I am finishing my residency training at a large urban hospital in Boston. We sit miles away from some of the best research institutions in the world, and also amongst the most disenfranchised in the city. On many days this paradox is stifling – namely, the stark contrast between money for social services versus emerging robotic technology. I want to live in both worlds, but also recognize the status that allows me to say this in the first place. This is all a background to a phrase I uttered for the first time the other night, and my attempt to understand where it came from. In speaking to another physician, I commented “you should really consider coming to work here, there is nowhere else you will see such interesting pathology.” Part of this comment was likely parroting, as I have heard this phrase dispensed dozens of times amongst other doctors. But at the same time, saying this made me feel uneasy.
I imagined my interview with the St. Louis public schools a decade ago, and responding to their question of why I wanted to work with kids in the inner city. An analogous phrase may be “Well, I am really interested in teaching mathematics, but really I look forward to seeing the interesting pathology of the students.” Of course, this was not my motivation for becoming a teacher (I don’t believe there is such a thing as a pathological student, nor of a pathological patient), but I found this sentiment to be both hidden and widespread in medicine.
To be clear, I have heard this phrase in all medical fields. At a conference on prison health, a psychiatrist who worked in prisons for twenty years commented, “one of the advantages is the range of interesting pathology. It is amazing.” When the medical profession labels disease as interesting, what exactly are we trying to say? Moreover, what types of thinking are we excluding with such a statement? On the face of it, I think we are trying to say that it is interesting to see what is rare – the recurrent foot abscess that has been treated by every antibiotic in the book, or the additive impact of hepatitis, HIV, and alcoholism on a 40 year-old’s liver. I think we are trying to say that this is “real medicine,” that the further we move from health to disease, the more interesting it gets. We are interested in how the body fails.
I want to say that taking an interest of this sort is value neutral, but it is not. For the conditions that give rise to such interesting pathology are deeply political – the recurrent abscess born out of chronic homelessness, the diseased liver born out of years of substance abuse and poverty. To frame our work as apolitical – as interesting in virtue of its rare qualities, is to selectively ignore what is most important in healthcare, which is health. To frame what is most interesting about healthcare as biological disease is itself a rich value judgment. As an example, it is much less common to hear “Wow – that 96 year-old was so interesting. It’s amazing how she stays so healthy” than to hear about the latest biological targets for her forgetfulness.
Is it wrong to be interested in how the body fails? I hope not, as the world needs dedicated scientists and researchers. As a medical student, I asked a physiologist what they found so interesting about feedback pathways, and she remarked, “How cool is it that all this happens in the dark!” There is a place for scientific inquiry. But there is a difference between working in a lab and working in a clinic, and our language and orientation as practitioners should reflect this difference. To see the patient’s biology as interesting, and what drives ones’ work does not make it impossible to take an interest in the social causes of their disease. But it does orient clinicians to ask different types of questions, for our patients and also for us.
When I promoted my workplace as desirable in light of “interesting pathology” what I failed to mention was the challenge and reward of working for my patients, despite their pathology. What I failed to mention is that their liver disease is tragic, debilitating, and discomforting, and these are exactly the reasons I go to work. Language matters. It is telling what we as clinicians are willing to say to each other that we would not say to our patients. I’m writing this because I want to create a medical culture that questions what we label as interesting, and what that says about us. That’s an interesting conversation.
Image courtesy of Wikimedia Commons.