It was only as he leant forward that I could see the scoliosis the left ribs humped slightly higher than the right with a familiar twist. But in standing there was not a great deal to see. Some stretch marks to the skin on the left. I’d seen this young chap before. Now mid twenties. Not recognising him I dived deep into his history. Which is where things got interesting. He had back pain. Plus infrequent but severe right scapula pain. His lifestyle other than smoking (which he had stopped recently) and poor diet (as he never puts on weight) was relatively good. He played football once a week. He slept well. I saw him with his mother. She seemed the more concerned out of the two. I delved a bit deeper. This had been a problem awhile I started asking about if they had previous consultant opinion. They had. The mum took over at this point. It had been a very negative experience. They were told he would be in a wheelchair in his 30’s and the only thing that could be done was insert metal rods but they didn’t want to do that yet as it didn’t always help. Said what?!?! Any other input I asked. No. They were discharged to the GP. I was still in shock. Here he is now abandoned on the scrapheap. ‘No Man’s Land’.
This is the 2nd part in a series of blogs looking to expound on my CauseHealth talk in Nottingham entitled ‘Anecdote the Antidote’. The ability to navigate a case appears key to good healthcare. To make a case that anecdote or case study is integral to good healthcare we need to start with humans. What are they like? They are after all the recipients and often givers of healthcare. So, are humans objects or are they subjects?
Objects have mass, physical attributes, tangible quantity. Subjects on the other hand have no mass, abstract attributes and intangible quality.
Objects tend to be easier to measure, more consistent in their dispositions (think of the boiling point of water), therefore more predictable and more linear. It’s tangibility lends itself to realism (a philosophical view that things are real regardless of our minds). Examples of measuring objects include height, weight, speed. Subjects on the other hand are messy, less consistent in their dispositions (think of pain threshold), therefore less predictable and non-linear. Their intangibility lends itself to idealism (a philosophical view that things are constructed in the mind). Examples of subjects include pain, placebo, thought, emotion, efficacy.
Realism asserts that at least some aspect of our being, knowing (world) is independent from subjective perception, belief (us). It is real. However this need not be a dualistic rejection of the subjective, mind, thought, belief in favour of substance and matter (physicalism). More that the mind corresponds well to reality. This is opposed to idealism, global (metaphysical) scepticism or solipsism which denies mind independent (objective) existence. Or at least any view that does not pass the mind first. It is not brain bound. This is a reduction from a realist approach that our brain biology is of prime importance. More that it is mind centric. At the mercy of our representation of things. Unable to shake ensuing uncertainty. My blog has always highlighted the potential dangers of a version of realism that sees humans primarily as objects (robots!). But neither is it idealist, sceptical of our senses. It is important to realise that if we want to hold onto realism (which I personally do!) it is not at the expense of subjectivity.
So what is here for healthcare? Adam Meakins latest blog critiques medicine that approaches people like a car mechanic. Just an object that needs fixing. An alternator adjustment. A cam belt needing replacement. To follow this metaphor is to treat the person as an object. As a scoliosis. A pathology. In the traditional medical model this has been the norm. The person viewed as a body. A complex machine. To investigate. Control. Conquer. We are starting to understand the importance of the subject. The thoughts, beliefs, emotions of the individual.
The case identifies that my previous consultation had not identified significant information about him, his family and their relationship with his condition and previous healthcare experience. This has helped shape his ongoing management with plenty of reassurance. It has helped me see the human not the body. How often do we see people like this? On the scrapheap. It is not unusual for people to be left like this in the healthcare system. It is not unusual to hear people liken themselves to horse that needs to be put down. It is not unusual for descriptions to include “falling apart” and “old age and poverty”. I’m starting to feel like Tom Jones.
As a physiotherapist I am used to building up someones body (object). But what about building up people subjectively. As we know that objective degeneration is rarely the only problem. Maybe this reverses for the psychologist who is happy to build up the subject but less the object? I am interested in the ‘No Mans Land’ of healthcare. Where evidence falls. In rehabilitation we are rarely changing objective radiology bone structure, rotator cuff tendon appearance, bone density. Complex conditions often inhibit progress. So what do we do with the swathes of people here. Do we just leave them as there is no evidence? That doesn’t seem very caring. But do we then do we open up to allowing anything including false promise? A new way needs to be forged.
So are humans objects or subjects?! How do we get people off the scrapheap?? Is the scrapheap objective or subjective?! And why should we even care it makes my head hurt?! My next blog in this series will hopefully start to unpack this some more!
Be more human. Be less robot.
Thanks for reading this far.
My slides from the CauseHealthPT talk are available here: