Levels of racism: a theoretic framework and a gardener's tale.

by Camara Phyllis Jones

Am J Public Health. 2000 August; 90(8): 1212–1215.

Note:This is one of the key articles on racism in health care and in our society.

Abstract: The  author  presents  a  theoretic framework for understanding racism on 3 levels: institutionalized, personally mediated, and internalized. This framework is useful  for  raising  new  hypotheses about the basis of race-associated differences in health outcomes, as well as for designing effective interventions to eliminate those differences.

She then presents an allegory about a gardener with 2 flower boxes, rich and

poor soil, and red and pink flowers. This allegory illustrates the relationship between the 3 levels of racism and may guide our thinking about how to intervene to mitigate the impacts of racism on health. It may also serve as a tool for starting  a  national  conversation  on racism.Link to Free Full Text.

Osler's Bedside Library Revisited

Osler's bedside library revisited—books for the 21st century: Personal Views

Sanjay A Pai and Roop D Gursahani. BMJ. 2005 Dec 17; 331(7530): 1482.

Free Full Text. (scroll down to page 4)

Medical education is, in many ways, incomplete. Although we are taught about the science of medicine, most medical school curriculums lack formal teaching on the humanity of medicine. Ethics, history, and philosophy are not taught formally in many schools. William Osler was one of the earliest to realise this, and in 1904 he proposed a bedside library for medical students. 

This is a thoughtful article that is worth reading.  Free Full Text. (scroll down to page 4)

Image from the BMJ article

Heartsink Patients

Heartsink" patients exasperate, defeat, and overwhelm their doctors by their behaviour. A group of such patients was followed up over five years in a general practice, and this paper describes what happened to them. As a group they were often in employment and in stable relationships, though women were over represented. Half the group were subjected to a management plan which seemed to make them less heartsink over the five year period. While heartsink patients often have serious medical problems, they are a disparate group of individuals whose only common thread seems to be the distress they cause their doctor and the practice. Heartsink as a phenomenon has features that are unique to general practice.

T. C. O'Dowd. Five years of heartsink patients in general practice. BMJ. 1988 Aug 20; 297(6647): 528–530.  Free Full Text.

[This is an important article.  We all see these patients.  Some of us groan when we see them on the daily list.  Others may look forward to the challenge.  Heartsink patients may be those who are stuck in a chaos story.  They are not questing and have not achieved restitution (see  Frank, AW.  The Wounded Storyteller).

Death is no longer just in the hands of god or fate, but often a decision

"On 30 October 2017 I had just landed at Heathrow from Melbourne. I had the strangest feeling I should not go directly to bed. I wondered if I should visit my mother, Margaret Black, a 92 year old retired anaesthetist living very independently in a warden assisted housing complex in Kent. At midday I got a call from my sister—mum had developed abdominal pain, pressed the alarm button, and phoned her GP. Could I go?

There is much discussion about the right of an individual to die, but not enough about the role of relatives and friends"  Dr. Black's essay is powerfully resonant with our lives.

Black ME. Death is no longer just in the hands of god or fate, but often a decision.  BMJ. 2018 May 22;361:k2217.

Full BMJ article

p53 and Me

Shekinah N.C. Elmore, MD

NEJM May 24, 2018

This is an extraordinary Perspective piece in the New England Journal by a young oncology resident who has the p53  mutation. This is seen in people with Li-Fraumani syndrome.

" A mutation like mine threatens to consume your whole imagination, especially with regards to the future. You start making crazy calculations..."

" Genetic knowledge is power only if both clinician and patient are equipped to move beyond a result and toward action, even if that merely means living well with what we know."

 She feels that people like her need to be studied not just for the data of their genomics but to help build programs for learning to teach people how to live with the uncertainties that their mutations will engender. 

This short essay is has many valuable teaching moments. She says, "I want as many of my days as possible to be untethered to the scans, biopsies and long waiting room sojourns. This is a cry from one who has been there for minimally disruptive medicine.

Trying to Put a Value on the Doctor-Patient Relationship

This is an important article in the NY Times Sunday Magazine (May 20, 2018).

In its push for profits, the U.S. health care system has made it difficult for patients to get personal attention from doctors. But what if hands-on medicine actually saves money — and lives?

The question of what the role of a primary-care physician should be, and how it should be valued, has perhaps never been more urgent. That figure, typically a general practitioner, family doctor or internist, is a patient’s first and often most personal connection to the rest of the health care system. But well-known corporations are betting that Americans would prefer to have health care 'delivered' by a trusted brand rather than a trusted physician."

Kim Tingley's  thoughtful piece is a "keeper' worthy of study.

Photos from a famous 1948 Life magazine article on the life of a country doctor.

Body Ritual among the Nacirema

The anthropologist Clyde Kluckhohn has pointed out that man is distinguished from other living organisms by three characteristics of human activity: the systematic making of tools; the use of abstract language; and religion. Religion is a broad term, embodying not only belief in a supernatural power but also an elaborate web of myth, theology and ritual. Most people like religion in their hearts and in their houses of worship, and they are delighted that modern science has largely emancipated them from irrational ritual and ceremony in medical habits. It is both disturbing and instructive, therefore, to learn that right in the midst of Western civilization there is a tribe of natives that practices daily elaborate rituals filled with mysterious and magical elements designed to sustain the health and well-being of the body. Another distinguished anthropologist, Horace Miner, was able to gain the confidence of these natives, and he has reported on his scientific investigations in an illuminating essay entitled, "Body Ritual among the Nacirema."

See “Miner, “Body Ritual among the Nacirema” The American Anthropologist 1956

Miner’s essay was cited in Barbara Ehrenreich’s book, Natural Causes (2018)

Dermatological PUVA Ritual

High Energy Proton Beam Ritual

Norwegian High Priestess performs Skin Screening Ritual