Why science alone cannot save medicine
The shifting of the tides struck me with fervor. I was no longer entrapped by a big, expensive training hospital in a big city. I found myself sitting on a swivel chair, before a computer, inputting data from a patient I just saw.
Stories like hers aren’t atypical: “Doc, ang dami po kasi, hindi ko na maintindihan.”
She was referring to the tumult of medications she had laid on the table. I winced at the soft, aluminum mats that encased capsules and tablets screaming different sizes and proportions.
I had to ask about the purpose of each and every tablet, because, no, doctors aren’t supposed to guess. We have to be sure.
I heard the disembodied voices of the-powers-that-be that governed training programs. There is no space for “uhms” or infinitesimal pauses that whisper doubt. Are you sure? “Yes, po, doc. I’m sure.”
“’Nay, bakit po may Clopidogrel?” I asked her, gazing at her and her companion’s eyes. They had the look of a relatively well-off family.
What they didn’t teach in medical school is this: The drug of choice cannot always be afforded by the people you’re studying for. The favorite adage of medicine in the country is simple: Serve the people. Yet most of the people cannot pay. They forgot to teach us how to be sensitive about that. The drug of choice may not always be the drug we need to choose.
My patient paused at the question, blubbering and a little hesitant.
“Para saan po ito?” I asked, waving the medicine, trying to pursue that elusive memory of the explanation I was sure her previous doctor had once told her.
She answered, I heaved a sigh and gave her a smile. She was my 40th patient that day, and I was a little worn off. The rivers of patience still rich, but a little short on the upstream gullies that supply them.
The patient smiled at me, and I teased her: “Ma’am, kayo ah, aalamin niyo para hindi tayo nanghuhula.”
She caught up with the playful tone. Maybe I managed, despite myself, not to sound too condescending. “’Yan kasi, hindi iniintindi yung sinasabi ng doktor,” her daughter admonished her. I
just grinned; she was doing the litany for me, I thought.
“Kasi, doc, naospital na siya dati.” She began to explain. Bingo.
“Bakit po?” I asked, trying not to sound too inquisitive.
“Ewan, na stroke po ’ata,” she said, shrugging off her ignorance of her mother’s condition.
I looked at Lola and she just sat, shy and a little quiet, except for that excuse she unhesitatingly told me: “Hindi ko naiintindihan.”
The examination was short and sweet, but thorough. I heard the heart and heard an irregular beat. Bingo No. 2 — that explained one drug.
I noted her faltering gait when she entered the clinic, and the neurological examination revealed weakness on the left side of the body. Stroke. Bingo No. 3. That explained another drug.
Slowly but surely, they told me snippets of information that helped me piece the puzzle of this woman’s health status. I discovered two things: She resorted to treating her diabetes with herbal medications, and she felt intimidated and scared of doctors. “Natatakot nga po ako pumunta sa inyo ngayon eh.”
A few minutes later, I endeavored to explain to her the need to start another medication, a luxury I could do more now that I was in the community.
“Mahal po ito, ma’am. Mabibili niyo po ba?” Her companion looked at her with some anxiety. “Kung kailangan po, doc, eh,” she responded.
Lola, on the other hand, was already thanking me profusely for having taken time to explain. I asked them to stop the herbal medications, citing the unnecessary expense and explaining that what we were prescribing were no less than the fruits of the greatest minds of the 21st century, thus evidence-based and worth every penny.
But, no, I didn’t phrase it that way. “Evidence-based medicine” is an alien concept in the community. They wouldn’t understand and, sounding too academic, might risk reverting them to their herbs-over-medicine ways.
As I closed my EMR, I pondered, this is perhaps how medicine could actually save lives — by simple explanation. Unless doctors put it out there, no amount of evidence can convince a patient to take this pill over herbs sold in boxes and advertised in radio commercials.
Sometimes, doctors are too stressed to take time to explain, and this matters because medicine has the tendency to become too pedantic. When put on the spot, doctors can resort to memorized allocutions lifted from textbook pathophysiology and revalida lingo.
How many patients have I failed in the hospital just because I didn’t have time to explain that magic word: evidence?
Evidence is all about disinterested facts, the medium of the truth that cherishes science as the ring bearer to health. If evidence forgets to teach trainees the social reality that dealing with patients involves not just manner and reputation-building but also the need to understand culture, politics, economics, norms and even history, including our own culture as a health profession, then medicine is no different from mainstream media: an unwitting victim of alternative facts, fake news and sensationalism made manifest by the antivaccination movement and influential quacks that people go to simply because they know something we don’t — that medicine is not just a natural science, it is also sociological.
It matters how we say the truths we have learned, and with that thought I felt a prickly pressure on my neck. I hope, now that I’m in the community, that I managed to convince this patient to add the right pill to her daily essentials, and that I didn’t sound too scholastic about it. I tried to understand where her intimidation was coming from, and as I rode the jeepney home, I realized another thing: We are all afraid of what we refuse to know. I felt that, at least, I had accompanied my patient in facing the things she didn’t want to know about her disease and her medications.
I’m still afraid she might revert to the comfort of believing the shower of ads and dubious claims on TV and radio about herbal medicines and the like. But I hope she takes her medications. I hope the visible contentment she showed me was indeed an indication that, henceforth, she would.
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JM Deblois, 28, is a family and community medicine physician in Cavite, and is planning to take up higher studies in medical anthropology/literary and cultural studies.
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