As a student known to sleep through a larger portion of my immunology lectures, the material, for me personally, lacked a little oomph. IgM. APC. CD28. C4b2a3b. A litany of cells, cytokines, and receptor molecules with unimaginative names and, often, even less enticing tasks that sounded more like a roll call for Star Wars characters. Little did I know, however, that the lessons imprinted on me in immunology translated to a much broader message.
Our biological well-being relies on the body’s meticulous ability to distinguish between the innate and the foreign. Thus, recognizing our own self is a lesson imbued to us by our own immune system. If the crux of good health relies on our body’s ability to recognize the “self” from “non-self” then being a good doctor, in my opinion, is about recognizing one’s own motives, perceptions, and attitudes against the backdrop of competing interests.
While conducting a research study on undertreated pain in sickle cell patients in a small middle-income nation, I interviewed around 40 sickle cell patients. After several long weeks of talking to patients, they all seemed to blend together as one in my head. However, one particular patient would always stick out in my mind. William, as I’ll call him, was rather gaunt and scraggly when he walked into the clinic where I was conducting interviews. His uncharacteristically hollow and worn face spoke volumes about his disposition and how mismanaged his pain was as a result of his disease.
Nevertheless, it wasn’t his face or his stature that made him more noticeable in my mind, but rather something about his eyes. There was a glaring yellowish tone within them, signs of full-blown jaundice, a common symptom of the disease, but even that was far from what made them distinctive. It was, instead, the dejected look he carried about him, a man who lost that sustaining spark to carry on. More so than his body, it was his spirit that was crippled.
My fifteen-minute questionnaire transformed into a two-hour conversation where William informed me how he had lost his livelihood for the third time that year due to his lack of effective pain management. His intermittent pain crisis kept him from being reliable on the job. The burden of sickle cell made William feel like a burden, himself, upon his mother who was now the sole supporter of him, his stay-at-home wife, and his three children.
His days were filled with impromptu doctor’s visits and blood transfusions. William was also not blind to how he was treated by those very physicians entrusted with his care. As a result of William’s frequent visits to the hospital during his massive sickle cell crisis, William’s physicians started becoming skeptical of his true intentions in seeking medical care and pain medication despite knowing the patient’s history and his disease.
Consequently, William received little more than aspirin, even in the face of unfathomable distress. Requesting more robust pain medication, however, as William informed me, came with a high price. It’s often widely feared in many third world nations that prescription of strong pain relief medication can suddenly lead to substance abuse and patient dependence. Stigmatization among physicians and even politicians, which leads to more stringent regulations on the accessibility of pain medication, can prevent sickle cell patients from accessing stronger analgesics even in the face of actual need.
Thus, William’s body in trying to sieve the “foreign” abnormal red blood cells from the normal ones produced by his body, was also contributing to his deteriorating health and ever-lasting pain by working his spleen and liver overtime. However, his doctors’ inability to sieve through their own misguided perceptions was only exacerbating William’s pain.
William being prescribed aspirin, an ephemeral, ineffective solution for a chronic problem, is much akin to putting a band-aid over a bullet-hole. Accordingly, William was forced to learn to curb however much of his pain he could through alternative avenues, one being sound therapy where focusing on a particular rhythm or beat can help offset pain signaling pathways. William’s personal favorite is the sound of the beating heart: “Lub-Dub, Lub-Dub.” The only time he cracks a smile in those two hours is at the recitation of the resonance of his own heart valves.
Revealing his fascination with the soothing heart rhythm, William goes on to inform me that the sound described as “Lub-Dub” in English, is “Duhp-Teup” in German, and his personal favorite, “Dhak-Dhak” in Hindi. He quips, “It just goes to show you how we all march to the beat of a different drum.”
William was on to something. Extrinsically, both current and future physicians are exposed to a typical standardized medical education. Intrinsically however, these “beating” patterns that constitute our own worldviews, values, and attitudes differentiate how we relate to each affliction beyond the science, and to each patient beyond their affliction. Much like our own immune system cannot stave off infection and disease without first recognizing the self, physicians cannot hope to convey humility, transparency, and/or altruism without first becoming cognizant of where these traits stem from within themselves.
In a field that emphasizes delivery of care towards others, I feel introspection often can become undervalued. Despite the absence of a spark in William’s eyes, he still steadfastly held on to his vision of hopefully one day, not being disease-free, but leading a productive life despite of his disease. However, that should also be William’s doctors’ dream as well, not just William’s. His physicians lacked the self-knowledge to assess that medicine is simply much more than biology but a soft-spoken mosaic of sociological, psychosocial and political underpinnings that influence directly not only how physicians carry out their own tasks, but, indirectly, how patients live their lives well after their hospital visits.
However, as in everything with medicine, self-knowledge is useful only if administered in healthy doses. Too much and it impedes doctors’ abilities to successfully carry out their jobs while having too little can undermine the very pillars of medicine one wishes to uphold.