Very much in agreement and thank you for writing this. I think it’s also worth mentioning that the doctors I have known who understood the “thou” have all eventually left their profession because the business behind their practice wouldn’t allow them to spend more than three minutes per patient. That greed made it impossible for the doctors I have known who truly cared to take the time needed to see who was in front of them. I wonder how much of the seemingly indifferent behavior is really protection for the soul of a doctor who does care but has given up a belief that they will be allowed to act out of their own humanity.
The sad fact about these trends, if history is a reliable guide, is that prioritizing profit will erode the public trust to the point that scientific medicine loses its cultural authority. We might already be at that tipping point with vaccines. If the scientific physician or clinician is seen as cold, uncaring, and unavailable, then it doesn't matter how rigorous the CDC methods are for testing the recommended cocktail -- lots of people won't trust it.
I've had many conversations with friends who are either caregivers or wellness professionals outside of medicine, and there seem to be alternative communities forming that claim to be science-based, but aren't really endorsed by the AMA and that offer different takes from what you'd hear from a typical family physician. So it's a confusing time. I'm wary of homeopathists and other alternative practitioners, but I'm also increasingly mindful of how little the general medical apparatus cares about my actual wellness.
It's sad to hear that even physicians who still care are protecting themselves within the system and thus, perhaps unintentionally, conveying indifference to patients.
My experience definitely echoes what you are saying Robyn. I'm currently trying to figure out what my ongoing relationship to clinical medicine within the system will be. And you are absolutely right that there is a lot of self-protection and emotional suppression that happens just to make it through the day.
Thanks, Amy -- you remind me of Robin Wall Kimmerer. You should write a medical equivalent of Braiding Sweetgrass! I really appreciate how she explores the tensions between her scientific training and her indigenous knowledge.
Thank you Josh, Robin Wall Kimmerer is one of my favorite writers, and I am actually working on a book that is kind of in that vein. The concept is sort of a rewilding of healthcare. I think poor woman’s Robin Wall Kimmerer would be a wonderful career goal :)
Besides the folks you've already mentioned, I love the essays of Lewis Thomas and, on Substack, of Dr. Ana Bosch.
I observe that caring for the sick was a profession for thousands of years before medical science could help improve patient outcomes in any way. Long before doctors could cure anything, humans were still willing to pay someone just to be with them, to show sympathy (literally from the Greek, "to suffer with.") All the efficiencies in the world can't replace that sympathy.
Josh, this is a great read, and timely. AI in medicine is such a hot topic right now. I'm thinking to write an essay on it this year.
Could you link to the physician writer you reference in the beginning..the one who remarked how impersonal her care was?
"What I’ve learned from history is that when doctor-writers disappear, or their voices grow faint, public distrust of medicine grows." Interesting to think about this. I feel like I've seen more and more physicians running for public office of some kind as the lines between doctoring and public discourse are so intertwined. The surgeon who operates on gun violence/mass shooting victims often feels the need to do something about it rather that just operate. The OB-GYN physician who can longer safely perform an abortion needs to educate the public on its importance rather than having politicians spin it.
One book I would recommend is from a critical care physician writer named Rana Awdish, she's not on Substack, but wrote a book called In Shock. It details her near-death experience in the ICU and how medical culture in how patients are spoken about and treated needs to change.
Thank you, Istiaq! I see that you also write about narrative medicine but were too polite to promote your own work :). I'll look forward to exploring your series.
I have not heard of "In Shock," but it looks excellent. I'll order it straightaway and schedule it for a review later this year. Appreciate the lead!
I tried to find the Note that I referenced above, but it seems to have disappeared in the haystack. If I come across it, I'll share it with you privately. Since you write about narrative medicine, do you know of other Substacks explicitly devoted to the medical humanities?
hah, yes I'm also a Substack writer, so careful not to shove my work in everyone's face :)
One writer I enjoy reading here in the medical humanities is Mara Gordon (I tried linking here but was unsuccessful). She is a primary care doc who recently announced she is agented for a book soon, she writes about shame/stigma in medicine among other topics and I've found her work thought-provoking too.
In Shock is really good, I think you'll really enjoy it Josh!
Thank you for this very thoughtful and thought-provoking essay.
When working at Harvard Medical School I had regular contact with medical doctors. In conversation with one who had recently been hospitalised, he remarked about the detachment and aloofness of the attending physicians, and that it was the nurses that provided the sense of caring that was essential to his sense of actually being cared for. The experience was one of gaining self-awareness.
Since my work was in biomedical informatics, I also had intensive contact with researchers and MDs who identified as "informatics scientists." These were the days of Blackberrys and Palm Pilots, but even so there was a disappointing level of charlatanry about medical applications of technology (and among the MDs a certain distrust of the IT professionals).
The current efforts to integrate AI with medical care at the diagnostic level pose opportunities as well as potential to further separate clinicians from patients. With advancement of digital medical records, the 'chart' may well be replaced by an AI generated profile that aggregates and integrates a plethora of information about the patient (such as home/work location, environmental conditions in such places, geospatially encoded epidemiological information, etc.), still missing the obvious signs that only come into focus during personal contact. And wouldn't insurers and government agencies covet such information as well?
Interesting points, John -- thanks. It is indeed tantalizing to think that AI could cure cancer. And perhaps there is some utility in aiding diagnosis. But early AI seems to have been so prone to error and outright fabrication that I hope those systems are thoroughly vetted before being widely used.
The importance of an accurate medical history hasn't waned, and no physician can know what remains undisclosed. Danielle Ofri has written about "hand on the doorknob" moments when a patient is just about to leave and suddenly reveals something essential about their social history or living situation, or even about their medical history, that they've been hiding up until then. I-it systems don't much care whether that history gets shared or not -- they keep functioning on autopilot regardless. But a good doctor really does care about building trust, so that patterns of denial or secrecy can be broken.
Thank you for this thought-provoking article. The world of palliative and end-of-life care is a useful space for exploring the humanity of healthcare, not least because it has to come up honestly against the ‘failure’ of medicine to cure death and embrace the intimate, profound realities of mortality. Debates about the Assisted Dying Bill here, demonstrate the need for human judgement and compassion to be at the very heart of decision making at end of life.
From a UK perspective, I enjoyed Rachel Clarke’s Dear Life, in which she interweaves clinical examples with reflections about her father (also a medic) and his terminal illness. While slightly less personal, Kathryn Mannix’s With the End in Mind is also a powerful reminder of the importance of the I-thou relationship in the process of dying. And I need to get round to reading neurosurgeon’s And Finally…at some point.
As an aside, I’d like to know if there are many published narratives from healthcare professionals who come from less privileged backgrounds than these…
Thanks for the suggestions. I'm not at all familiar with books by UK physicians (although I did enjoy Henry Marsh's "Do No Harm").
Danielle Ofri and Damon Tweedy are two American physicians who grew up with less privilege. I'll have to think more on it.
Perhaps you are familiar with Margaret Edson's play "Wit," also adapted for film with Emma Thompson? I know of no finer commentary on health, illness, and the language used in health care than Edson's play.
From a practioner perspective, it can be challenging to enjoy the patient-doctor relationship when patients come in with AI recommendations and specific demands. It is frustrating to have patients watch TV and listen to various pharma ads and Dr Google and come expecting a quick fix. As patients, many of us cannot accept our own histological time frame for healing because health has been idealized with instant gratification.
My patient today wasn't loving my prescription of posture exercises, dynamic stretches and icing along with resting from tennis and switching to biking for 7-10 days--but prednisone did the trick of taking his pain away so he could continue with tennis. That was prescribed over an email! I have advised him through his knee, hip, and shoulder replacements, but my advice regarding his back pain wasn't good enough.
My attempts to discuss hydration and protein intake with patients is not razzle-dazzle despite the #1 side-effect of many of the 18 drugs my patients are on is dehydration. Discussing intake of sugar or processed food is definitely not the cause of their acid reflux and they read on the internet gallbladders are not needed... so the I-it relationship can be just as difficult from the practioner perspective.
I agree that when the human side of medicine is highlighted, trust grows. I read a lot of medical writing, unfortunately my understanding is that many books written by doctors that are on the shelves are only published if the book includes some sort of fad diet plan versus just presenting the science. I believe this may also contribute to the distrust and idea that there is one "right" answer.
Our healthcare system and attitude around what health actually means to each individual all needs an overhaul. I do agree that returning to medical practice as an art and humanizing care is part of that. There are practioners out there doing their best to do that in a "sick care" system, but as consumers of health, we may need to understand there is an art and patience to healing as well.
Excellent points about the patient's responsibility to bring an "I-thou" perspective to the relationship, too. I feel the burden rests more on the doctor, since the patient comes to that relationship vulnerable and often afraid (it's not the patient's job to care about the doctor's holistic wellbeing in necessarily the same way, given the power differential), but you're right that healing requires patience and that no one can expect good results if they don't show respect for actual expertise.
I remember how silly the "wellness" plans promoted by my former employer seemed to me. You could earn insurance discounts or other one-off rewards by completing hydration or exercise or diet challenges. But these would typically run for 2-4 weeks and never recur. Presumably the thinking was that someone would see benefits and then continue on their own, but it was a very transactional mentality. I asked once if I could get a similar credit for uploading my Garmin data to show annual running and cycling mileage and got a blank stare.
It doesn't help that the U.S. food system creates a home-to-hospital pipeline. It takes a lot of energy and education to make healthy choices in the grocery store and more $ than a lot of people have to buy locally at farmers markets. Most people know, I think, that food is a form of medicine, but because the deck is stacked and bad cultural habits are baked in, that is a hard tide to turn.
I understand in an emergency, the patient is not caring about the doctor. How different our ERs would be if patients (non,emergent) were given lemon balm tea! Although, I suggest bone broth and apple cider vinegar and some patients think I'm out of my mind -- again because we are conditioned to believe that natural remedies are not adequate.
I love that my patients care about my well-being, I had a patient text me about her Orioles returning today. I realize I am possibly in a different setting as a PT, but I think it is important to have a symbiotic relationship in healthcare. And if it were easier for more professionals to be able to choose independent practice and spend more time with patients, I think they would. As patients, we should have a healthcare team who really care for us and know us. In return, we should care that they are not overworked and able to actually be a caregiver.
As consumers, we need to demand more of the system by not hastily choosing telehealth, pharmaceutical remedies, and emergent care clinics over proficient professionals at all levels who consider us as an individual. I believe what you are suggesting with writing in an I-thou method can positively influence the system and encourage patients to seek out more compasionate medical care.
I so agree that AI diagnosis and treatment creates the I-it relationship. And it feels awful to receive.
At my most recent surgery, I was on a gurney, waiting while everyone (about ten people) bustled around the room, setting up trays of equipment, setting up the anesthesia, attaching multiple machines etc, and I was about as visible as a stuffed animal would be on that gurney.
Until something magical happened. A tall man, with large warm hands, came and sat took my left hand in both of his. His voice deep and resonant, as he said, I’m going to be monitoring your nerves during this entire operation, start to finish, and I promise I’ll take good care of you. It’s my only job in this OR, and I’m good at what I do. He looked me right in the eyes, and smiled (I could tell because his eyes crinkled above his mask.
This human interaction was SO important to me, as the doctors were operating on my cervical spine, and it’s a high risk area to remove bone.
I tried to find his name to thank him for his humanity, but I was unable to track him down.
Thank you for sharing The Nettle Witch Josh! And I definitely second that Bess Stillman is an astoundingly good writer.
Regarding what Foucault said, I wonder if the cadaverizing the body is more about how we learn to see a body as it's separate parts rather than the connections through that process.
I think that time pressure really pushes us toward I-it relationships and giving doctors and other health professionals autonomy over their time again could make a huge difference in developing relationships that facilitate healing.
People are starting to use ChatGPT as their therapist. Given the expense of healthcare, I suspect using it as one's doctor isn't far off. I understand the desire too and that current interactions with the healthcare system often don't feel much different than interacting with a robot. I think it neglects the many factors like relationship and placebo that are intimately involved in healing, but for which we can't (or at least don't yet) understand the mechanism.
I always have too much to say when I read your work! :)
I could take a deeper dive into Foucault. He was mining clinical treatises by Xavier Bichat and others who had a truly utopian view of clinical medicine that enabled a God complex. When the taboo on autopsy was lifted in France, and physicians from America had to travel to Europe to study anatomy in the cutting edge way (no pun intended), there was so much focus on what to learn from the corpse that the emphasis on humanity really fell away. So it wasn't cadaverizing the body in Foucault's thinking, it was cadaverizing life, the living, breathing patient, that defined the clinical gaze.
I can't imagine using ChatGPT as my doctor. I have a really good doctor, but there is a lot she's not qualified to talk about, and at age 50 I feel like there are holistic dimensions of my health that I'd like to explore but don't have a lot of guidance about. Maybe vitamins and other supplements would be good, but which ones? Do I need the complex blood work that I hear some friends talk about (not even sure what those tests are called, but there seem to be alternative practitioners that offer them)? Lots of questions.
I have at least resolved to stop using the drop-in clinics unless absolutely necessary, as the quality of care seems lower, overprescription seems higher, and less is covered by insurance.
Foucault was sullied by association for me by a really dumb class in grad school :) But I think a deeper dive would be interesting. I was wondering if that breaking things down into parts is sort of the means to cadaverizing life. That's what interests me so much about indigenous science and traditional ecological knowledge was how did they learn so much by observing the whole carefully within its environment.
At the risk of being self-promotional, I'm beta testing health coaching services right now at a substantial discount and I’d be happy to chat sometime about if what I'm offering fits what you are hoping to explore about your health.
Yeah, I think a lot of people soured on Foucault in grad school. His "Birth of the Clinic" is marvelous, however. First-class research and (in my opinion) eminently readable.
Here's a sample paragraph from my dissertation, where I use Foucault to examine Roger Chillingworth in "The Scarlet Letter." Few remember Chillingworth from that novel, but he is a curious blend of medical traditions (herbalism from his Native American captivity, alchemy, and clinical science) and reflects how deeply distrusted scientific physicians were in the 19th century:
"As both a man of science and a learned physician, Chillingworth often exhibits characteristics more typical of the nineteenth century than the seventeenth-century setting of the romance. Most specifically, he resembles the hundreds of American physicians, including Oliver Wendell Holmes, who studied in Paris between 1820 and 1860, “return[ing] as devoted disciples of the new clinical methods” (Browner 141). One of these methods was clinical observation, which Michel Foucault describes as “the Gaze that envelops, caresses, details, atomizes the most individual flesh[,] […] that fixed, attentive, rather dilated gaze which, from the height of death, has already condemned life” (171). From his appearance at the scaffold in the opening scenes to the close of the romance, Chillingworth fixes his eye on those around him with just this sort of penetrating and attentive gaze."
A comment over at Inner Life made me think that I ought to retool my series to focus more explicitly on medical humanities. There are a lot of Substacks on medicine, lots of Substacks on literature, not many (any?) that explicitly focus on writing by or about doctors (or illness narratives, specifically). Perhaps that's the Ikigai I've been looking for.
Let's talk privately about your coaching venture :)
Thanks for the suggestion, Jim! The medical humanities had a nice run and I expect will still survive at institutions with adequate funding. The purpose of Narrative Medicine is to cultivate just what you describe: a broader imagination for caregivers. As is the case with many other things, the value of humanities education in medicine will likely need to be understood, at least for a time, by its absence.
Thanks for this thoughtful essay, Joshua. I’ve been thinking a lot about AI lately, as it’s being used in design and academia. Why? What’s the appeal? My first thought was the cult of perfection. I can feel all sorts of ideas bubbling up. Signing off now to go journal. We’ll see what emerges.
It's early days yet. This firm uses it a lot to, as they say, "ideate." Which, if you ask me, is the most fun part of being an architect. I'm def not in a hurry to give that away to a machine. https://www.mvrdv.com/
Joshua, your reference one of my favorite books and I love this essay. You’re absolutely spot on with the reflection on how we are moving to. I-it relationship relationships, and the damage that this causes. Truly, we do need to move toward I-thou relationships. Humanity requires it.
Very much in agreement and thank you for writing this. I think it’s also worth mentioning that the doctors I have known who understood the “thou” have all eventually left their profession because the business behind their practice wouldn’t allow them to spend more than three minutes per patient. That greed made it impossible for the doctors I have known who truly cared to take the time needed to see who was in front of them. I wonder how much of the seemingly indifferent behavior is really protection for the soul of a doctor who does care but has given up a belief that they will be allowed to act out of their own humanity.
The sad fact about these trends, if history is a reliable guide, is that prioritizing profit will erode the public trust to the point that scientific medicine loses its cultural authority. We might already be at that tipping point with vaccines. If the scientific physician or clinician is seen as cold, uncaring, and unavailable, then it doesn't matter how rigorous the CDC methods are for testing the recommended cocktail -- lots of people won't trust it.
I've had many conversations with friends who are either caregivers or wellness professionals outside of medicine, and there seem to be alternative communities forming that claim to be science-based, but aren't really endorsed by the AMA and that offer different takes from what you'd hear from a typical family physician. So it's a confusing time. I'm wary of homeopathists and other alternative practitioners, but I'm also increasingly mindful of how little the general medical apparatus cares about my actual wellness.
It's sad to hear that even physicians who still care are protecting themselves within the system and thus, perhaps unintentionally, conveying indifference to patients.
My experience definitely echoes what you are saying Robyn. I'm currently trying to figure out what my ongoing relationship to clinical medicine within the system will be. And you are absolutely right that there is a lot of self-protection and emotional suppression that happens just to make it through the day.
Thanks, Amy -- you remind me of Robin Wall Kimmerer. You should write a medical equivalent of Braiding Sweetgrass! I really appreciate how she explores the tensions between her scientific training and her indigenous knowledge.
Thank you Josh, Robin Wall Kimmerer is one of my favorite writers, and I am actually working on a book that is kind of in that vein. The concept is sort of a rewilding of healthcare. I think poor woman’s Robin Wall Kimmerer would be a wonderful career goal :)
Lovely -- I will buy a copy as soon as it's available!
Besides the folks you've already mentioned, I love the essays of Lewis Thomas and, on Substack, of Dr. Ana Bosch.
I observe that caring for the sick was a profession for thousands of years before medical science could help improve patient outcomes in any way. Long before doctors could cure anything, humans were still willing to pay someone just to be with them, to show sympathy (literally from the Greek, "to suffer with.") All the efficiencies in the world can't replace that sympathy.
Yes, Lewis Thomas is a gem! I don't know Dr. Bosch's Substack, so thanks for the lead.
Love your point about sympathy. As Tey noted in a separate comment, it doesn't take much time and can make all the difference.
Josh, this is a great read, and timely. AI in medicine is such a hot topic right now. I'm thinking to write an essay on it this year.
Could you link to the physician writer you reference in the beginning..the one who remarked how impersonal her care was?
"What I’ve learned from history is that when doctor-writers disappear, or their voices grow faint, public distrust of medicine grows." Interesting to think about this. I feel like I've seen more and more physicians running for public office of some kind as the lines between doctoring and public discourse are so intertwined. The surgeon who operates on gun violence/mass shooting victims often feels the need to do something about it rather that just operate. The OB-GYN physician who can longer safely perform an abortion needs to educate the public on its importance rather than having politicians spin it.
One book I would recommend is from a critical care physician writer named Rana Awdish, she's not on Substack, but wrote a book called In Shock. It details her near-death experience in the ICU and how medical culture in how patients are spoken about and treated needs to change.
Thank you, Istiaq! I see that you also write about narrative medicine but were too polite to promote your own work :). I'll look forward to exploring your series.
I have not heard of "In Shock," but it looks excellent. I'll order it straightaway and schedule it for a review later this year. Appreciate the lead!
I tried to find the Note that I referenced above, but it seems to have disappeared in the haystack. If I come across it, I'll share it with you privately. Since you write about narrative medicine, do you know of other Substacks explicitly devoted to the medical humanities?
hah, yes I'm also a Substack writer, so careful not to shove my work in everyone's face :)
One writer I enjoy reading here in the medical humanities is Mara Gordon (I tried linking here but was unsuccessful). She is a primary care doc who recently announced she is agented for a book soon, she writes about shame/stigma in medicine among other topics and I've found her work thought-provoking too.
In Shock is really good, I think you'll really enjoy it Josh!
Thank you for this very thoughtful and thought-provoking essay.
When working at Harvard Medical School I had regular contact with medical doctors. In conversation with one who had recently been hospitalised, he remarked about the detachment and aloofness of the attending physicians, and that it was the nurses that provided the sense of caring that was essential to his sense of actually being cared for. The experience was one of gaining self-awareness.
Since my work was in biomedical informatics, I also had intensive contact with researchers and MDs who identified as "informatics scientists." These were the days of Blackberrys and Palm Pilots, but even so there was a disappointing level of charlatanry about medical applications of technology (and among the MDs a certain distrust of the IT professionals).
The current efforts to integrate AI with medical care at the diagnostic level pose opportunities as well as potential to further separate clinicians from patients. With advancement of digital medical records, the 'chart' may well be replaced by an AI generated profile that aggregates and integrates a plethora of information about the patient (such as home/work location, environmental conditions in such places, geospatially encoded epidemiological information, etc.), still missing the obvious signs that only come into focus during personal contact. And wouldn't insurers and government agencies covet such information as well?
Interesting points, John -- thanks. It is indeed tantalizing to think that AI could cure cancer. And perhaps there is some utility in aiding diagnosis. But early AI seems to have been so prone to error and outright fabrication that I hope those systems are thoroughly vetted before being widely used.
The importance of an accurate medical history hasn't waned, and no physician can know what remains undisclosed. Danielle Ofri has written about "hand on the doorknob" moments when a patient is just about to leave and suddenly reveals something essential about their social history or living situation, or even about their medical history, that they've been hiding up until then. I-it systems don't much care whether that history gets shared or not -- they keep functioning on autopilot regardless. But a good doctor really does care about building trust, so that patterns of denial or secrecy can be broken.
I always find Gavin Francis very humane in the way he discusses medicine and his life as a GP. https://www.gavinfrancis.com/
Thank you, Jeffrey!
Thank you for this thought-provoking article. The world of palliative and end-of-life care is a useful space for exploring the humanity of healthcare, not least because it has to come up honestly against the ‘failure’ of medicine to cure death and embrace the intimate, profound realities of mortality. Debates about the Assisted Dying Bill here, demonstrate the need for human judgement and compassion to be at the very heart of decision making at end of life.
From a UK perspective, I enjoyed Rachel Clarke’s Dear Life, in which she interweaves clinical examples with reflections about her father (also a medic) and his terminal illness. While slightly less personal, Kathryn Mannix’s With the End in Mind is also a powerful reminder of the importance of the I-thou relationship in the process of dying. And I need to get round to reading neurosurgeon’s And Finally…at some point.
As an aside, I’d like to know if there are many published narratives from healthcare professionals who come from less privileged backgrounds than these…
Thanks for the suggestions. I'm not at all familiar with books by UK physicians (although I did enjoy Henry Marsh's "Do No Harm").
Danielle Ofri and Damon Tweedy are two American physicians who grew up with less privilege. I'll have to think more on it.
Perhaps you are familiar with Margaret Edson's play "Wit," also adapted for film with Emma Thompson? I know of no finer commentary on health, illness, and the language used in health care than Edson's play.
Yes, meant Henry Marsh’s And Finally - missed out his name! Thanks for the other recommendations
From a practioner perspective, it can be challenging to enjoy the patient-doctor relationship when patients come in with AI recommendations and specific demands. It is frustrating to have patients watch TV and listen to various pharma ads and Dr Google and come expecting a quick fix. As patients, many of us cannot accept our own histological time frame for healing because health has been idealized with instant gratification.
My patient today wasn't loving my prescription of posture exercises, dynamic stretches and icing along with resting from tennis and switching to biking for 7-10 days--but prednisone did the trick of taking his pain away so he could continue with tennis. That was prescribed over an email! I have advised him through his knee, hip, and shoulder replacements, but my advice regarding his back pain wasn't good enough.
My attempts to discuss hydration and protein intake with patients is not razzle-dazzle despite the #1 side-effect of many of the 18 drugs my patients are on is dehydration. Discussing intake of sugar or processed food is definitely not the cause of their acid reflux and they read on the internet gallbladders are not needed... so the I-it relationship can be just as difficult from the practioner perspective.
I agree that when the human side of medicine is highlighted, trust grows. I read a lot of medical writing, unfortunately my understanding is that many books written by doctors that are on the shelves are only published if the book includes some sort of fad diet plan versus just presenting the science. I believe this may also contribute to the distrust and idea that there is one "right" answer.
Our healthcare system and attitude around what health actually means to each individual all needs an overhaul. I do agree that returning to medical practice as an art and humanizing care is part of that. There are practioners out there doing their best to do that in a "sick care" system, but as consumers of health, we may need to understand there is an art and patience to healing as well.
Excellent points about the patient's responsibility to bring an "I-thou" perspective to the relationship, too. I feel the burden rests more on the doctor, since the patient comes to that relationship vulnerable and often afraid (it's not the patient's job to care about the doctor's holistic wellbeing in necessarily the same way, given the power differential), but you're right that healing requires patience and that no one can expect good results if they don't show respect for actual expertise.
I remember how silly the "wellness" plans promoted by my former employer seemed to me. You could earn insurance discounts or other one-off rewards by completing hydration or exercise or diet challenges. But these would typically run for 2-4 weeks and never recur. Presumably the thinking was that someone would see benefits and then continue on their own, but it was a very transactional mentality. I asked once if I could get a similar credit for uploading my Garmin data to show annual running and cycling mileage and got a blank stare.
It doesn't help that the U.S. food system creates a home-to-hospital pipeline. It takes a lot of energy and education to make healthy choices in the grocery store and more $ than a lot of people have to buy locally at farmers markets. Most people know, I think, that food is a form of medicine, but because the deck is stacked and bad cultural habits are baked in, that is a hard tide to turn.
I understand in an emergency, the patient is not caring about the doctor. How different our ERs would be if patients (non,emergent) were given lemon balm tea! Although, I suggest bone broth and apple cider vinegar and some patients think I'm out of my mind -- again because we are conditioned to believe that natural remedies are not adequate.
I love that my patients care about my well-being, I had a patient text me about her Orioles returning today. I realize I am possibly in a different setting as a PT, but I think it is important to have a symbiotic relationship in healthcare. And if it were easier for more professionals to be able to choose independent practice and spend more time with patients, I think they would. As patients, we should have a healthcare team who really care for us and know us. In return, we should care that they are not overworked and able to actually be a caregiver.
As consumers, we need to demand more of the system by not hastily choosing telehealth, pharmaceutical remedies, and emergent care clinics over proficient professionals at all levels who consider us as an individual. I believe what you are suggesting with writing in an I-thou method can positively influence the system and encourage patients to seek out more compasionate medical care.
Agree on all counts!
I so agree that AI diagnosis and treatment creates the I-it relationship. And it feels awful to receive.
At my most recent surgery, I was on a gurney, waiting while everyone (about ten people) bustled around the room, setting up trays of equipment, setting up the anesthesia, attaching multiple machines etc, and I was about as visible as a stuffed animal would be on that gurney.
Until something magical happened. A tall man, with large warm hands, came and sat took my left hand in both of his. His voice deep and resonant, as he said, I’m going to be monitoring your nerves during this entire operation, start to finish, and I promise I’ll take good care of you. It’s my only job in this OR, and I’m good at what I do. He looked me right in the eyes, and smiled (I could tell because his eyes crinkled above his mask.
This human interaction was SO important to me, as the doctors were operating on my cervical spine, and it’s a high risk area to remove bone.
I tried to find his name to thank him for his humanity, but I was unable to track him down.
A lovely moment to share. And it took almost no time at all.
Thank you for sharing The Nettle Witch Josh! And I definitely second that Bess Stillman is an astoundingly good writer.
Regarding what Foucault said, I wonder if the cadaverizing the body is more about how we learn to see a body as it's separate parts rather than the connections through that process.
I think that time pressure really pushes us toward I-it relationships and giving doctors and other health professionals autonomy over their time again could make a huge difference in developing relationships that facilitate healing.
People are starting to use ChatGPT as their therapist. Given the expense of healthcare, I suspect using it as one's doctor isn't far off. I understand the desire too and that current interactions with the healthcare system often don't feel much different than interacting with a robot. I think it neglects the many factors like relationship and placebo that are intimately involved in healing, but for which we can't (or at least don't yet) understand the mechanism.
I always have too much to say when I read your work! :)
I could take a deeper dive into Foucault. He was mining clinical treatises by Xavier Bichat and others who had a truly utopian view of clinical medicine that enabled a God complex. When the taboo on autopsy was lifted in France, and physicians from America had to travel to Europe to study anatomy in the cutting edge way (no pun intended), there was so much focus on what to learn from the corpse that the emphasis on humanity really fell away. So it wasn't cadaverizing the body in Foucault's thinking, it was cadaverizing life, the living, breathing patient, that defined the clinical gaze.
I can't imagine using ChatGPT as my doctor. I have a really good doctor, but there is a lot she's not qualified to talk about, and at age 50 I feel like there are holistic dimensions of my health that I'd like to explore but don't have a lot of guidance about. Maybe vitamins and other supplements would be good, but which ones? Do I need the complex blood work that I hear some friends talk about (not even sure what those tests are called, but there seem to be alternative practitioners that offer them)? Lots of questions.
I have at least resolved to stop using the drop-in clinics unless absolutely necessary, as the quality of care seems lower, overprescription seems higher, and less is covered by insurance.
Foucault was sullied by association for me by a really dumb class in grad school :) But I think a deeper dive would be interesting. I was wondering if that breaking things down into parts is sort of the means to cadaverizing life. That's what interests me so much about indigenous science and traditional ecological knowledge was how did they learn so much by observing the whole carefully within its environment.
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Yeah, I think a lot of people soured on Foucault in grad school. His "Birth of the Clinic" is marvelous, however. First-class research and (in my opinion) eminently readable.
Here's a sample paragraph from my dissertation, where I use Foucault to examine Roger Chillingworth in "The Scarlet Letter." Few remember Chillingworth from that novel, but he is a curious blend of medical traditions (herbalism from his Native American captivity, alchemy, and clinical science) and reflects how deeply distrusted scientific physicians were in the 19th century:
"As both a man of science and a learned physician, Chillingworth often exhibits characteristics more typical of the nineteenth century than the seventeenth-century setting of the romance. Most specifically, he resembles the hundreds of American physicians, including Oliver Wendell Holmes, who studied in Paris between 1820 and 1860, “return[ing] as devoted disciples of the new clinical methods” (Browner 141). One of these methods was clinical observation, which Michel Foucault describes as “the Gaze that envelops, caresses, details, atomizes the most individual flesh[,] […] that fixed, attentive, rather dilated gaze which, from the height of death, has already condemned life” (171). From his appearance at the scaffold in the opening scenes to the close of the romance, Chillingworth fixes his eye on those around him with just this sort of penetrating and attentive gaze."
A comment over at Inner Life made me think that I ought to retool my series to focus more explicitly on medical humanities. There are a lot of Substacks on medicine, lots of Substacks on literature, not many (any?) that explicitly focus on writing by or about doctors (or illness narratives, specifically). Perhaps that's the Ikigai I've been looking for.
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Nice essay, thanks for sharing. I couldn't agree more that caregivers (of all sorts) need more engagement with beauty, understanding & reflection. Your piece reminds me of Katy Bowler's journey as well: https://katebowler.com/books/everything-happens-for-a-reason-and-other-lies-ive-loved/
Thanks for the suggestion, Jim! The medical humanities had a nice run and I expect will still survive at institutions with adequate funding. The purpose of Narrative Medicine is to cultivate just what you describe: a broader imagination for caregivers. As is the case with many other things, the value of humanities education in medicine will likely need to be understood, at least for a time, by its absence.
Thanks for this thoughtful essay, Joshua. I’ve been thinking a lot about AI lately, as it’s being used in design and academia. Why? What’s the appeal? My first thought was the cult of perfection. I can feel all sorts of ideas bubbling up. Signing off now to go journal. We’ll see what emerges.
Ah, I hadn't thought about design, but that makes sense. Are homes now being designed by AI? I guess they must be. I'd love to hear more about that.
It's early days yet. This firm uses it a lot to, as they say, "ideate." Which, if you ask me, is the most fun part of being an architect. I'm def not in a hurry to give that away to a machine. https://www.mvrdv.com/
Joshua, your reference one of my favorite books and I love this essay. You’re absolutely spot on with the reflection on how we are moving to. I-it relationship relationships, and the damage that this causes. Truly, we do need to move toward I-thou relationships. Humanity requires it.