Sunday, June 28, 2015

Your First Patient - Anatomy Lab and the Language of Medicine

"Your First Patient: The opportunity to dissect a human body is a once in a lifetime opportunity.  The cadaver that you will use for dissection was donated by a person who wished to make a contribution to your education as a physician.  It is not possible to put into words the emotions experienced by that individual as he or she made the decision to become a body donor.  It goes without saying that the value of the gift that the donor has made to you cannot be measured, and can only be repaid by the proper care and use of the cadaver.  The cadaver must be treated with the same respect and dignity that are usually reserved for the living patient."
Grant's Dissector, 15th edition
Your first patient.  These were the first words I would be assigned to read when I began my first year of medical school.  They are the opening words of the introduction to Grant's Dissector, a dissection manual used by medical students around the world, and are intended to frame students' understanding of the cadaver from which they will derive their first lessons in human anatomy and medicine overall.  I found the notionthat we would perceive the deceased body as our first patientto be comforting and disconcerting at the same time: comforting because I was hopeful that the standards of our treatment of the cadaver would be raised to the level of respect and compassion that would be owed to a live patient, but disconcerting because I dreaded that the standards of our treatment of patients would instead be lowered to the level of dispassionate objectification and dehumanization that the anonymous, embalmed body might evoke.

Rite of Passage

The first day was unforgettable. One of my lab partners broke into tears upon unzipping the body bag lying on the stainless steel table before us.  Such raw emotions were apparent across the lab, which was otherwise dead silent in those first moments.  For some, it was the first time seeing a dead body, while for many others it was the nearest they had ever been to one.  While our first patient may have not been alive for months, the unique features of her face and contours of her hands made the living person she once was feel palpably near; even speaking seemed to violate the solemnity of the scene.

For several hours a day, five days a week for eight weeks, we would dissect, transect, and strip our first patient down to the bones, literally.  Progressing from region to region of the body, we would be responsible for identifying various anatomical features.  Beyond mere naming, this involved perceiving each structure with multiple senses: seeing the blood vessels branching through the limbs, touching the hard stones discovered in the gall bladder, smelling the partially digested material seeping out of the intestines.  Needless to say, the task at hand required that our raw emotions from the first day be tempered, our visceral reactions subdued.  In a word, we had to become desensitized.

The meaning of this word, desensitized, changed through the course of anatomy lab.  At the start, it denoted a process of growth out of fear and disgust and into curiosity and awe, from hesitating to even speak to confidently removing layers of fascia as a team, relying on one another's skills and knowledge for collective success in a novel and challenging task of learning.  The value of such a transition in one's medical training is enormous.  Yet, by the end of the eight weeks, desensitized had taken on an entirely different meaning for some students.  These were the students who would begin handling their cadavers with the delicacy of a rag doll, who would make inappropriate jokes during the genitourinary section, and who ultimately would treat their "first patient" like one would an object that had never been alive.

The Language of Medicine

Todd Olson, PhD, an anatomist at Albert Einstein College of Medicine, said that "anatomy is the foundation for the language of medicine: the language health-care professionals use for communicating about patients."  Dr. Olson was most likely referring to the basic anatomical vocabulary of medicine, the terminologia anatomica, that one first learns in the anatomy lab and that subsequently forms the foundation of concise and accurate discourse between physicians about the health and disease of patients.  Yet, in the wake of recent attention on how doctor's speak of patients, generated by a conversation secretly recorded by a sedated patient undergoing a colonoscopy, one cannot help but wonder about the other possible meanings of the statement.  Is the language of medicine that is learned in anatomy lab limited to anatomical vocabulary, or does it extend to our less technical conversations about patients and even the extent to which our words respect and humanize the people in our care?

This question is often left out of debates about the need for cadaver dissection in medical training, yet it represents some of the most important lessons and formative experiences of anatomy lab.  In interactions with their "first patient", some students discover a profound appreciation for humanity and a humbling reminder of the unique privileges and responsibilities we shoulder as physicians.  Others merely learn mechanisms of coping during this encounter with death, how to suspend their emotional reaction and physical repugnance while distancing themselves from any sense of the human life that the cadaver once had.  Regardless of what we take with us from anatomy lab, apart from the smell of formaldehyde, the experience imparts much more on our language and training than the names of anatomical structures, and this contribution to our medical education deserves both caution and attention.

Saturday, June 28, 2014

What Ramadan Can Teach Us in the Struggle for "Health for All"

"In 20 years from now, at the half century of Alma-Ata, we could see a different world, with basic health care reaching many of the poorest families.  However, to achieve this goal, we have to revitalize the original revolutionary principles of Alma-Ata, sticking consistently to the core values of universal access for care, equity, community participation, intersectoral collaboration, and appropriate use of resources."
—Lawn et al, Alma-Ata 30 years on: revolutionary, relevant, and time to revitalize
This Ramadan (the Islamic month of fasting), I find myself reflecting on the 1978 Declaration of Alma-Ata, a groundbreaking achievement in the history of public health.  Adopted at the International Conference on Primary Care in Almaty, Kazakhstan, the Alma-Ata Declaration defined a comprehensive approach for addressing poverty, ill health, and malnutrition that shifted the focus from biomedical interventions alone to the inclusion of social determinants, from hospitals alone to entire communities, in the struggle to attain equity and social justice in global health.

Alma-Ata and the Lessons of Ramadan

While the Alma-Ata Declaration most immediately resonates with the enshrining of health as a human right in Islam, I believe that its connection to Muslim ethics in general and Ramadan in particular extends even further, reaching toward the very heart of this month's teachings.  The ritual of fasting provides a means of not only cultivating God-consciousness but also encouraging collective empathy and the provision of basic necessities to the poor.  This is emphasized by the Qur'anic instruction for Muslims incapable of fasting to feed one indigent person for each day of Ramadan that is missed (Qur'an, 2:184).  The guidelines of the Alma-Ata Declaration, which establish a commitment to providing basic health services at the local level and rectifying gross inequities in health, are thus intimately related to these lessons of Ramadan.

I would argue, however, that fasting also offers to teach us something less obvious and more meaningful about the nature of social justice, something never explicitly mentioned in the Alma-Ata Declaration, and that is the need for sacrifice.  There exist many well-intentioned individuals who, in the words of physician-anthropologist Paul Farmer, "think all the world's problems can be fixed without any cost to themselves."  Central to the practice of fasting, beyond empathy and charity, is voluntary abstention for a time from what is otherwise accessible, without which the act of worship is incomplete.  For public health and medicine in an age of energy scarcity, similar discipline and sacrifice in the face of unsustainable practices of consumption may be the only means of making lasting progress toward the vision of the Alma-Ata Declaration.

Peak Oil, Health, and Healthcare

The reason for this is that the remarkable improvements in health achieved by low- and middle-income countries in recent decades are increasingly threatened by peak oil, or the predicted peak and decline in global production of petroleum products.  While many disagree on the timing and nature of the "peak," imminent changes in the price and availability of crude oil are predicted to severely affect the health and nutrition of poor communities, whose populations and health systems are extremely vulnerable to fluctuations in food and fuel prices.  Even without the additional implications of climate change and environmental degradation, the challenges of peak oil threaten to directly and indirectly exacerbate existing problems of poor governance, armed conflict, shortages of health workers, and dependence on foreign aid in the face of growing population size.

While generally absent from the lexicon of heath professionals, there is little doubt that peak oil is intimately tied to our modern healthcare system, which is largely built around the use of petroleum-based products or production methods.  Perhaps the most notable of these are plastic disposable products in the hospital waste stream, which continue to occupy limited landfill space and partly explain the contribution of healthcare costs to oil prices.  Moreover, overuse of various lab tests, high vehicle use among healthcare personnel, and the overall dependence of healthcare on the transportation sector add to the problem.  With declining availability of cheap oil, the healthcare system will inevitably need to adapt to survive by substantially curtailing energy consumption and resource waste.


As Muslims around the world refrain from consuming food or drink during the daylight hours this month, my thoughts are consumed by the relevance of fastingthe embodiment of sacrifice and moderationto the impending threat of peak oil to the health of all.  In this crisis of consumption where neither the blame nor cost is equally shared by all communities, empathy toward those in most need among us must be central to the future directions of our collective response.  For all of these reasons, I pray that the lessons of Ramadan can help guide us as we seek ways to adapt to the growing challenge of peak oil while preserving the vision and commitment of the Alma-Ata Declaration to equity, social justice, and health for all.

Sunday, June 15, 2014

The Eastern Medicine Revolution? Not Quite

"The Eastern Medicine Revolution?" These were the words emblazoned across the screen behind Dr. David L. Katz, founding director of the Yale-Griffin Prevention Research Center, as he discussed the growing popularity of holistic integrative medicine on a recent edition of the Katie Couric Show. The conversation centered on the opening of Cleveland Clinic's Chinese herb therapy ward in January of this year, the first of its kind at a major US hospital. Dr. Katz argued—convincingly, I might add—that some instances where "alternative" medicines are criticized for lack of sufficient supporting evidence are more attributable to the profit motive driving drug development than to any lack of efficacy. Citing the case of coenzyme Q10, Dr. Katz explained that financial incentives drastically bias medical research against alternative medicines, which often cannot easily be patented for marketing and thus less often receive sufficient funding for extensive research and regulatory approval.

Not all "eastern medicines," however, are created equal in the eyes of many, and while Dr. Katz's argument lands a powerful blow to the general portrayal of holistic medicine as quackery, it would be a mistake to conclude that money can tell us the whole story.  This is especially true in the case of traditional Islamic medicine.  On the rare occasion that Islam can be discussed independent of the political rhetoric surrounding Muslims, terrorism, and immigration in Europe and the United States, Islamic medicine rarely exists in popular media without the word "medieval" preceding it.  While describing the study of Islamic medicine or even defining the concept of holistic medicine are challenging and important topics, the question I hope to explore here is whether the conventional medical establishments of the United States and Europe are ready to begin embracing even the possibility of traditional Islamic medicine representing an alternative treatment option, as they increasingly have for traditional Chinese therapies.  My answer is no, they are not quite prepared for such a step.

Why the United States and Europe are NOT ready to embrace the possibility of traditional Islamic medicine as an option:

In addition to the challenge of profit motive demonstrated by Dr. Katz, traditional Islamic medicine faces the same difficulty encountered by nearly all understandings of illness originating outside the conventional biomedical model: the patronizing categorization as "beliefs" as opposed to knowledge.  While anthropologists have generally understood knowledge and beliefs as complimentary, health professionals tend to view the terms as contrasting, with "beliefs" connoting ideas that are irrational, erroneous, and obstructive to health.  As such, the very terms used within public health discourse often exclude Islamic medicine from serious consideration, along with other traditional forms of holistic medicine.

There also exist obstacles that are unique to Islamic medicine, however, as the portrayal of Islam and Muslims by medical writers is hardly neutral.  A review of medical literature from 1966 to 2005 revealed recurring latent biases, including notions that Islamic tradition is a barrier to modernity, that being an observant Muslim poses health risks, and that "Islam" represents a problem for healthcare delivery.  Even historic examinations of Islamic medicine frequently reduce "positive" elements to mere transmissions of Greek, Jewish, or Christian thought.  Such messages build on a long history of orientalist representations of Muslim societies as deficient and dehumanized Others, a phenomenon famously examined by Edward Said, to which medical discourse is no exception.  Nowhere is this more apparent, perhaps, than in depictions of Arabs and Muslims in psychodynamic literature post-9/11, during an era of suspicion and hostility toward Muslims and of military interventions in Muslim-majority countries by Europe and the United States.

Thus, to fully comprehend Islamic medicine's exclusion from the conversation around alternative medicine in the West, let alone from the conventional medical establishment, we must look beyond questions of research funding and evidence-based medicine.  While important, these issues speak little of the relationship between knowledge production and geopolitical power that are behind persisting orientalist narratives around Muslims and Islam in medical literature.  Until American and European health professionals and academics are prepared to critically address these narratives, Islamic medicine is unlikely to be included in any "Eastern medicine revolution" that may be underway.

Wednesday, June 11, 2014

3 Reasons Premedical Students Need the Liberal Arts

In his commencement address at Sarah Lawrence College, international affairs journalist and author Fareed Zakaria defended the value of a liberal arts education.  "At its essence," explained Zakaria, "a liberal education is an education to free the mind from dogma, from controls, from constraints.  It is an exercise in freedom."  His speech, I imagine, was well received and much appreciated by the over 400 graduates earning liberal arts degrees that day in the midst of declining funding, popularity, and respect for their chosen field.

Premedical students, presumably destined for the prestige and pay scale of a medical career, might imagine themselves to be outsideor maybe even abovethe scope of Zakaria's message.  If you are among them, you are seriously mistaken, potentially to the detriment of both your higher education in general and your professional training as a future physician.  Rather than strategically choosing classes on the basis of how easily you can fulfill breadth requirements while completing the premedical curriculum, I would urge you to pay closer attention to your courses in the liberal arts, and here are the three most important reasons why:

1. The liberal arts teach you the power of words and language, which are the basis for communication and the relationship between doctor and patient.

Despite incredible advances in technology, modern medicine remains as much about communication as about any of the biomedical sciences.  In fact, with the leading causes of premature mortality being driven by behavioral and societal factors, better communicationwhether in counseling individual patients or informing the larger publicmay be the most important tool in addressing our greatest public health challenges today.  Conveying the importance of exercise, vaccination, or any other preventive action to another person, however, requires more than presenting cliché public health messages or statistics.  It also requires an understanding of the immense power of words and language to shape ideas and change people, hallmarks of a liberal arts education.  Moreover, such an understanding of language opens a window into the unique human experiences behind a person's words.  It allows you to learn empathy and make a genuine connection with the person in your care.

2. The liberal arts train you to be critical thinkers and lifelong learners, cornerstones of the medical profession.

While the scientific method provides a foundation for much of medical practice, empirical and quantitative methods have limits to the questions they can answer.  When it comes to the grayer areas of uncertainty, including many clinical decisions and ethical judgments faced by physicians every day, the critical thinking and analytic skills emphasized by a liberal arts education become essential.  They allow a physician to consider various perspectives, seek evidence, and construct an argument for specific action.  There can be no skill more vital to a doctor than this ability to take reasoned action in the face of uncertainty.  Furthermore, the open mind and inquiring attitude that this skill imparts lends itself to continued learning and adaptation, even as the available evidence and standard practices change with each passing year.

3. The liberal arts prepare you to tackle the more complex questions facing physicians, including what role they should play in society, politics, and promotion of social justice.

Contrary to what the progressive commercialization of medicine would have us believe, medicine continues to be "a calling, not a business," in the words of William Osler.  Physicians continue to bear a social obligation of service and integrity toward the patients and communities with whom they work.  In many ways, the liberal arts offer to elevate our level of discourse above the ever-changing market forces and administrative policies in medicine and to thereby ensure that these principles are never unwittingly compromised under external pressure.  Additionally, it provides a framework for beginning to address the larger social and political issues involved in promoting greater justice in the distribution of healthcare resources.  These represent priorities that deserve our greatest attention as future doctors and that require us to "free the mind from dogma, from controls, from constraints" and exercise the freedom of thought afforded to us by the liberal arts.