Soc

Someone from AA asked me to help teach his class. More specifically, he asked me to lead a session of his intro to sociology class devoted to health care. He is trying to get his kids to consider societies various institutions from a perspective of inequality. Health care and inequality is big topic and he has given me a lot of latitude in what to present. But as interested as I am in how inequality manifests itself in health care and how health care succeeds or fails in addressing these, I find that I am far more interested in considering the broader question: what is health care? Is it really an institution? What is health? What is a health care provider? With respect to our bodies, aren't we all health care providers? This is a bit slippery, I guess. But perhaps the class and I will get at how, as an institution, health care is different than, say, the auto industry, or the restaurant industry. In a sense, even if we don't go to a clinic or a hospital, or buy vitamins or medications, we all engage in health care. The final outcome isn't a car or a meal, it's us; how long and how well we live. In the end, whether we are paid or unpaid practitioners, that's what we are engaged in: trying to help each other live better and longer.

One of the incredibly illuminating and often frustrating aspects of working in health care is encountering differing belief systems around health. They teach you about this in medical school, and most students were probably something like me, shrugging the topic off and preferring to focus on what I considered to be the meat of medicine: physiology, pharmacology, immunology, etc, etc. And I was, and still am, a pretty progressive, open-minded and patient guy--I like to think. And also a vegetarian, so maybe my meat analogy isn't terribly apt. Anyway, a problem arises when the person across from the table has vastly different tastes, if you will. There are plenty of people out there who do not believe in physiology and pharmacology and immunology. They don't know what they are, and possessing a worldview that works perfectly well for them, have little interest in learning about or working within a system that requires them to accept a mysterious and foreign set of principles. Obviously, this doesn't apply to everyone. Some people, like the perfect little patients on Gray's Anatomy are only to happy to put their full faith in every word that issues forth from MD's mouth. But there are plenty that do not, and there are those that say they do when treatment strategies are discussed, but when the doctor is gone, go and do their own thing. And then there are those who are half in and half out. One of my favorite examples of this is my patient, Martin. I have been seeing Martin for osteoarthritis and chronic pain related to a horrendous injury he suffered years ago, along with hypertension, and a positive TB test that required prophylactic antibiotics. It was very difficult to get him to take medication for the blood pressure though he readily accepted pain medication. Pain is right there in his face and it is clear to him that certain medications do a good job at helping with that. Blood pressure is something else entirely. When we first started working together, we didn't talk a lot about what he thought. I prescribed, he accepted. How often he took the medicine is uncertain. Sometimes his blood pressure was great and other times it wasn't. Finally, wondering if and when he was actually taking it, I asked him: do you believe in high blood pressure? "Yeah, doc. I believe in it?" I asked him why he believed in it. He answered because his mom had it and she had heart problems. So then comes the money question: do you think that you have it? "No. Not really." Why? "Because I feel normal. I don't feel like there is anything wrong." We had been over the whole silent killer thing before, and I think in his particular case, the obstacle is as much denial as it is an alternate belief system. Medicine is wonderful that way. Not only are many people predisposed not to believe in things like cancer you can't see and blockages in vessel deep within their bodies, they don't want to believe in that stuff either. There are plenty of times, like when I am sitting down to dinner, that I don't either. Though I have no real proof either way, I suspect that Martin took the anti-hypertensives and antibiotics (I hope) in order to placate the doctor so he could continue to get the pain medications. Clinical relationships are often about compromise. A more interesting and controversial question would be: "If you don't think that you have high blood pressure, what do you think we are doing when we take those readings off the dial and write them down? Are we screwing up the measurement? Or is it all just a scam designed to make us and the drug companies money?" I think I did ask him that once and he chuckled and deflected and moved onto another topic.

I remember a much sadder case of denial. I was asked to come visit the sister of a patient I had already been seeing for a few months. She stayed in a room just off of the living room, though no one had mentioned her to me and I was not even aware of her existence. Her name was Debra. As soon as I met her, it was plain to me that she was dying. The medical word for her appearance is cachexia. She was wasting away, not simply skinny but weak. Several months prior she had been walking around the house. Now was unable to stand, barely able to lift her torso off of the bed. The family had hired a caretaker, because she needed one, but did not look further into what might be causing such a rapid decline. A little questioning revealed that she had been diagnosed with lung cancer two years prior. According to Debra and her daughter, the specialists had cured the cancer and there was no need to go back. After a few phone calls and faxes to her oncologist, I learned that at the time of diagnosis, the cancer was already in her brain. They gave her radiation, but she did not like the way it made her feel so missed a lot of appointments, and ultimately decided not to return. The doctor may have said that he could no longer see the cancer on imaging studies, or perhaps he even used the word remission. They had grabbed onto this life raft and turned it into a cure. But now after nearly two years, after she had grown ,sicker and sicker, when I asked her daughter if she thought that the cancer might have come back, I received a steadfast "No." They had taken good care of her and provided her with a good diet. She no longer smoked. There were no negative influences in her life so there was no reason for the cancer to have returned. Cause and effect. Game and match. It's the big question that people in medicine are perhaps the most ill-equipped to answer: why? Not how. How is complicated and in times of crisis goes way past everyone; and to those in the grip of disease, often irrelevant. Why? Why me? Where in my life did I go wrong? What did I do to deserve this?