Archive for the ‘Medicine’ Category

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“One can gain a lot of experience in a country practice,” I thought as I fell asleep, “but even so one must go on and on reading, reading . . . more and more . . .”

— Mikhail Bulgakov, “A Country Doctor’s Notebook”

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Shweder says that under the metaphor of accident or chance, “suffering is to be treated by the intervention of . . . agents who possess expert skills of some kind, relevant to treating the problem.” Traditional cultures believe that the main responsibility in dark times belongs to the sufferers themselves. The things that need to be done are forms of internal “soul work”—learning patience, wisdom, and faithfulness. Contemporary culture, however, does not see suffering as an opportunity or test—and certainly never as a punishment. Because sufferers are victims of the impersonal universe, sufferers are referred to experts—whether medical, psychological, social, or civil—whose job is the alleviation of the pain by the removal of as many stressors as possible.

But this move—making suffering the domain of experts—has led to great confusion in our society, because different guilds of experts differ markedly on what they think sufferers should do. As both a trained psychotherapist and an anthropologist, James Davies is in a good position to see this. He writes, “During the twentieth century most people living in contemporary society have become increasingly confused about why they suffer emotionally.” He then lists “biomedical psychiatry, academic psychiatry, genetics, modern economics” and says, “As each tradition was based on its own distinctive assumptions and pursued its own goals via its own methods, each largely favored reducing human suffering to one predominant cause (e.g., biology, faulty cognition, unsatisfied self-interest).” As the saying goes, if you are an expert in hammers, every problem looks like a nail. This has led to understandable perplexity. The secular model puts sufferers in the hands of experts, but the specialization and reductionism of the different kinds of experts leaves people bewildered.

Davies’s findings support Shweder’s analysis. He explains how the secular model encourages psychotherapists to “decontextualize” suffering, not seeing it, as older cultures have, as an integral part of a person’s life story. Davies refers to a BBC interview with Dr. Robert Spitzer in 2007. Spitzer is a psychiatrist who headed the taskforce that in 1980 wrote the DSM-III (third edition of the Diagnostic and Statistical Manual of Mental Disorders) of the American Psychiatric Association. The DSM-III sought to develop more uniformity of psychiatric diagnoses. When interviewed twenty-five years later by the BBC, Spitzer admitted that, in hindsight, he believed they had wrongly labeled many normal human experiences of grief, sorrow, and anxiety as mental disorders. When the interviewer asked: “So you have effectively medicalized much ordinary human sadness?” Spitzer responded, “I think we have to some extent. . . . How serious a problem it is, is not known . . . twenty percent, thirty percent . . . but that is a considerable amount.”

— Timothy Keller, Walking with God through Pain and Suffering

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Touching with the naked ear was one of the great advances in the history of medicine. Once it was learned that the heart and lungs made sounds of their own, and that the sounds were sometimes useful for diagnosis, physicians placed an ear over the heart, and over areas on the front and back of the chest, and listened. It is hard to imagine a friendlier human gesture, a more intimate signal of personal concern and affection, than these close bowed heads affixed to the skin. The stethoscope was invented in the nineteenth century, vastly enhancing the acoustics of the thorax, but removing the physician a certain distance from his patient. It was the earliest device of many still to come, one new technology after another, designed to increase that distance.

Today, the doctor can perform a great many of his most essential tasks from his office in another building without ever seeing the patient. There are even computer programs for the taking of a history: a clerk can ask the questions and check the boxes on a printed form, and the computer will instantly provide a printout of the diagnostic possibilities to be considered and the laboratory procedures to be undertaken. Instead of spending forty-five minutes listening to the chest and palpating the abdomen, the doctor can sign a slip which sends the patient off to the X-ray department for a CT scan, with the expectation of seeing within the hour, in exquisite detail, all the body’s internal organs which he formerly had to make guesses about with his fingers and ears. The biochemistry laboratory eliminates the need for pondering and waiting for the appearance of new signs and symptoms. Computerized devices reveal electronic intimacies of the flawed heart or malfunctioning brain with a precision far beyond the touch or reach, or even the imagining, of the physician at the bedside a few generations back.

The doctor can set himself, if he likes, at a distance, remote from the patient and the family, never touching anyone beyond a perfunctory handshake as the first and only contact. Medicine is no longer the laying on of hands, it is more like the reading of signals from machines.

— Lewis Thomas, “Leech, Leech, Et Cetera”

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“Admission, Children’s Unit” by Theodore Deppe

Like the story of St. Lawrence that repelled me
when I heard it in high school, how he taught
his disciples to recognize the smell
of sin, then sent them in pairs through the Roman Empire,
separating good from evil, brother from brother.
Scrap of legend I’d forgotten until, interviewing a woman,
I drew my breath in and smelled
her, catching a scent that was there, then not there.

She said her son set fire to his own room,
she’d found him fanning it with a comic, and what
should she have done? Her red hair
was pulled back in a braid, she tugged at its flames,
and what she’d done, it turns out, was hold her son
so her boyfriend could burn him with cigarettes.
The details didn’t, of course, come out at first,
but I sensed them. The boy’s refusal to take off his shirt.
His letting me, finally, lift it to his shoulders
and examine the six wounds, raised, ashy, second
or third degree, arranged in a cross.

Silence in the room, and then the mother blaming
the boyfriend, blaming the boy himself.
I kept talking to her in a calm voice, straining
for something I thought I smelled beneath
her cheap perfume, a scent–how can I describe this?–
as if something not physical had begun to rot.

I’d like to say all this happened when I first started
to work as a nurse, before I’d learned not to judge
the parents, but this was last week, the mother was crying,
I thought of handing her a box of tissues, and didn’t.

When the Romans crucified Lawrence,
he asked Jesus to forgive him for judging others.
He wept on the cross because he smelled his own sin.

Sullen and wordless, the boy got up, brought his mother
the scented, blue Kleenex from my desk,
pressed his head into her side. Bunching
the bottom of her sweatshirt in both hands,
he anchored himself to her. Glared at me.
It took four of us to pry him from his mother’s arms.

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When an individual is in good health, organic function is only background noise. For an individual in poor health, organic function becomes relevant in two ways. One is the intrinsic value of normal function, apparent when disease causes pain or suffering. The second is the instrumental value of health. Normal or adequate organic function is a primary good through which we pursue our other goals. If medicine is to serve us as individuals, it must address organic function on both levels.

As the science of organic function, physiology must be seen as the servant of our other goals and thus of the human values that determine those goals. For better or worse, human values often lie well within the realm of uncertainty. Even our own personal values may be frequently uncertain—at least in the context of illness, where complex choices may be layered on pain and fear. The values of our patients are all the more remote from our grasp. It is little wonder that physicians may seek refuge in the science of the organism, and that our patients are often eager followers of our firm—but perhaps misguided—lead on technical adventures.

— Jeffrey R. Botkin, “The Seductive Beauty of Physiology”

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Part XII from “The Cadaver” by Alice Jones

Having fed like a worm on the bones of the dead
or like a bird, on the body’s worms,
you grow large and leave home
prepared for your adult life
of minding the sick, performing
technical procedures on the dying.
You know where you are
when, after your young patient dies,
you go to the morgue, see them place
her on the elevated metal table,
hear the dozens of aluminum-tipped ends
of her cornrowed braids clatter
as they fall away limply
from her blue-lipped face. You watch
her resilient skin give way
under the bright blade as they open
the large flaps of her body’s walls,
sever the great vessels, lift out
her heart and lungs in one piece,
hung from the cartilage handle
of her trachea. You recite the branches
as they trace her pulmonary arteries
searching for the clot that killed her.
On the hospital wards, there are moments
that remind you of the lab, when you tell
the old man to turn his head, so you can
insert the needle in his jugular, enter beside
the belly of the sternocleidomastoid.
You know how it wraps its tendon
along the clavicle, feel the vein’s
sheath give, watch the paper drape
over his breathing face lift for a second,
then you forget again that this meat
you dig in is warm and pulsing,
as you aim your precise hand
at the visible landmarks of the unseen world
whose map now lies in your mind.


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If I were a medical student or an intern, just getting ready to begin, I would be more worried about this aspect of my future than anything else. I would be apprehensive that my real job, caring for sick people, might soon be taken away, leaving me with the quite different occupation of looking after machines. I would be trying to figure out ways to keep this from happening.

— Lewis Thomas, The Youngest Science

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