Francesca Heard, DTM&H February 2018
"Language is the most human intervention", Oliver Sacks wrote. He acknowledged that medicine is not simply a science of pathophysiology and diagnostics; it is also the complex interaction between art and humanity. This was reflected in his stories, often medical mysteries and conundrums only solved after delving deep into the patient's background and narrative.
This notion is easily forgotten as medical advances becomes more and more sophisticated, when ordering an investigation is easier than taking a history. But I feel that these principles are still strongly upheld within the crux of the DTM&H, when in resource poor settings, you cannot rely simply on diagnostics to complete the story.
Doctors have historically been very good at creating narratives. Some of the greatest and most thoughtful writers were physicians. More recently, Atul Gawande, a surgeon and renowned author, has formed part of the new generation of doctors as writers, championing the idea that narrative practice strengthens medicine: "For human beings, life is meaningful because it is a story. A story has a sense of a whole, and its arc is determined by the significant moments, the ones where something happens"
In its simplest form, the most obvious point where this resonated for me was during the mental health teaching, where Dr Maureen Wilkinson coached us through how to form a narrative with the patient with mental health issues. This relies on letting the patient construct their story and us understanding the importance of language. It could not apply more to the practice of psychiatry in resource limited settings. Patients with mental health diagnoses can be locked up, abused and segregated from their communities. The language surrounding these patients is often one of stigmatisation. Our role as physicians (and even as all-encompassing mental health workers depending on where we will practice) is to eliminate this negativity from the narrative and re-write it, to tell the patient's own story of who they are and where they want to be.
Historically, depictions of medical conditions in literature have helped us place them into context and analyse their social and political impact. During TB week I could not help but think of how this condition has been portrayed frequently in literature, originally described under the term 'consumption' in the 14th century owing to the extreme weight loss seen as it progresses untreated. It wasn't until the 18th and 19th century that TB, or 'consumption', was particularly romanticised in literature, with poets such as John Keats (who also was a qualified physician who turned his hand to writing) becoming the poster-boy for the disease, as seen in An Ode to a Nightingale: "The weariness, the fever, and the fret / Here, where men sit and hear each other groan".
Consumption took many lives in and out of literature. Although her illness is not named, it is widely assumed that Victor Hugo's Fantine in Les Miserables also suffered its fate. However, what is different here is that Hugo emphasises the victimisation of Fantine, the extreme poverty she was in being the principle cause of her illness. Her consumption is a consequence of social deprivation: "What is the true story of Fantine? It is the story of society's purchase of a slave. A slave purchased from poverty, hunger, cold, loneliness, defencelessness, destitution." Ultimately, society failed her in many ways and her death reflects this: "[She] was buried in the common grave of the cemetery, which is for everybody and for all, and in which the poor are lost."
For me this is one of the most pertinent issues that the DTM&H seeks to portray: poverty and social deprivation are the biggest determinants of illness for many. It is society's (and especially health care workers') responsibility to equip those in need with the tools to prevent such an occurrence. We need to let empathy and humanity strengthen our practice in order to tell the patient's story. In the words of Oliver Sacks, to come full circle: "In examining disease, we gain wisdom about anatomy and physiology and biology. In examining the person with disease, we gain wisdom about life".