The article 'Trambiclínicas, pilantrópicos, and mulambulatórios: Medical slang in Rio de Janeiro, Brazil', in keeping with its numerous metaphorical examples is I.I.I (Inquisitive, Instigating, and Indocile, in the best sense of the word). I believe it allows for two readings, which I describe below and in both of which (as versions) I see pertinence and legitimacy. The first focuses on the scientific concatenation proposed by the study. The second begins with the study's proposal as a stimulus for ideas and dialogue.

A 'closed' reading

The paper begins with a hypothesis that could be summarized, with unavoidable loss, as following: scientific and deontological discourses, albeit constitutive, are insufficient to express the totality of medical ethos. According to the author, another semantic field, 'medical slang', a difficult term to translate [into Portuguese], is capable of expressing this ethos in a less orthodox and more sensitive way. From the onset the author challenges the familiar notion that this type of metaphorical recourse is used to maintain a distance between physician and patient (a role played better by medical jargon) or as a means to relax from tension experienced in the medical work process (more commonly dealt with by conversation on sex, football, etc.). Finally, he contends that 'medical slang' creates new meanings in the relations between physicians, between physician and patient, in the acquisition of new knowledge, and in the physician's relationship to the health care system itself. He thus assumes that metaphors will be read not as 'substitution' or 'comparison' of meanings but as creative 'interaction'.

Taking this point of departure, two major expectations can be generated in the reader. The first is to see the elements or characteristics of this medical ethos revealed, based on an analysis of this 'medical slang'. If the interpretation of 'medical slang' is a strategy, an ethnographic recourse allowing for an epistemological or socio-anthropological reading of the medical ethos, it is fair to hope that such an analysis will play this heuristic role. The second is to perceive, based on the examples of the empirical study performed, how such metaphors create new meanings, that is, how this attribution of (figurative) meaning gains symbolic recognition by its community of origin and is capable of ascribing new meaning to concrete relations, metaphorized by 'medical slang'.

The medical ethos is situated in a context of paradigmatic transition and rewritten in a scenario of "deprofessionalization" and "hypercrisis" in the Brazilian health system. The author thus perceives the challenge raised as follows by Bourdieu (1996:24) [translated here from the Portuguese version into English]: "(...) linguistic competence per se, defined abstractly, outside of everything to which it owes the social conditions of its production, attempts to deal with discourse in all its conjunctural singularity. In fact, as long as linguists ignore the constitutive limits of their science, they have no other alternative but to seek desperately in language what is inscribed in the social relations within which it functions, or to perform sociology (without realizing it), that is, running the risk of discovering in grammar itself what spontaneous sociology imported unconsciously for itself."

Still, in this article, the 'social conditions for the production' of 'medical slang' can also be read as a backdrop or frame for the many examples quoted. What are the relations (ethical and socio-econo-cultural) in this broad scenario of hypercrisis that allow for the emergence and persistence of trambiclínicas, pilantrópicos, and Embromeds? Are they the same as those that trace the meaning of the mulambulatórios? Are they the same as those shedding light on the act of labeling poor patients as mulambos or estropícios? To demarcate a very broad backdrop provides a safe, yet non-specific, anchor.

In fact, the article neither promises nor announces such an exercise, a role proper to a sociological or historical analysis. How, then, does one situate the medical ethos, which one might suppose has changed over these last 20 years of observation? Or more directly, what do these many metaphorical examples 'mean' [querem dizer, literally "want to say" in Portuguese ­ Translator's note] from the point of view of this medical ethos? What is 'revealed' in this ethos when the physician uses the metaphors JEC (for "Jesus is calling"), DPP ("leave her for the next shift") to designate refusal to treat some patients or when others are referred to as trubufu, pimba, mulambo, estropício? The jocose terms, according to the author, are associated with discrimination of an ethnic (for blacks), aesthetic (for the obese), or socioeconomic nature (for the poor), or even with the severity of the clinical state (poliesculhambados). In addition, based on such vivid examples, what can be said about the physician-physician relationship itself? Does calling a medical student a 'bullhead' (an ugly little fish that lives in the deepest, darkest river bottom) allow one to infer that medical training has a very strong hierarchical sense or that the student goes through a ritual moment of initiation (a "rite of passage") of which humiliation is a part? To treat patients through a health care plan called Embromed designates a very different relationship between the physician and the health care institution than those involved in the logic of the Pafúncio plan.

In the article, the numerous examples are present together with a raw richness, bearing implicit relations with different meanings (both attributed and socially experienced), comprising a vivid and instigating mosaic. The text might perhaps benefit from a less descriptive stance, with inferential hypotheses encompassing the narrative and distinguishing between the origins of the various terms.

Would it be incorrect to imagine that the medical ethos is actualized in multiple facets, gaining specificity in its various institutional cultures (the emergency ward, maternity ward, outpatient clinic, etc.)? In the public sector as compared to the private? Based on prevailing working conditions? Based on hierarchical conditions?

A second expectation would be that of perceiving how "medical slang", in the form of proverbs, puns, jokes, and jests, using metaphorical interaction, creates new meanings for the physician-patient relationship, medical knowledge, and health care institutions. In an excerpt from page 14 of the manuscript: "(...) In the case of Carioca medical slang, it would be as if calling the patient a mulambo could be reduced to a literal translation 'ragged, poor, and black' skirting the interactions of the metaphor with the physician's own socioeconomic and cultural world (according to the interactive view, metaphor does not merely express an existing meaning; on the contrary, it creates new meaning). Thus, the metaphor mulambo does not merely express social exclusion, it helps to create it." In another excerpt, from page 16 of the manuscript: "Mulambulatório is a pun formed by mulambo, meaning 'rag', incorporated into the Portuguese language from Quimbondo, a Bantu language, and used here metaphorically as 'beggar', plus ambulatório, or 'outpatient department'. An interactive interpretation of this pun/metaphor suggests that such an outpatient clinic not only treats the mulambos, but also helps to create them."

How so? Without a doubt, the metaphor as an expression of exclusion is evident, but does it help to create it? To create meaning, in the sense of ascribing a new symbolic dimension to exclusion, and thus to recreate or actualize it is one thing, while to create exclusion is another. Or is there a mediation between enunciating and constituting reality? By enunciating does one not enunciate what is already constituted, albeit still not revealed or visible? What relationship does the author see between the word and the thing, the "symbolic efficacy of constituting reality"? This would be a rich field for further exploration by Peterson's talent, since it is the paper's central hypothesis.

An 'open' reading

The paper is based on a proposal which could be summed up as follows, with the advantage of adding another reading to it: the scientific and deontological discourses, although constitutive, are not sufficient to express the totality of medical ethos. According to the proposal, another semantic field (amongst others not cited), that of 'medical slang', is capable of expressing this ethos in a less orthodox and more sensitive way, while also serving as one of its fields for creating new meanings. That is, this ethos is expressed in the relations between physicians themselves, physicians and patients, in the acquisition of new clinical knowledge, and in the relationship to the health system itself.

Based on this investigative wager, the irreducible conflict between the context of medical 'deprofessionalization'; the dismantling of health care services and the health 'utopia' (in the sense of a guiding set of ideals); lack of resources; and aggravation of social iniquities, far from constituting a mere backdrop, hologrammatically permeates the daily routine of these professionals and the medical ethos. Its field of specificity for each concrete social relationship (physician-physician, physician-patient, in the acquisition of new clinical knowledge, and vis-à-vis the health care system itself) needs to be detailed in appropriate studies and in a creative way, to draw out daily life, experienced circumstances, and the marks of use, as described by Certau (1994:82), [translated from the Portuguese version into English ­ T. n.] "(...) the ways by which utensils, proverbs, or other discourses are marked by uses; presenting for analysis the marks of acts or processes of enunciation (...) in a broader way, thus indicating a social historicity in which representational systems or constructive procedures no longer appear merely as normative frames, but as tools that can be manipulated by users".

The constitution of new meanings thus occurs in a metaphorical field, of linguistic exchanges, as in a field of social exchanges, of conflict, of the search for prestige and legitimization amongst peers. In other words, the discourses produced by physicians for patients and health care institutions occur in different contexts of experiences and based on a logic of relationship between symbolic forces.

When the paper works so beautifully with the metaphor "The ICU is a torture room", it gives us a clue for understanding the creation of new meanings, whereby in the symbolic binomial 'torture room/ICU', torture adds meaning to the ICU, while the ICU adds a 'therapeutic' dimension to torture. Is a revealing representational dimension of this ethos insinuated (the need for torment and its legitimacy as therapy in 'extreme' cases)? When the physician calls public outpatient clinics mulambulatórios, is he not attempting to push the idea of mulambos away from his own self-image? After all, by 'treating' mulambos, and faced with the absolute inability to change their social and human reality, would such proximity not turn him into a mulambo, too? As the author suggests, these are clavicles/little keys in a symbolic archeology as rich as it is necessary: valuable subsidies for a discussion on trends in health ethics.

BOURDIEU, P., 1996. A Economia das Trocas Lingüísticas. São Paulo: Edusp.

CERTEAU, M., 1994. A Invenção do Cotidiano. As Artes de Fazer. Petrópolis: Vozes.