Face It, Doctor, All Medicine Is Postmodern

Description Dr. Peter Pinto with the Urologic Oncology Branch at the National Cancer Institute (NCI) examines a patient. (NCI/Wikimedia Commons)

Description Dr. Peter Pinto with the Urologic Oncology Branch at the National Cancer Institute (NCI) examines a patient. (NCI/Wikimedia Commons)

By. Dr. Steven Schlozman
Guest contributor

Greetings from the Narrative Medicine conference at Kings College in London, where, I must unhappily report, Americans at this highly international gathering are looked upon with not a little disappointment.

While we in the U.S. can feel a certain hegemony and even pride in our diagnostic and technical prowess (to paraphrase one of the workshops I attended), we are perceived as having forgotten how we ought to listen to our patients’ stories.

This is hardly an original criticism, but still, it made me quite sad. I know that some of the conclusions I heard in discussions were more grand than accurate — “The American medical system does not and will not focus on these matters!” — but I also know as a medical educator that hearing a patient’s words as stories themselves is something that we teach parenthetically rather than directly.

Attempts by my colleagues and myself to teach these ideas more explicitly have in fact been met with various forms of passive and active resistance. “If you want to stress this in your teaching, you must have rigorous scientific data to support why you’re teaching it,” we’re told.

Here is how far we have gotten from what has always been to me the core of why I became and love being a doctor:

This meeting, a medical meeting, focused on fundamental postmodern edicts of epistemology.  Can you imagine my delight in hearing words like “postmodern” and “epistemology” at a medical gathering? I’ve often wondered, how can medicine be anything but postmodern?

If they want to become any sort of doctor, they should learn to tolerate ambiguity.

If postmodernism is roughly defined as the willingness and even capitulation that we endure discomfort with the fact that we might never know with certainty what we think we know, then I can think of no better way to describe the tribulations and wonders of being a physician.

I tell my medical students that if they want to become psychiatrists, they must learn to tolerate ambiguity. However, that comment is a bit of a ruse and I regret saying it now. I should generalize and broaden the sentiment. I should say that if they want to become any sort of doctor they should learn to tolerate ambiguity.

Take the fact that I have ruptured both of my Achilles tendons. At first glance, you might ask: What could be less ambiguous than this particularly injury?  You feel a sharp, knife-like pain just below your calf muscle, you fall unexpectedly to the ground, and the calf muscle itself rolls up like a window shade into a rounded knot that is uncomfortably close to the back of your knee.

The orthopedic surgeon sees you, laughs a bit, makes a comment about weekend warriors and such, and then reminds you of the various athletes who have endured the same injury (Kobe Bryant most recently, I think).  “Yeah, it’s ruptured,” the surgeon says, “and I’ll fix it on Friday.”

“But twice?!” I’m thinking. Twice I’ve ruptured this damned tendon? On both legs? (I only have two, thank goodness…).  Why me?  Why did this happen to me?

As Louis C.K tells us in multiple and hilarious droll iterations, this stuff just happens. It is part of the existential pain of existence, of being human, of trying to play basketball after age 40 without stretching (as I did), of the shame that accompanies the question from my surgeon: “Did you stretch?” (Answer: “No.”) To which he laughingly replies “Next time, you should stretch.”  (Thanks, doc.)

Next time…

Can there be a next time?  Can I play basketball again without risking re-rupture?  Well, maybe, they tell me.

And there is the crux of the ambiguity, hiding in my very personal anxiety about getting old, but still not knowing how old is too old…of not knowing whether, if I do stretch, how much stretching is enough, and of not knowing whether the repair of my tendon will hurt, and so on and so forth. You get the idea.

To say that shrinks have a monopoly on ambiguity is just plain wrong, and I apologize here for any sense I may have created in my teaching and writing that suggests otherwise.

Here is where medicine can take a long-overdue cue from our colleagues in the arts. The medical sensibility expects the subjective narrative to be translated into objectively defined disease. That is, the history and physical yield the one and only diagnosis.

But such thinking is in fact anathema to scholars of literature and art. You cannot know the meaning of any story per se. You can personally identify a meaning, and there are perhaps incorrect meanings to be gleaned, but to create an almost mathematical equation that a story yields a necessarily and unitarily correct meaning is as off-putting to writers as it is to patients.

We can’t be robots and also be doctors.

In fact, a nice bit of research shows that when a doctor overrides a patient’s protests or dissatisfaction and insists that he or she has accurately diagnosed a disease, that behavior predicts consistently lousy outcomes for the patient — even if, in the strictest of medical terms, the diagnosis is correct.

This, again, is something I think we in medicine all know well. But somehow, through the bullying of market forces, and our desires to seem professional and scientific, and through a host of other socio-cultural forces, we may let it happen without noting the potential damage we can do to our patients and to our field.

To be sure, these same criticisms have been levied not just at American medicine but also at all of medicine. We are not being singled out. But American medicine is seen, whether we or the rest of the world like it or not, as at least one aspect of the “gold standard” of doctoring. So people at this meeting in London worried in very polite ways that if we do not get our act together, we will lose the wonder of what we do as doctors in the States, and the rest of the global medical community may follow us down that very wrong path.

We can’t be robots and also be doctors. That story has been told in countless dystopian novels and cheesy science fiction movies. We should instead be vulnerable, flawed, and celebrative humans as we march medicine forward.

Dr. Steven Schlozman is an assistant professor of psychiatry at Harvard Medical School and a staff child psychiatrist at Massachusetts General Hospital. He is also the Co-Director of Medical Student Education in Psychiatry. His first novel, “The Zombie Autopsies,” was published in 2011.

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