The clinical and the social
Sunday, June 28 2009
I think themes for Grand Rounds is a bad idea, but Edwin Leap’s question – “What would you like to say to future physicians?” – is one I have thought about prior. So, imagine you are a graduating medical student, and I am your fabulously well-paid commencement speaker*:
Hello Class of [insert year]. Congratulations on this very special day. If you think your parents are excited for you, wait till you hear from your lenders. I don’t envy you that.
Nor do I envy you the effort you have had to expend to get here. You must be tired. I will be brief.
Your education and training puts you in the elite of knowledge-based professions. In this increasingly knowledge-driven economy, you are drawing ever closer to the peak. Your skills are invaluable to society; your expertise essential to civilized life. Without you or people like you, our society would literally fall apart. You can expect – and you will command – tremendous respect for your achievements and accomplishments thus far.
There are, however, different kinds of knowledge. You have been trained in the clinical, and nobody in their right mind will question your qualifications of clinical issues. Which isn’t to say you won’t be questioned; there’s always Jenny McCarthy, whose most valuable contribution to civilization was sucking the chrome off a trailer hitch in “BASEketball“.
But the people who come to see you: they will come because your knowledge can help them. Many of them will depend on you – their lives will depend on you – to use your knowledge to solve a problem they face. Diseases. Injuries. Disabilities. And I trust you will excel in this task.
The vast majority of problems you will see have a simple, straightforward remedy. Antibiotics for strep. A cast for a broken bone. Stitches for a deep cut. A band-aid and reassurance for a worried parent.
And the people you see – the people you help – will be tremendously grateful to you. You will have their thanks, and their respect, and no small amount of their money. (Someone will get the money, anyway – even if your share seems too small.) And they will leave the clinic and go back to their homes, to their lives, to their worlds.
For a few of your patients, your knowledge won’t be enough. You won’t know how to cure Huntington’s disease. You won’t know how to cure MS, or RA, or IBD, or any of dozens of illnesses still baffling medical science. For people with these diseases, your knowledge won’t be enough. You won’t have the knowledge necessary to send them back to their lives. Nobody does. That’s something you – and they – will have to learn to live with, for the time being. Their problems will be ongoing, and will cost these people tremendously – in money, in time, in tears, sweat, blood.
Many of them will die from their illnesses. And I am sorry you will have to be party to that. Don’t torture yourself if you didn’t know enough to save them. Just don’t stop learning.
In the meantime, the fact that their illnesses persist means they will face a myriad of additional problems. These problems are not clinical. They are beyond your training and expertise.
To take an example from my own life: shortly after I graduated from college, I was in the middle of a mild flare of my disease. I was functional, I could work, but I looked sick. And as I interviewed for jobs – I was well-qualified – it was obvious that I was sick. And nobody would hire me. Which meant I could not get health insurance. These problems affected my clinical situation – I volunteered for clinical trials, as a way to get health care – but they were not simply clinical problems.
Your patients will face stigma. They will struggle through routine, daily tasks. They will have difficulty working. They will have difficulty paying you to help them. They will face emotional stress and pain well beyond what their physical condition might suggest. Spouses and loved ones will reject and abandon them.
Many of them will face these struggles utterly alone. And they will bring their lives into your clinic. You will be sorely tempted to ignore these problems, or to minimize them, but you should not.
You are right to think that these are not “your problems”, because they are not clinical problems. They are not the problems you have been trained to address. We might call them instead “social problems” – to capture in a broad stroke what is economic, emotional, relational, and political about being ill. Disease may be a clinical problem at root, but illness in full bloom is very much a social problem.
Just as there is clinical knowledge – and you are its vanguard – so there is social knowledge. Many of you – thank God – have an aptitude for social knowledge, but you are not experts. In fact, precious few people are. Most of your patients – the ones who need your help the most – will not have access to anyone will the sort of social-knowledge expertise that might help them.
So they will face a host of problems for which there is no “doctor”. And some of these social problems will be more pernicious than disease itself. Some of these problems will be every bit as disabling as their diagnosis.
As experts in clinical knowledge, you are taught to narrow problems down to a single point. It’s not enough to treat every skin problem the same, nor every skin cancer the same. You instead narrow the problem down to a single point – basal cell carcinoma, perhaps – and that is the problem you solve. Yes, I am oversimplifying – but a great many of the problems you have been trained to solve are like this.
Social problems are not like this. They do not exist at a single point. They are often vast and nebulous, in defiance of any attempt to narrow or simplify them. They are often “wicked”, in the technical sense – you think you’re solving one problem, and create three others.
I am not saying you should shy away from these problems. I am warning you: they are much tougher than anything you are trained for. I want you to be engaged and interested in how your patients live outside the clinic, but if you think you have found a simple, single solution to their problems, you are wrong. You are applying clinical knowledge to social problems, and at best you will not help your patients. At worst, you will harm them, perhaps grievously.
(And by the way, you will never be sued or punished for this sort of mistake , as you might be for clinical mistakes. There are doctors who destroy their patients with clinical solutions to social problems, without ever realizing what they are doing. I have survived two of them myself.)
To offer a possibly controversial example on a large scale: we are in the midst of a debate over health care reform, with physicians tending towards either pole. On on side, there are physicians who vehemently insist that the market is the solution to our health care problems, as if “the market” were a pill dispensed by your local economist that we could all take. On the other side, there are physicians who vociferously push for a single-payer overhaul – as if we could simply anaesthetize our health-care system, wheel it into the OR, and emerge a few hours later with single-payer. This is clinical thinking, applied to social problems.
Neither one has much chance of working, at least not in the ways their physician supporters expect. It takes social knowledge to appreciate that fact.
But even if you don’t know much about social problems, you can always learn. There are ways to train people to be experts in social knowledge. You have likely received minimal, if any, training in the social problems surrounding disease, and for that I am sorry. I wish it were otherwise, but perhaps the clinical was already demanding enough.
In all likelihood, you will learn most of your social knowledge on your own. One of your best resources – apart from here and now – is, of course, your patients. Listen to them. Talk to them. Ask them about their lives. Ask them how you can help. As you learn, do not be too quick to arrive at your conclusions.
Whatever else you do, please do not assume that your expertise lends itself to social knowledge. When you step through the clinic doors into the realm of the social, you have just as much to learn as the rest of us. You are just as unqualified as anyone else.
Rest assured: you can spend your entire career in ignorance of the social problems your patients face, and still be a very fine doctor by the standards of your field. You may choose to ignore those problems and focus exclusively on clinical problems – and many of you probably will. But if you are among them, for Pete’s sake, don’t pretend you are doing anything more.
A few of you will attempt to balance social and clinical knowledge, and your reputation as a clinician will likely suffer. But the payoff is this: if you succeed, if you come to appreciate the social problems patients face even half as much as you understand their clinical problems, you will have the ability to help millions of people. It goes without saying that you will not see most of these people in your clinic, but your knowledge will have tremendous potential to transform their lives for the better – in fact, to transform society for the better.
In either case, you first must learn to recognize the difference between the clinical and social. If you cannot do that, you might well be a help to your patients, but you will never – never – be the help they need.
Again, congratulations – and good luck.
*Attention medical schools: it is in fact possible for you to live out this fantasy, and my definition of “fabulously well-paid” is really quite modest. Email me.
Thank you for this post Duncan.
found you via Edwin…nice post about the complexity of patient care. As a nurse, I’ve been struggling with the dilemna of balancing the science of my job and the “laying on of hands” part. In this scientific world, the first seems like it’s trumping the second. The whole is more than a sum of its parts defintely applies here.
Thanks for the insight.