Musings on Medicine

Author Note: This was published through Facebook several years ago, but as part of this blog’s reboot, is finding a new home here.

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 some 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 a potnetial expense to the patient, if not in physical cost then an emotional one. 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. One area of medicine can be held to a paradoxically higher standard. Consider this example:

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 is able to speak to RW over the phone to assess his health status. After the conversation and based on his medical history and past episodes, the staff member determines that an immediate in-person psychiatric evaluation 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 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.

Now consider this alternate 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 reflect, 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 appreciate. As medicine transitions into an era fraught with new challenges in gaps in access and care, in combating historically incurable diseases, we should pause. For how are we supposed to foster systemic changes and push the frontiers of science without a deeper, philosophical, understanding of the field to guide us.

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On the Corner of Scott and Skidmore

The corner of Scott and Skidmore is a place known to very few. It offers the rare observer a view of a bleak yet paradoxically serene landscape. A pristine blanket of snow covers the ground, punctuated only by the spindly trees. Beyond the road and tree line, past a pair of well-worn train tracks, the partially frozen Scioto River begins its sharp bend towards Columbus proper. A mix of small industrial buildings rounds out the scene, lying dark and quiet along the street. The area seems devoid of life, save for several pairs of footprints tracking towards the river.

The footprints are of various depths and age, suggesting a well-used path by persons unknown. The tracks continue through a break in the thin tree line, across the well-worn tracks, and towards the Scioto. There, amid a grove of leafless trees, one can discover a harsh truth amid a forgotten urban wilderness.

This is the home of a couple who endeavor to share what little they have with others, even though they have so little themselves. Here are the shelters of men who wake up at four in the morning to find paying work to support themselves. And in this small grove sleep veterans of war in the shadow of the Franklin County Veterans Memorial, long forgotten by the country that they served. 

The grove has been raided by police backed by politicians, who threaten its inhabitants with un-payable fines, eviction, and imprisonment. It has been the target of a merciless Mother Nature, who batters the shelters with snow, wind, and freezing temperatures. And its residents must navigate through a convoluted and overburdened social service system if they hope to receive any type of organized aid. 

Although some grapple with issues of alcohol abuse, drug addiction, or mental health problems, all of the homeless of Columbus are ultimately in a battle each and every day to simply survive. If you pause and listen to their stories, you will hear a tale that often shatters the image of the persistent panhandler or comatose vagrant. Instead, their voices will tell you a very human story…

Author Note: The homeless camp described in this vignette is actually a secondary camp created after the first was forcibly evicted by the city a year earlier. At that first camp, situated off of an abandoned road off of Greenlawn Avenue, a de facto camp mayor, homeless himself, and long-term or permanent residents, had created a functioning society in the middle of another stretch of woods. They coordinated with non-profit organizations and church groups for aid and helped new residents settle in, find working wages, and abide by camp rules.

The first camp soon came to the attention of city officials, who responded first by placing concrete barriers on the abandoned road to prevent local non-profit organizations from reaching camp inhabitants. Months later, police officers were sent to arrest and relocate any remaining residents of the camp. All camp shelters were torn down and the residents were transferred to local homeless shelters. It is unclear how many of the residents sent to these shelters were able to be placed in stable housing and how many ended up back on the streets.

This essay was written nearly six years ago to this posting (shared first through Facebook, then a now-defunct medical blog, and finally finding a new home here). At the time of the writing, city officials and local police were regularly threatening eviction. It is likely that, today this camp no longer exists…

As an aspiring physician, some of my future patients will have extenuating circumstances, some of which, like the lives of those described here, will be extraordinary. These circumstances will adversely affect their ability to access, receive, and maintain their connection to health care systems.

Without an appreciation of these difficulties, we as healthcare providers run the risk of mislabeling poor circumstances with poor motivation, of confusing mistrust with belligerency. Only through understanding, not only of our patients’ circumstances, but also of the social services and support systems available in our local communities, will we have the ability to truly help our patients beyond the clinic.