“You must help me if you can”
— Jackson Browne, “Doctor my Eyes”
In his song, Jackson Brown asks the Doctor “to help me understand” a world “with . . .evil.” The artist “hears the cries” of suffering and asks the doctor whether it was “unwise to leave them [his eyes] open for so long?”
Doctors aren’t usually much help. They’re not shamans. But that is what Jackson Brown needed. That’s what we all need. Too often we get the opposite.
Medical anthropologist Jean Comaroff illuminates this well. In her ethnographic work “Medicine: Symbol and Ideology”(1982) she provides a cross-cultural comparison of the healing systems of Africa’s Tshidi-Borolong and Western biomedicine. Comaroff investigated the universal paradoxes associated with the illness experience, especially the existential question about personhood. She argued that sick individuals among Tshidi are “healed” through communal rituals which are performed to reinforce or restore the well-being of the body politic as a whole.
In contrast, under Western capitalism, the sick person is caught within the prevailing ideology of rational individualism which “rests upon the reinforcement of the very symbolic oppositions which, in the context of affliction, we sense and try to transcend” (Comaroff 1982:61). Comaroff concluded that “thus, with an alienated image of the self, caught in the opposition between psyche and soma, and cut adrift from the wider social and moral context, we attempt to impose ‘meaning’ upon an estranged world” (Comaroff 1982:61).
Doctors are, generally speaking, agents of neoliberalism. They catch us at our most vulnerable states when their “teachable moments” have greatest impact. The answers we get largely reproduce the estrangement, reproducing communal quiescence. As an institution saturated with capitalist culture, the medical establishment nurtures cults of professionalism (Bledstein, 1976) and creates “disciplined minds” of conformity (McKenna 2010, 2011, Schmidt, 2000).
In his important book, “Hippocrates’ Shadow: Secrets from the House of Medicine,” physician David Newman (2008:195) offers a “beginner’s list” of how biomedicine deceives. As an insider he testifies that, “our knowledge is far more limited than most believe; we advocate for interventions we know don’t work; we disagree on seemingly fundamental issues of science; at system levels we care nothing about communication; we choose technology over touch; we openly defy established evidence; we deny and decry a placebo effect while we tacitly accept and enlist it.”
How do we help people better recognize the cultural hokum of biomedicine so that they can overcome estrangements before they are given the jolt of a cancer diagnosis (as half will be in their lives)?
Negative Dialectics in the Air
I teach medical anthropology. Despite medicine’s wealth of problems, it is still viewed as “the best in the world,” especially by an army of Pre-Med students who descend on my classes. They pay technological homage to heroic medicine — on TV shows like Chicago Hope and House — that greatly glamorize “medicine,” or as medical anthropologists call it, “biomedicine,” a conception which accounts for the narrow microbiological orientation of this field.
“Can I sign up for your class Professor but still be 30 minutes late for class each day?”
“Why is that?
“I’m taking chemistry (or biology) and it overlaps with your class times. You know how important that is. I need to have it for the MCATs.”
I have lost count how many times I’ve been asked a version of this question.
“My class is about eliminating the MCATs, the MDOGs or whatever alphabet soup the academic technicians throw at you,” I respond. “It’s about revolutionary medicine. If you can’t make my entire class, I will not let you in. Besides, the class is already full. But I’ll be glad to speak with you about medicine at any other time.”
Many come expecting an exotic cipher for a captivating med school application. Instead they get Adorno.
“The fundamental causes of ill health are out of the control of biology and chemistry,” I tell them, “and “indeed, any open recognition of the real causes would call into question the very system that allows [medical professionals] to own and market their commodity” Most of these Pre-Med students are caught on the conveyor belt of pathophysiological indoctrination to become that commodity!
A Communal Ritual in the Classroom
Sickness is a massive threat to the social order. It’s much too important to be left to doctors, biochemists and insurers. When someone gets seriously ill, the experience can provide a rare life-altering chance for them to question their deepest assumptions about their lives, especially living in a harsh, careless culture like the U.S. where class warfare rages and leaves the wounds on their psyches and bodies. But the medical establishment ignores or marginalizes the incessant questioning required for this radical education.
So, on the first day of class I pass out the following assignment to help students work through this dynamic. The five page paper is due two weeks hence. It’s intended to awaken students to ask the very questions as Jackson Browne asks.
Medical Anthropology
Tell Us About your Last Doctor Visit
For this essay you are asked to critically reflect on your last interaction with a biomedical care practitioner (e.g. allopathic physician, nurse practitioner, nurse, physician’s assistant, EMT). If you have never interacted with a biomedical practitioner, you are free to write about your interactions with any healing practitioner (e.g. curandero, homeopath, shaman), or with anyone who has ever cared for you. However, for this exercise it is best to analyze a representative of the dominant medical system in the U.S., which is biomedicine. Also, if you do not feel comfortable writing directly about yourself, you may interview a friend or relative (keeping their identity confidential) and ask them the?questions below. For privacy reasons you may assert that you are reporting on an interview, even if it happens to be about yourself.
?
In your essay, please address the following:
1)??? Briefly describe the setting.
2)??? What was your presenting complaint?
3)??? How did the practitioner interact with you? (her/his demeanor, history taking, physical)
4)??? Did you feel you had enough time to discuss all your questions and concerns? Why or why not?
5)??? Did the practitioner acknowledge your own phenomenological experience?
6)??? If relevant, what questions might you have liked to discuss with the practitioner that you did not? Why not?
7)??? Were you satisfied with the practitioner’s diagnosis(es)?
8)??? Do you believe that there were any social and/or environmental origins to the complaint you registered? If so, what, in your opinion, were they?? Did the practitioner discuss this topic with you?
9)??? Do you believe that the practitioner helped to heal you?
10) In your opinion, might there have been an iatrogenic component to the care?
11) What, if anything might the practitioner (and their support staff) have done better?
12) How would you rate this practitioner? Excellent, good, average, below average, poor?
I receive papers back two weeks later. I take careful notes of their themes and write up an analysis (for discussion later in the semester). I return the papers and students pair off for awhile to share their stories with a classmate. The hum in the room rises to a crescendo as students divulge vital details about their lives (or their interviewee’s life) that they have rarely, if ever, critically contemplated. Then we open things up to dialogue.
Students discuss some really exceptional doctors, nurses and healers who have helped them through very difficult times. There are always health professionals in my classes, including nurses, Pre-Med students, and technicians. They often write about their backstage “House of God” horrors (see Samuel Shem’s classic expose of medicine) in their papers. Tears and laughter stir the room. We all learn much.
You never know what will happen. Here is one recent testimony that got everyone’s attention.
“During the summer, I was working in a pain management clinic and my job was taking the medical history and doing the physical examination for the new and return patients. . . .over 90% of the patients are drug addicts and psychologically ill (schizophrenic). . . .At first, I wasn’t getting the idea how the treatment . . .helped those people. . . . Some of them heard about how the physician operated and some had “marketers” that brought them there. After a month working there and knowing exactly how the system was running, I got to know that some of the marketers are not legit but . . . .were street pharmacists; where they paid people who don’t have any marijuana or narcotics in their blood to come and act as if they are suffering from pains and then take their prescription pills to the streets. And the Doctor didn’t care what was happening and didn’t want to know; as long as the patients are clean he would even promise them for a higher dose in the next visit. . .My friend in the clinic who was the manager told me that in the past year the Doctor made over 8 million dollars in profits. That’s a little too much for one clinic, isn’t it? . .just two days ago, one of my friends told me that she quit after the FBI came in to investigate the clinic. . . .maybe they closed it down now. . .”
Testimonies such as this help us peer into the everyday life of clinical medicine in our own backyards. When combined with the ethnographic details of forty private medical encounters — in which a large number of my students reveal how they have been harmed, misdiagnosed or hurt by medicine — they begin to show the contours of what is really happening in clinics in the community.
Biomedicine Helps and Hurts
In our discussion I reveal that I have been helped — even saved — by medicine. For example, two melanomas were diagnosed and excised in 1992. Like many children, my ears were drained of fluid on several occasions, stopping a plague of earaches. A severe concussion from a baseball bat to the head, when I was 12, was closely monitored in the hospital for a week.
On the other hand, like nearly everyone, I’ve experienced the other side of medicine, where mistakes, misdiagnoses and scare tactics have been harmful: a hematoma in my leg from an inappropriate clinical drug that got me to the ER; several missed diagnoses of melanoma preceding its fortunate discovery; a “false positive” about a lung mass that resulted in having part of my right lung needlessly extracted in 2005.
It’s called “iatrogenesis,” an illness caused by the doctor or medical system. Ivan Illich alerted the world to this phenomenon in his foundational Medical Nemesis (1976). Students are surprised it is so common in their group testimonies.
I tell them that medical students are not taught much about systematic forms of iatrogenesis. These include clinical (direct harm), social (medicalization) and cultural (loss of traditional healing modalities) as defined by Illich. Issues of capitalism and political economy are poorly addressed in medial education as well. I note that the U.S. National Academy of Sciences does draw attention to some of the clinical iatrogenesis. For example a 2000 report study by the Institute on Medicine, To Err is Human, estimated that up to 98,000 die each year from hospital errors alone (NAS, 2000). But this is only the tip of the iceberg, especially when we account for things like the speed-up of physicians and nurses by insurers, the clinical marginalization of “patient” voice (Freire 1970, McKnight 1995) and the “nocebo effect,” harmful, unpleasant or undesirable effects of medicine.
In contrast, anthropologist Daniel Moerman (2002) has written extensively about the “placebo effect” (what he calls the meaning response) which rallies the mind/body’s internal healing modes (in ways not well understood), and argues that it is a powerful healing modality that should be a fundamental part of medical education. But it is not. Moerman argues that biomedicine’s neglect of emotion, ritual and culture mean that medical education is “as much of a hindrance as a help.”
We All Need a Good Shaman
Most students are surprised to hear that I had a childhood physician who did house calls. Whenever I was sick in bed, he’d ascend the stairs of our tiny row house just outside of Philadelphia. Through bouts of measles, mumps, and even a heatstroke Dr. Haynes came. Sitting on my mattress, he touched me, performed his magic, and told me that everything was going to be alright. He treated my brother and sister if need be and even checked my father’s blood pressure. Dr. Haynes was a true family doctor, a caring man.
By today’s standards, Dr. Haynes spent way too much time with us. He listened to my stories. He once insisted that I repeat the story about the home run I’d hit two nights earlier, asking for more details. To what field had I hit the ball? How did I feel rounding the bases? I showed him the giant praying mantis I’d found in the shrubs. I felt like Dr. Haynes really understood me. He saw the context where I lived and took an interest in me. I remember asking my mother, “why does Dr. Haynes ask me so much about things that have nothing to do with being sick?”
All I know is that I felt better after he left. So did my mother.
We “made meaning” on a shared world.
Oh how times have changed. Today I travel to the “family” doctor at the mall and she treats me all alone without my family present! She follows managed care protocols. I still repeat stories but they’re not about baseball. First I write down my story of symptoms on the intake form, later I tell the nurse the same story, and a while later I tell the same tale to my doctor. The doctor portion of the visit takes only a few minutes and there is little talk about my feelings outside of how they relate to my “presenting complaint.”
But, like Jackson Brown, I have a lot of complaints!
And now, with electronic patient records (EPS), my doctor rarely even looks at me as she busily types away on a computer. But I am watching her, feeling more estranged. Incidentally, EPS efficacy is being seriously challenged for having little or no evidence of improved clinical outcomes (Black 2011).
We must take back medical education from the biologists, chemists and bean counters. As part of this effort we can teach citizen/students a great deal about medicine if we elicit their experiential knowledge. And listen to their stories. . .together. We must attend to the experiences they bring with them into the classroom and make that curricular material. We need to convert our private sufferings into public issues, as I begin to do in this communal exercise. There were 956 million physician’s office visits in 2008 (CDC 2008). The great majority of these clinical encounters are lost to the social science/journalistic record. We need to capture this data and broadcast it to our communities. These stories must be reclaimed in order to galvanize “patients” to lose their patience and become active.
A version of this article was originally published in the Society for Applied Anthropology Newsletter, Vol. 22:2, May 2011. Tim Wallace, editor.
Brian McKenna lives in Michigan. He can be reached at: mckenna193@aol.com
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