Originally written during Thanksgiving break… working on catching up in my reflective life!
No updates in a while because anatomy has been somewhat out of control. There is just so much information… I could never hope to be completely on top of it. And dissection lab has gotten more and more strange, though no less interesting, as our cadavers have become less and less human-like. I was surprised that I didn’t have a harder time emotionally with the head and neck and the genitalia dissections, but I think by then the whole process of donning the scrubs and lab coats and walking into the lab with its smells and unzipping the body bag had become routine, and so the content itself had become less charged just by virtue of the familiarity of its context. I’m not sure how I feel about that, because it seems that that is exactly the attitude that keeps physicians from attending to the unique individual patient when the context is just one more case of congestive heart failure or pediatric ear infection. At the same time, people seem to think that desensitization is necessary and that in order to do your job as a physician you have to be somewhat insensitive to the person within the body. Is that really true? Is sensitivity a form of failure, setting you up to get too emotionally overwrought or burned out during patient encounters, or is it a completely alternative and viable approach to clinical medicine? I don’t suppose I can know the answer until I have had much more patient experience and I have some actual responsibility. Still, I often found myself defending the actions and attitudes of the sensitive and caring Cameron (the only woman on the team) in the TV show “House”, while simultaneously identifying with her occasional weakness as a clinician and wondering how I would fare in the same circumstances.
An excerpt from my personal reflections on my Patient-Doctor I patient encounter for this week:
“I enjoyed my interview with Ms. K and regretted that she had to be taken downstairs for an echo before we were finished talking. Looking back, she is the first patient that I have interviewed for PD that I have felt truly worried about, not just empathetic. I think it is partly because she was obviously not doing well, and partly because she had so many overlapping problems that the medical system had been unable to take care of. I got the sense that resolution of one of her major issues (her current complaint, her depression, or her smoking) would lead to significant improvements in other areas of her life: for example, she reported intending to see a doctor about her teeth and intending to do something about her cataracts, but feeling too depressed and then being too sick for the last few months. In terms of the interview itself, I felt that we had created a good rapport and that she was opening up to me. She claimed she had never told anyone about her incontinence or her arthritis…. She was obviously trying to be engaging and I felt that I did a good job of eliciting and acknowledging her concerns.”
While I wish we spent more of our time in Patient-Doctor I actually interviewing (logistical issues and the way in which our particular group is run often intervene, not always for the worse but not always the way I would want things to be), I am getting an incredible amount of patient perspective from my Mentored Clinical Casebook patient. I haven’t written about him yet here because I am keeping extensive notes and reflections that will later be incorporated into the final written Casebook and they’re not yet at all processed. I’ve also been talking about him to anyone who will listen… I can’t go into too much detail, but suffice to say that I know I am learning one of the biggest intended lessons of the Casebook Project: that patients and their lives are inextricable from their medical issues. My patient is a gay man who has been HIV-positive since the 1980s, and he has been telling me his life story in installments over the last three weeks. I had intended to work in an expanded medical interview format and talk to him first about his medical history and then get into social history etcetera, but it soon became very obvious to me that that would make no sense. I mostly let him talk and just ask a few clarifying or redirecting questions, so he has been giving me a coherent picture of his life as he sees it. And it doesn’t fit into the discrete boxes of medical, social, employment, etcetera. Instead, he has been going chronologically, and for any given moment in his life all of its elements are inextricably intertwined: how his relationships were affected by his psychology and spirituality, how his spiritual outlook was affected by his health, how his health affected his employment, how his family interacted with his illness, and so on.
This is the essence of what medical anthropologist Arthur Kleinman has famously described as the “illness experience”: beyond the biological and medical meaning of a condition (the disease), how has it impacted the patient’s life, and how does the patient make sense of it within the framework of their own individual beliefs and sociocultural context? I have had my own illness experience, one that truly brought home to me what I describe as the ripples of influence of health upon all other aspects of life. I’m pasting here a response paper I wrote for Kleinman’s class “Culture, Illness, and Healing: An Introduction to Medical Anthropology” because it sets out all the circumstances of my experience in some detail. There was more at the end relating it to the course readings, but this is the meat of it.
On a trip to Italy and England in the August before starting college, a high school graduation present from my parents, I was sick nearly from the beginning. In Italy, it was tonsillitis on top of some kind of viral infection. By the time I got to England, the tonsillitis was improving and I seemed to be getting healthier. Brushing my teeth one night, I noticed that I was having a little trouble swishing the water around in my mouth, but I was exhausted and so didn’t think anything of it. The next morning when I woke up, the left half of my face was completely paralyzed.
I saw a doctor in a very modest clinic in London, who took only a few minutes to diagnose me, telling me I had Bell’s palsy. The virus in Italy had attacked a facial nerve, and there wasn’t much I could do but wait for it to grow back. He was vague when I asked how long it would take for me to get better, saying maybe six weeks or two months and reassuring me that because I was young I should recover quickly and then probably be “almost back to normal.”
I burst into tears in the doctor’s office, further upsetting my mother beside me and clearly making the very matter-of-fact doctor uncomfortable. He dismissed me with a prescription. I do cry easily, but there was something even stronger underlying my reaction than the thought of looking like that for a while, or even of being “sick” when I had always been so healthy. The first thing I had thought of there in the doctor’s office was music. I had played the flute for nine years at that point. I had considered my senior recital in June a triumph, the best I had ever played; I had nearly finished perfecting the audition pieces that would be my gateway to a musical life in college. Now, it was painfully obvious to me that I wouldn’t be able to play with my face the way it was; the pessimist in me wondered if I would ever play again. That was the thought that was so unbearable. Even worse, music had always been my solace or escape when I was upset and stressed by a pre-Ivy league high school life. Now, not only did I not have the one thing to which I devoted the most time outside of school; I also had lost my way of dealing with that loss.
The doctor clearly had no way of knowing the special significance of this disease in my life, and how it would shape my illness experience in a way that even a more medically serious disease might not have. This to me is a perfect illustration of the distinction Professor Kleinman draws between disease and illness. The medical reality of my condition, the disease, was an easily diagnosed neurological problem caused by a virus that had produced an inflammation and would take time for the nerve to re-grow. This highly reductionist “cause and effect” understanding satisfied the doctor. Admittedly, as a neurobiology concentrator and pre-med, it both satisfied and intrigued me; or rather, it would have, had I not been the patient.
My illness experience, however, was shaped as much by the circumstances of my life as by the disease itself, and would have been very different for another person in another situation. For me, the impact of the disease itself was inseparable from its context: I knew I was embarking upon my freshman year of college and meeting the people I would be spending the next four years of my life with, and I would do so as “not quite myself.” Yet, I still managed to make friends, to explain my face hesitantly to my Freshman Outdoor Program group and have them say “oh, okay,” to join the ballroom dance team where I could only manage half of the smile that we were obligated to wear on the competition floor, and even to find that people could still be romantically attracted to me. It was the loss of music, of my musical life, that impacted me most profoundly, especially as I inevitably fell in with the “orchestra kids” just as I had in high school. Individually, if I had been a different person without the major role music played in my life, my illness experience would have been very different; socially, if my parents and the people I met in college had not been so supportive and understanding, my illness experience would have been very different.
This experience that was so galvanizing for the psychosocial part of me as a future medical caregiver has now come full circle, because during head and neck week in anatomy, we learned all about the cranial nerves and specifically cranial nerve VII: the facial nerve. Its main role is to provide motor innervation (movement stimulus) to the “muscles of facial expression,” an appropriately named group of superficial muscles of the face and neck that allow you to smile, frown, raise your eyebrows, wink and blink, and do all the other things that allow human beings to communicate so much to each other using only their faces. It has a few other functions, all of which made perfect sense with my biomedical experience of Bell’s palsy. I’m at the point now where I can talk easily about this experience, so it was just fascinating to learn about it more from a medical perspective. I can guarantee that that is one cranial nerve I won’t forget on our final exam next week!
