A Machine?

I wrote this reflection piece for an assignment in my Medical Student Leadership Group course, in response to a prompt about how the biomedical concept of "the body as a machine" impacts encounters between doctors and patients. I think there are aspects of it that I never want to forget I felt, so I wanted to include it here...

When my brain wears its “physician-in-training” hat, the phrase “body as a machine” is steel-cold: impersonal, robotic, non-humanistic – that is, everything I have strived to avoid in my patient interactions to date, and will forever strive to avoid in caring for patients in the future. When my brain wears its “cycling coach” hat, “body as a machine” means something entirely different: efficient, coordinated, empowered. I’ve appreciated this discrepancy/duality for some time now – for as long as I’ve been a cycling coach (and specifically, deliberately use the “machine” metaphor with my clients/students), I’ve also been on my road to medicine – and always been mindful of the avoidance of all the things associated with the first interpretation I described. The discrepancy never bothered me, however, until right now.

When I coach athletes to envision their “body as a machine” – that is, for those who find the approach effective – the comfort and confidence of being an entity that is deliberately designed to achieve is indeed empowering. That makes sense… for healthy people. The concept of a machine with parts that break – that need a “service call” to repair the specific broken component, which is sufficient to send the machine back out into the world on its way – strikes me as dehumanizing once health is removed from the equation. Healthy people can make the choice to envision their bodies as though an objective third-person for purposes of mental clarity; when people are sick and seek care from – in many cases – a stranger, objectification is an entirely different act.

I am mindful of how many times my clinical research patients, friends, or family have told me about physicians who “didn’t try to get to know (them) as people” – of the bad tastes in their mouth, the therapeutic distrust. I am mindful of my own personal experiences as a patient – what it felt like to know that I was conceptualized as a “review of systems” list, a set of imaging/procedure results. “Body as a machine” could not be less empowering a construct.

I remember my initial exposure to objectification from the “inside.” I had just made the transition from forensic psychology (my former world, before deciding to go back to school for my pre-med pre-requisites), and had landed my first legit “medical gig” as a clinical research coordinator in gastroenterology. My chief project was the development of a big bio-repository to support genomic/proteomic research in Inflammatory Bowel Disease – and I was in a prime location to recruit patients for it, but for the fact that my center was the go-to place for IBD in the area – meaning that many of the patients seen there were coming from all over, paying out-of-pocket, and thus of a relatively homogeneous socioeconomic class. My PI and I decided that it would be fantastic if I could also recruit at the weekly clinic where the GI Fellows saw low-income patients (general GI complaints, mostly – but it was worth a shot!). I stationed myself in the room where the fellows hung out between patients, and presented to the attending physician preceptors. I had never been in a room with so many doctors before. I was BEYOND intimidated – and BEYOND fascinated. The idea of doctors teaching doctors…. and being able to hear it all (and scribble notes furiously on, on the notepad I kept in the side pocket of my *gasp* white coat) – why, I thought it was the best thing to ever happen in the world.

Except when it wasn’t. Each Friday, I was “treated” to three hours of off-color, dismissive, and utterly offensive remarks in that “hangout room” littered throughout what was otherwise clearly thorough, diligent care. What amazed me was that so many objectifying remarks were delivered so casually – it was so ingrained into the culture.

"The Pouch in Room 5…” began one fellow. The what? This sort of thing went on, and gradually I came to learn common surgical treatments – and of how common it was to refer to people who have had to undergo them, and live with their aftermath, by shorthand names for their surgical procedures. I hated this and made a mental note to never, ever do this. My boss (my mentor) never did this, and I very much appreciated that about her.

I also remember my first exposure to the term “case” being interchangeable with “patient” – another thing I could never wrap my brain around, and hated so. “This sucks, I have 5 cases today,” I remember one attending saying in the hallway outside the endoscopy suite. I didn’t know what he meant. I thought about it for a minute or so, and I realized that he was actually referring to five PEOPLE who had to undergo an invasive procedure that scared the hell out of them, mostly under only conscious sedation (as would happen for patients without insurance a lot of the time). I was distressed. I began to hear it more frequently, and I accepted that this was “the way it was.” I never, ever used that term myself like that – I didn’t feel comfortable doing it, and might not ever. “Mrs. X’s case is complicated” was the modification I’d make, for example, which fortunately did not draw attention to my obstinacy.

Objectification also extended to stereotyping by diagnosis – a phenomenon that didn’t shock/disturb me as much as it should have at the time… until it hit close to home. My own gastroenterologist occasionally preceptored this fellows’ clinic from time to time – a very nice guy, someone with whom I had a fine therapeutic relationship as well as a very good professional relationship (compartmentalization worked well…). I was talking with him and one of the fellows in the same room where all of this craziness I’ve described all transpired. The fellow started to present the case of a woman having a flare of Irritable Bowel Syndrome. My physician, the preceptor, groaned and exclaimed: “Oh, you know those IBS patients… they just need to go home and get laid.”

Note: He treats me for IBS.

I took the experience in stride. I should have been offended, but I wasn’t. I just told myself that I would dedicate my life to never making anyone feel the way I should have felt right then. A year or so later, I shared this story with my boss – also a gastroenterologist – who, while horrified, attempted a rationalization… thinking that I would benefit from one. She offered that, during GI training, patients with certain diagnoses were overrepresented in the 3AM phone calls one would receive, etc. – and that objectification results as a coping mechanism, whether for good or bad. I acknowledged that I could see that as adaptive, sure. Was I naïve in my immediate conclusion that I would NEVER let that happen to me during my own training? If this “adaptation” is indeed adaptive – is it that much more adaptive than some other alternative I, and others, have and will develop over time?

Has “body as a machine” also evolved as an adaptation – to instill objectivity, to prevent against affective heuristics? I don’t know; maybe. I’ll certainly keep an eye out for it – trying to keep everything in context. At the end of the day, I would not be surprised if ultimately I learn to strike a balance: once I learn the specifics of the smooth, efficient “body as machine” and how to recognize when something goes awry, I might be able to cognitively process it that way – but as far as how I relate to a patient, I will be mindful of not projecting that outwards. I know too well how it hurts.