By Brian McKenna
University of Michigan-Dearborn
“You must help me if you can.” Jackson Browne, “Doctor My Eyes”
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).
I teach medical anthropology. Despite biomedicine’s apparent problems, it is still viewed as “the best in the world,” especially by an army of Pre-Med students who descend on my classes. I find that it is very hard to break the spell of medical hubris unless critical pedagogical strategies are employed. Technological homage to MRI, CATSCAN and heroic medicine—on TV shows like Chicago Hope and House—greatly glamorize “medicine,” or as medical anthropologists call it, “biomedicine,” a conception which accounts for the narrow microbiological orientation of this field.
I know that the fundamental causes of ill health are out of the control of biomedicine, 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” (Sanders, 1985:117).
This message subverts common sense. How to best educate students about the veracity of this assertion and its implications? So powerful is the Doctor persona that he assumes a shamanistic aura to many. In his song, Jackson Brown asks the Doctor “to help me understand” a world “with . . .evil” where he “hears the cries” of fear and suffering. He asks the doctor whether he should have become educated in the first place and whether “it was unwise to leave them [his eyes] open for so long?”
Browne has reached a very down point in his life and is searching for meaning in his crisis. But that’s not something that a conventional doctor can provide for him.
The singer is asking the doctor whether ignorance and denial are the preferred defense to handle the world, rather than the enlightenment path he chose. In general, biomedical doctors are steeped in ignorance and denial themselves and not well educated to show others how to make meaning in order to heal. The medical anthropologist Jean Comaroff illuminates this well in her important work “Medicine: Symbol and Ideology” (1982) which provides a cross-cultural comparison of the healing systems of the Tshidi-Borolong and Western biomedicine. Comaroff investigated the universal paradoxes associated with the illness experience, especially the existential question about personhood. Comaroff argued that sick individuals among Tshidi are “healed” through communal rituals which are per¬formed 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 ra¬tional individualism which “rests upon the reinforcement of the very symbolic opposi¬tions 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).
How do we help student/citizens recognize the haunting cultural politics of biomedicine so that they can overcome estrangements and transform medicine in their lives? How do we alert them to this before they are given the jolt of a cancer diagnosis (as half will be in their lives).
This article discusses one pedagogical tactic that seems to have merit: a radical interrogation of students own doctor visits, discussed communally. On the first day of class I pass out the following assignment. I tell students to be prepared to share their stories in class. The five page paper is due two weeks hence. It serves as a lens for the entire semester to follow. I take them on a path that integrates art, emotion, biography, and critical theory, all with the intent of preparing them with the tools to take back medicine and their education. The semester is intended as a critical jolt in itself, to awaken students to ask the very questions as Jackson Browne asks. Here is the assignment.
Applied Medical Anthropology
Tell Us About your Last Doctor Visit
By Brian McKenna
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:
- Briefly describe the setting.
- What was your presenting complaint?
- How did the practitioner interact with you? (her/his demeanor, history taking, physical)
- Did you feel you had enough time to discuss all your questions and concerns? Why or why not?
- Did the practitioner acknowledge your own phenomenological experience?
- If relevant, what questions might you have liked to discuss with the practitioner that you did not? Why not?
- Were you satisfied with the practitioner’s diagnosis(es)?
- 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?
- Do you believe that the practitioner helped to heal you?
- In your opinion, might there have been an iatrogenic component to the care?
- What, if anything, might the practitioner (and their support staff) have done better?
- How would you rate this practitioner? Excellent, good, average, below average, poor?
I receive student papers back two weeks after they are assigned. I read them and perform a content analysis of their themes. Then I return them a week later and we spend the day discussing them. I begin by having the students pair off for ten minutes 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 the class up for dialogue. As we dialogue I write given generative themes on the blackboard. This serves as the basis for future lectures. 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 (who intern) and technicians. They often write about their secretive “House of God” experiences (Newman 2008) in their papers. The day is always filled with tears, laughter and insight. We all learn much.
Making Meaning in an Estranged Neoliberal World
In a future column I will share the details of one class assignment, including a content analysis of forty papers, generative themes, and dialogue points. In the past, students were fascinated by iatrogenesis, physician communication, and what it means to heal. Here is some of what I share with them in future classes.
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 (see also Grossinger 2001, Mendelsohn 1979). Issues of political economy are poorly addressed as well (Bear et al 2003, Sanders 1985). 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 (see also Baer and Singer 2008, Coreil and Mull 1990, Davis 2007, 3, Engle 1977, McKenna 2010, 2011, Singer 2009, Smith-Nonini 2010).
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 response, and argues that it is a powerful healing modality that should be a fundamental part of medical education. But it is not. He argues that biomedicine’s neglect of emotion, ritual and culture mean that medical education is “as much of a hindrance as a help” (Moerman, 2002:13). I often make his book, “Meaning, Medicine and the ‘placebo effect,’” a required reading.
I share the tale of my childhood physician, Dr. Robert Haynes. As a youth in the early 1960s, whenever I was sick in bed, I tell them, the good doctor appeared, ascending the stairs of our tiny row house just outside Philadelphia. Through bouts of measles, mumps, and even a heatstroke he came. Sitting on the side of 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 quietly listened to my stories. He even 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.
I contrast that with today’s protocols. I travel to the “family” doctor at a mall-based clinic and she treats me singly, following “managed care” protocols. I still repeat stories but they’re not about baseball. I tell the doctor the same story about my symptoms that I’d just written down in the waiting room and just told to the nurse minutes before. It’s a 20 minute drive to get there and a 30 minute wait. The doctor portion of the visit takes, on average, ten minutes and there is little talk about my feelings outside of how they relate to my “presenting complaint.” Like Jackson Browne and most of us, I have a lot of complaints!
And now, with electronic patient records (EPR), my doctor rarely even looks at me as she busily types away on a computer. But I am watching her, feeling more estranged. Incidentally, EPR efficacy is being seriously challenged for having little or no evidence of improved clinical outcomes (Black 2011).
Anthropologists can teach students a great deal about medicine if they elicit their experiential knowledge. We must attend to the cultural capital they bring with them into the classroom and make that curricular material. This is applied anthropology. It links theory and praxis, the social and personal. It echo’s Horace Miner’s well-known Nacirema (also about iatrogenesis).
Moreover, 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 ethnographic record. We need to schematically research and capture this data and broadcast it to our local communities. These stories must be ethnographically reclaimed in order to galvanize “patients” to lose their patience and become active.
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