A month after school starts, first year students at Harvard Medical School are thrust into the very best medical classrooms: the patient wards. There we learn that before we understand medicine, we must first learn to uncover stories. These stories are just as powerful as exams and lab tests in addressing the patient’s health.
Take for example Mr. S, a 52-year-old Bostonian. He talked about severe, acute hip pain, a result of an infection. The pain forced him to use crutches. His skin was yellow, his face sallow.
He immediately denied having HIV/AIDS. He mentioned drugs I did not know at the time: Harvoni, for example, which evoked innocent memories of “Haribo” gummy bears instead of hepatitis medication. A bit of social history: He hadn’t held a job in years, and lived with his mom, his primary support system. I dug deeper and his story began to take shape.
Drug use: He admitted to using heroin, and had stopped only six months prior. When he started? At 19.
I asked naively, “How often did you use?”
His response: “It’s heroin, so every day.”
He described his constellation of ailments. “It was overwhelming.”
Mr. S probed the link between his hip infection and his drug use. He wondered if he should blame himself for his pain. The clinical picture gave his questions more sense: Joint infections can result from dirty needles used to inject drugs.
Mr. S was evidently struggling, medically and otherwise. He said he “got lucky” in receiving Harvoni, suggesting socioeconomic stress: He wouldn’t have been able to afford the drug if not for his insurance. His reasons for getting into heroin: His friends were doing it, he tried once, and was hooked. His unemployment and drug use were locked in a dangerous spiral.
Was his self-blame warranted? Or was his suffering the fault of his environment? How much was his poor health associated with the social forces that shaped his actions?
Mr. S’s emaciation reminded me of a patient I met some months before school while shadowing at a hospital in Manila. Mrs. L could barely speak, a stroke having impaired her speech some years before. Writhing, she gestured toward her mouth, asking for food. The physician explained that she was fasting while waiting for surgery—a total foot amputation was in order. Why? Her foot was consumed by necrosis, a complication worsened by her uncontrolled diabetes. The physician unwrapped her foot: It was black like charcoal, starved of oxygen and prey to infection.
Mrs. L never made it to the operating room. Unlike Mr. S, she was not as “lucky.”
But what killed Mrs. L? Was it truly her infection, or was it, again, a mélange of social forces? She probably was unaware of the medical urgency of advancing necrosis. She probably lived far from a clinic. She probably delayed seeking care to avoid dipping into family savings. I could only guess at her story, but figured this much: Like Mr. S, she, too, had been locked in a dangerous spiral.
One questions what a slew of life experiences both good and bad does to the human spirit. How does our biology respond, and how do we respond to our biology? How separate are “we” and “our biology”? How much are our actions—and their consequences—truly our own?
A growing body of scientific evidence studies the means in which life experiences are recorded biologically. Epigenetics analyzes changes in gene expression levels that are mediated by modifications in DNA structure but not in basic sequence. Changes in our brain wiring have been postulated as a link between lived experiences and behavior. These modifications are both inherited and acquired throughout the life of the organism and affect an individual’s biochemistry and behavior. They are a biological retelling of our stories.
Each person gathers data through experience, processes and interprets them, and shares stories. These stories are not so different from our medical stories, even those outside the medically esoteric: scars that tell of previous conflicts, elevated blood sugar levels that narrate earlier comedies, cancers that signal our genetic tragedies. The social merges with the biological.
These patients’ stories show that health is only partially in our control. We live with the consequences of both our actions and the actions the world takes on us—a unique drama that plays out on a biological stage. These social forces, tied with our inherent and individual biology, tell the story of our health.
Edward Christopher Dee, 24, a product of Xavier School and Yale University, is a first year med student at Harvard Medical School.