Musings on Medicine: Part I
As long as I could remember, I have always wanted to become a physician. This dream was fostered through a combination of a childhood illness, my mother's experience in the medical profession, and a passion for both the complexity of science and the art of the human experience. Over the years, I never questioned or wavered in my choice. Medicine, to me, was a calling, a noble profession imbued with deep significance since its inception centuries ago. Yet paradoxically, for nearly all of my life, I neither truly understood the implications nor the consequences of my career choice.
Only recently, in my last semester of college, have I been able to untangle some of the deceivingly cryptic catchphrases used in medicine. I would like to consider two recent musings here:
1) Medicine's goal is to improve the human condition.
This phrase is so simplistic and profound. Few other professions embody such an idealistic outlook towards not only the work of its tenants but the benefits of that work for society and the world. No wonder that variations of these words (such as its (in)famous cousin, "I want to help people") have been used by medical professionals and interviewing students alike. However, Foucault in his work The Birth of the Clinic: An Archaeology of Medical Perception offers a unique thinking point:
"But to look in order to know, to show in order to teach, is not this a tacit form of violence, all the more abusive for its silence, upon a sick body that demands to be comforted, not displayed?"
Foucault describes in an excerpt of this work the rise of the hospital system due to the advent of scientific reasoning. As a consequence, the physician develops a "gaze," an ability to see what has not been seen before (not only literally through technological advances but also figuratively through this new form of thought). The gaze subsequently creates an object out of the subject. Objectification is the subject of the quotation; in the hospital environment, patients become objects of training and research, a far cry from improving the human condition. Examples ranging from Henrietta Lacks to free clinics continue to illustrate this principle. No matter how genuine the scientific inquiry or mentorship might be, no matter how much prodding and poking eventually leads to a remission or cure, such efforts comes at the expense of the patient, if not in physical cost then in personal dignity. Based on current socioeconomic factors, this expense is often placed disproportionately on the poor.
2) Medicine is imperfect.
Not all patients can be saved. Not all pain and suffering can be prevented. And, based on the previous musing, not everyone is treated fairly. This true statement is accepted nearly universally. A section of medicine tends to be held to a paradoxically higher standard, as this example illustrates:
RW is a middle age male patient who has been treated his entire life for schizophrenic episodes. For the past five years, he has undergone regular follow-ups at a large, teaching hospital with the same psychiatrist and mental health team. One day, RW's mental health begins to deteriorate for unknown reasons. The medical staff is notified of the change in condition by RW's family and a next-day appointment is scheduled at the medical center. Medical staff provide pertinent health information to the patient's family and a staff member speaks to RW over the phone to personally to assess his health status. After the conversation and based on his medical history, the staff member determines that an immediate psychiatric consult is not necessary. The family is advised to call the medical center if anything changes.
In the evening, RW experiences a serious psychiatric episode and becomes combative. Police are called by the family. An altercation develops where RW assaults a police officer with an improvised weapon; in the aftermath, RW was shot and killed by the police while one police officer was seriously injured. Media reports cite misdiagnosis and mishandling of RW's case by the medical center. Health professionals and community leaders reiterate the need for stronger mental health services in RW's community.
Mental health has long been a marginalized area of healthcare. But despite its unpopularity among physician trainees and lack of much needed funding, its short fallings have always come to the attention of the general public compared to "mainstream" medicine. Consider this case:
A cancer patient, CH, who is in remission undergoes continuous follow-up to monitor her condition. In her fifth year of remission, between two of her follow-ups, a mass develops. Treatment is promptly initiated but despite her medical team's best efforts, the cancer becomes metastatic and she passes away just months later. Her family and her medical team hold a memorial for CH.
In both examples, a chronic, debilitating condition is monitored with stringent follow-up and prompt treatment. A "medical failure," an inevitable event, occurs in both examples. Yet, in the latter case, there is no backlash, no blame towards the medical profession. Maybe a key difference lies in the harm to others that mental health cases could pose, combined with the social stigma that accompanies a mental health diagnosis. Yet, a slight irony exists in the double standard that society has created with respect to psychological versus biological health.
The more I think, the more ironies and paradoxes I find in what we have defined as medicine and healthcare. I now see how buzzwords such as humanistic medicine or holistic care have a depth of meaning that I can only begin to comprehend. And even hidden in the obvious lies wisdom that many can not, or refuse to, see.
Perhaps these musings are not as profound as I found them to be, but I do believe they are important. As medicine transitions into an era fraught with new challenges in gaps in access and care, in combating historically incurable diseases, we must stop and simply think. For how are we supposed to foster systemic changes and push the frontiers of science without a deeper, philosophical, understanding of the field to not only guide us, but also drive us?
