An Engineer in a White Coat
A medical engineering student's lasting impressions of clinical medicine.
I am not a medical student. Yet I had the privilege of spending 5 weeks in the life of one at Mt. Auburn Hospital in Cambridge, MA, as part of my Medical Engineering PhD program. It was one of the most educational and eye-opening experiences of my career - a beautifully diverse introduction to clinical care and a world removed from my usual day to day as a scientist and engineer. I've come to think about these 5 weeks as a birds-eye view of a day in the clinic. Clinical medicine is an interplay between two parallel worlds that seldom overlap. In one universe, there are humans as potential patients, going about their lives. The investment banker, the professor, the retired grandparent, the great-grandparent, the recent immigrant. In another, there is the constant churning of different hospital units and departments, the emergency room (ER), wards, surgery, clinic, GI, all referring patients to receive some care from each other, be it interventional, diagnostic, or a brief consult. The interaction of these two worlds can be seamless, but more often than not is like a spinning wheel trying to get traction on solid ground - rocky at first and hopefully steady soon thereafter. By observing this interplay first hand I have come to realize a few different points:
Healthcare is a societal contract that we are automatically part of, regardless if we wish to be or not. We can spread infections to each other, we can hurt each other, and we can care for each other. Healthcare is much more than an ER visit when sick, but rather a constant touch and go that everyone should be enrolled in to maintain good health. In this, the primary care provider (PCP) is an absolutely critical component of the system. They serve as the primary point of reference for help navigating the system (the GPS), the adviser to recommend what steps need to be taken to remain in health (the encyclopedia), the confidante who takes into account personal wishes and factors in what to recommend (the friend), and the record-keeper who guarantees continuity of care (the manager). This personal touch is vital for all other providers as well. The ER doctor needs to patiently empathize with and understand people's complaints, and the nurses need to build rapport for patients to acquiesce to all the poking and prodding. With the advent of artificial intelligence and machine learning, we are quick to point out how much of medicine can be automated using technology. What we are quick to forget, however, is the essentialness of the human touch for patients.
Healthcare is inherently fragmented. It would be simply impossible for a single individual to do everything. In this, there lies a fragility and strength. Fragility in that we are liable for errors of communication or hand-offs. Strength in that there are always others ready to step up to the plate if a provider is unable to. People like to compare the healthcare system with aviation - a world where organization and a system of procedures and checks have achieved remarkable standards of safety. Indeed, there is much to learn from aviation. However, we must be realistic; a patient's single journey in a hospital is infinitely more complicated than a flight. It is an unpredictable, constantly-changing trajectory affected by a multitude of factors. Perhaps a more apt comparison is a single flight that lasts multiple days, involves 10 rather than 3 pilots, where each of the 10 pilots are simultaneously flying 15 planes, and where every single decision is only made after consulting all 300 passengers on board.
Another element of fragmentation stems from the need to not only tailor but also contextualize care for patients. Research articles are quick to cite tools for personalized and precision medicine. This is distinct from contextualization, however, which relates to patients' desire to lead a lifestyle according to their own wants, often regardless of how healthy that is. Patients might simply enjoy the lifestyle of drinking or smoking and be unwilling to quit. Lack of willpower and health literacy can also lead to unhealthy lifestyle choices. While this can be frustrating from the pragmatism of health maintenance, we must realize the important role of psychology in our definition of "healthy". Hippocrates outlined three factors in the practice of medicine: the disease, the patient, and the physician . Providers can sometimes relegate the patient to secondary importance to the disease. Life, however, can be quite unpleasant if all pleasures are stripped from it. The point of healthcare is not to ensure we all take off and land safely, but rather that we maximize our enjoyment during flight and minimize our distress during the inevitable fall. Exposure to this element is vital to motivate and inform biomedical engineering students and researchers on the applicability of their work, beyond traditional engineering curricula . This is a world apart from the unmet medical need paragraphs we see in paper introductions or grants.
The commonality of the human condition became apparent through all the patient interactions, regardless of nationality or race. Common themes were pride and a desire to be in control. This lead to some patients being reluctant to talk to providers and distrustful of every treatment choice, mostly out of fear of the unknown and perhaps, fear of an adverse outcome or death. Interestingly, these opinions were significantly greater in those without close family and friend connections, as if feeling alone rendered one more vulnerable and therefore more fearful. Patients surrounded by family, seemingly content with life no matter how bad their health, were inevitably the ones more trusting of the care they received, more upbeat in all circumstances, and also the ones to claim "I can't wait to get out of here and go home" while simultaneously claiming "oh well, if this is the end so be it". What else would allow a wheelchair-bound 66-year-old with cerebral palsy, uncontrolled diabetes, and severe bipedal cellulitis to claim gratitude that their condition was not life-threatening? It rendered most of the complaints I've uttered in life to ring hollow in my own ears. I've learnt that to be in this position is perhaps one of the most enviable in life - to simultaneously love life and not fear death. I am not sure I'm quite there yet, but I hope that one day I will.
1. Chadwick, J. Hippocratic Writings. (Penguin Classics, 1984).
2. Karagözoglu, B. in 2013 The International Conference on Technological Advances in Electrical, Electronics and Computer Engineering (TAEECE). 430-436.