The Mother of the Beast

heart bookshelf and EKG

Editor’s Note: This post is one of two pieces on the Introduction to Social Medicine and Global Health course at Harvard Medical School. Read the other piece here.

By: Benjamin Oldfield, MD, a fourth-year resident in the urban health-focused combined internal medicine-pediatrics residency program at Johns Hopkins Hospital

When asked about my medical school experience, I like to map my memories onto the arc of an epic poem. Both are lengthy, traversing vast ground, formative—the allegory seems to fit. First-year began in medias res, in the middle of things, as epics tend to do. Like the horrific storm at the beginning of Vergil’s Aeneid, a tumultuous splash of cadaveric parenchyma saturated my first months at Harvard Medical School.

The trials and tribulations mounted from there. Often, epic heroes find themselves faced with challenges they never expected, for which they don’t feel equipped. Consider Beowulf. The hero, after destroying Grendel, next must defeat Grendel’s mother in a battle at the bottom of a lake. There, Beowulf’s armor and sword initially present more of a burden than an advantage. The metal weighs him down. Again, the medical training–epic poem allegory holds. If poor health was the beast we as medical students were training to fight, we had to ask ourselves about the underlying determinants of disease. That is, what is the mother of disease? And what skills do we need to combat her? Questions like these left this neophyte submerged and sinking in a sea of signaling pathways and amino acid structures.

My first patient encounter involved a man who had schizophrenia and presented to various emergency departments with regularity. I asked myself why he didn’t have an identifiable outpatient plan. Then, after an experience in the pediatric emergency department, I wondered why care providers had differing attitudes towards analgesic management when treating children with cancer versus children with sickle-cell anemia.

Trying to make sense of these and other conflicts and shortcomings in our health care system broadened my horizons at the same time that it turned my attention inward. I pondered why the majority of my colleagues looked forward to careers as specialists when the deficit of primary care physicians was clear. Deeper yet, I wondered what inherent biases I would bring to my future practice.

Poverty, racism, social determinants of health, our incentives and biases as physicians—these constitute the figurative mother of the beast. Yet, traditional medical training offers few tools to tackle these drivers of disease. The Introduction to Social Medicine and Global Health course that Kasper and her colleagues describe in their recent Academic Medicine article, however, became my guide in this fight. In small-group tutorials, we worked through cases that took us to faraway lands to wrestle with foreign health care systems (How does the Peruvian system reach, and not reach, isolated villages in its poorest areas?), discussed the utility of community health workers in urban America (focusing on our backyard in Boston), and learned about the historical context for our professional sovereignty as physicians (in all its controversy). More than an introduction to population health, the course wove in the social sciences and the humanities to help us understand that diseases had social meanings and generated social responses—all of which had clinical import for our patients-to-be.

These conversations about the social determinants of health led me to Chiapas, Mexico’s southernmost state, to pilot telephone-based decision-support tools among community health workers. They’ve emboldened me to question why low-wage employees at the hospital where I’m now a house officer rely on government assistance programs—like Medicaid and food stamps—for their basic needs, despite their connection to a world-class health care institution.

You’ve probably gathered that I appreciate stories and works of literature. In fact, I co-direct with Lauren Small, adjunct professor of English and creative writing at the University of Maryland, a narrative medicine reading group at my hospital. There, stories and art form a fulcrum for a diverse group of staff to weigh the challenges of our daily practices and to find common ground. We recently read the Bertolt Brecht poem, “A Worker’s Speech to a Doctor,” which was first introduced to me in an Introduction to Social Medicine and Global Health session. After linking poor living conditions, specifically a lack of warmth, to his disease state, Brecht’s narrator asks his physician, “Where does the damp come from?” My reading group discussed the conspicuous absence of the doctor’s response and pondered how to respond to a modern-day incarnation of Brecht’s speaker. The stories behind the illnesses of our patients—systematic racism, structural violence, hidden incentives for providers and payers—form the underwater creature that drives much of the distribution and severity of their pathology. Some physicians may choose not to face that creature or to contend that she represents a fight best left for other professions. Introduction to Social Medicine and Global Health helped me to identify that creature, framed the skillset I need to combat her, and issued a call to action for change that continues to motivate me today.

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