct ice p e r se. Al-t h o u gh o u r s Al-t u d y h a s n o Al-t d e Al-t e c Al-t e d a n y p u n s fo r p r iva t e p ra ct ice, t h is e p h e m e ra l id e a l wa s r id icu le d in a film p ro d u ce d jo in t ly b y t h e Rio d e Ja n eiro a n d Sã o Pa u lo Ph ysicia n s’ Un io n s in t h e e a r ly 1980s, c a lle d A Day in th e Life of a Doctor. Th e m a in ch a ra ct e r is a p h ysicia n , n o t so re ce n t ly t ra in e d , wh o sp e n d s h is d a y r u sh -in g fro m o n e jo b t o a n o t h e r (fro m t h e tram bi-clín icato th e Em brom edto th e Plan o Pafú n cio, etc., ea ch with its own p ecu lia r a d m in istra tive-ove r- t h e ra p e u t ic p h ilo so p h y), a n d e n d s h is wo rkd a y in a p r iva t e o ffic e wh ic h h e sh ares with 83 o th er co llea gu es.
In a d d ition to lexicon izin g con flicts in clin i-ca l p ra ct ice, so m e m e t a p h o rs p la y a m o re a ctive ro le in exp la in in g o r in ter ven in g in h ea lth
-ca re rea lity. Th e p resid en t o f th e Rio d e Ja n eiro Sta te Med ica l Boa rd u ses m eta p h orica l iron y to c r it ic ize a t t e m p t s t o im p le m e n t m a lp ra c t ic e in su ra n ce in Bra zil. Th e fa ct t h a t m u lt in a t io n -a l in su r-a n ce co m p -a n ie s -a re b e h in d t h is e ffo r t is critiq u ed by a n a llitera tion b etween th e orig-in a l wo rd orig-in En glish , m a lp ra ct ice, a n d t h e e f-fe c t h e c o n t e n d s it wo u ld p r o d u c e a m o n gs t Bra zilia n d o cto rs, i.e., m al-estar(d isco n ten t o r m a la ise ): “Th e ch aotic situ ation of p u blic m ed-ical care in ou r cou n try h as favored th e grow th of m alp ractice in su ran ce, w h ich can on ly lead tom a l-esta r (d isco n ten t; m a la ise), u n certain ty, an d p reoccu p ation for p h ysician s” (Bo rd a llo, 1996:11).
An o th er exa m p le is th e ca m p a ign la u n ch ed b y t h e Bra zilia n So c ie t y o f Me d ic in e a n d Su rgery (Ca rm o, 1997) a ga in st em pu rroterapia, wh ich t h e So cie t y t ra n sla t e s lit e ra lly a s ‘se lf-m e d ica t io n’ (t h e fo cu s o f t h e lf-m e t a p h o r is t h e ve rb em p u rrar, o r ‘t o p u sh’, a s in t h e co m m o n Bra zilia n co llo q u ia lism em p u rrar com a barri-ga, lit e ra lly ‘t o p u sh wit h t h e b e lly’, i.e., “to fail to provide, or to postpon e, th e proper solu tion to
a problem” – Ferreira , 1986: 236).
M edical slang: sign of an ethical metamorphosis?
clin ica l p ra ctice, d u e to th e ‘d ep ro fessio n a liza -t io n’ a n d -t h e ‘fin i-t u d e’ o f re so u rce s d iscu sse d e a rlie r. Th e d ile m m a o f p h ysicia n s e n m e sh e d wit h in h e a lt h c a re in st it u t io n s is c la r ifie d b y Fre u d (1905:133) wh e n h e sa ys, “A p articu larly favorable occasion for ten d en tiou s jok es is p re-sen ted w h en th e in ten ded rebelliou s criticism is directed again st th e su bject h im self, or...again st som eon e in w h om th e su bject h as a sh are – a collective p erson ...” Bu t t h e q u e st io n re m a in s o p e n : d o m e d ica l jo ke s m e re ly e xp re ss a ske p -t ic ism o f -t h e ‘a n y-t h in g go e s’ -t yp e (Sc h ra m m , 1995:67), o r a re t h e y sign s o f a n in c ip ie n t a t -t e m p -t b y p h ysic ia n s -t o a d h e re -t o a se a rc h fo r n ew eth ics? Is th ere a sem a n tic ch a sm b etween m e d ic a l sla n g a n d d e o n t o lo gic a l p r in c ip le s p la cin g p h ysicia n s a n d p a tien ts in eth ica lly in com m u n icab le cam p s, as ‘m oral stran gers’ (En gelh a rd t, 1996)? Is th e im p licit critiq u e in m ed -ic a l sla n g c o n t ra r y t o a n y a n d a ll m o r a lit y – h e n c e , t h e p h ysic ia n t h r ows t h e p a t ie n t o u t with th e b a th wa ter – or d oes it m erely p oin t u p th e u n fea sib ility of p reva ilin g m ed ica l d eon tol-o gy? Su c h m tol-o ra l d ile m m a s h e lp e xp la in wh y t h e re a re so m a n y a n d su c h va r ie d m e d ic a l p u n s fo r h ea lth services. Su ffice it to reca ll th a t m a n y p h ysicia n s wo u ld b e fire d (a n d a fe w in fa c t a re ) if t h e y a va ile d t h e m se lve s o f t h e ir r igh t , gu a ra n t e e d b y t h e Co d e o f Et h ics o f t h e Rio d e Ja n e iro Sta te Me d ica l Bo a rd (CREMERJ, 1988: 9), “to refu se to exercise on e’s profession in a p u blic or p rivate in stitu tion w h ere w ork in g con dition s are n ot w orth y or m ay h arm th e p a-tien t...” [i.e., tram biclín icas, p ilan tróp icos, a n d m u lam bu latórios]. Th u s, n o t o n ly wo u ld th e se sa m e p h ysic ia n s d e sc e n d in t o p o ve r t y t h e m -se lve s, b u t t h e y wo u ld a lso fa il t o re lie ve t h e su ffe r in g a n d sa ve t h e live s o f c o u n t le ss p a -tien ts.
Clausura
Th e sem ester is over at th e In stitu to An a tô m ico. Several d ays ago Professor Clavicle tu rn ed su -pervision of dissection classes over to h is staff of resid en ts, an d n ow th at exam s are over, th e lat-ter are in th e an n ex basem en t, d issectin g sp eci-m en s for n ext seeci-m ester’s cou rse on Neu roan ato-m y. Th e fresh ato-m en , w h o by n ow boast th e n aato-m e Ac a d e s vu lga r is w ith a m ix tu re of p rid e an d sh am e, h ave left to celebrate, d rin k in g cold d rau gh t beer at a bar n ear th e ferryboat d ock s. Som e are alread y at th e bu s station , on th eir w ay to a tw o-w eek break in th e m ou n tain s or on th e coast.
Appendix I
Th e p o in t o f d e p a rtu re fo r th e tro p e s co lle cte d in th is stu d y wa s a list o f p u n s I p icked u p d u r-in g m y own m e d ic a l t ra r-in r-in g a t t h e Un ive r si-d a si-d e Fe si-d e ra l Flu m in e n se in Nit e r ó i, Rio si-d e Ja n e iro, fro m 1978 t o 1984. In Ma y 1995 I p re -se n t e d t h is list t o -se ve n h e a lt h p r o fe ssio n a ls tra in e d a t th re e d iffe re n t p u b lic u n ive rsitie s in Rio d e Ja n e ir o : a sp e c ia list in in fe c t io u s d is -ea ses, a p ed ia tricia n , a n o b stetricia n , a p sych i-a trist, i-a p sych ologist tri-a in ed in p sych oi-a n i-a lysis, a ge r ia t r ic ia n , a n d a re gist e re d n u r se , a skin g t h a t t h e y p r ovid e t h e ir own d e fin it io n s fo r t h e se t e r m s a n d re a ct t o t h e list , co m m e n t in g o n t h e d e fin it io n s give n b y o t h e r in t e r vie we e s a n d se a rch in g t h e ir m e m o r ie s fo r o t h e r sim i-la r e xa m p le s. Th e in it ia l in t e r vie ws we re p e fo rm e d b y p h o n e, a n d I la te r h e ld gro u p in te r-vie ws wit h t h re e p a r t icip a n t s e a ch . I u se d t h e ‘sn owb a ll’ m eth o d to id en tify co n ta cts (Becker, 1993). Ot h e r t ro p e s we re a d d e d t h r o u gh d is-c u ssio n o f t h e list wit h m y d o is-c t o ra l is-c o u r se c la ssm a t e s a t t h e Esc o la Na c io n a l d e Sa ú d e Pú b lica . Usin g a n o p en en d ed in ter view, in Ju -ly 1996 I ta p ed six h ou rs of in ter views with fou r a n e st h e t ist s a t a u n ive r sit y h o sp it a l in Rio. Th ese fo u r co llea gu es d isp la yed grea t versa tili-t y in tili-t h e ir u se o f m e tili-t a p h o r s tili-t o e xp la in tili-t h e ir d a ily p ro fe ssio n a l ro u t in e s. All o f t h e su b je ct s c o n se n t e d t o a n o n ym o u s q u o t in g o f t h e ir in -terviews. In terviews co n tin u e with m em b ers o f o th er m ed ica l sp ecia lties.
Appendix II
Exc e r p t o f in t e r vie w wit h e m e r ge n c y wa rd p h ysicia n / a n e st h e t ist fro m t h e Rio d e Ja n e iro Sta te Fire Briga d e Rescu e Sq u a d (m a le, 33): “An ICU, in m y opin ion , w ith h on orable exception s, is at o r t u re ro o m . I w ou ld n ever w an t to go to an ICU as a patien t m yself, except w h en th e pa-tien t is very w ell h an d led , in th e sen se of you r elim in atin g h is p ain an d con sciou sn ess. Be-cau se a patien t in th e ICU, if h e is lu cid, aw ak e, an d k n ow in g w h at is goin g on , m u st h ave th e sam e sen sation as if h e w as bein g tortu red . W h y do I say th is? Becau se h e n orm ally h as a tu be in his trachea, a n asogastric tu be, a u rin ary cath eter, several IV lin es, look in g m ore lik e aCh r ist m a s t re e, strap p ed d ow n to th e bed , u n d erstan d ? Can’t talk , can’t eat, fed by a tu be or IV lin e. So if h e’s aw ak e...n ot to m en tion th e n oise from th e m otors, w h ich cau ses a lot of trau m a...th ecrie s a n d wh isp e r s of th e oth er p atien ts n ex t to h im ...th e ligh ts, w h ich both er h im . An d n ot to m en tion th e teach in g p art, th e m ed stu d en ts, each on e w an tin g to p erform som e p roced u re, w an tin g toin ve n t som eth in g. M an y p atien ts, u n fortu n ately, aregu in ea p igs forp h ysicia n sin train in g.”
Acknowledgements
Th is re se a rch is b e in g co n d u cte d u n d e r a gra n t fro m t h e Bra zilia n Na t io n a l Re se a rc h Co u n c il (CN Pq ). I sh o u ld em p h a size th e im p o rta n ce o f cla sses a n d d iscu ssio n s wit h m y t h e sis su p e r viso r, b io e t h icist Fe r -m in Rola n d Sch ra -m -m , Coed itor of Cadern os de Saú de Pú blicaLu is Da vid Ca st ie l (wit h h is go o d - h u m o re d re fle ct io n s o n m e t a p h o r in e p id e m io lo gy), so cio lo -gist Ma r ia He le n a Ma c h a d o, a n d lin gu ist s Br u n a Fra n ch e t t o a n d Jü rge n He ye o f t h e Mu se u Na cio n a l a n d Po n tifícia Un iversid a d e Ca tó lica d o Rio d e Ja n eiro, resp ectively. Sp ecia l th a n ks to Ed itor Ca rlos Coim
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