Immediately before the release of DSM-5, a group of psychiatric thought leaders published the results of field tests of DSM-5 diagnostic criteria. They characterized the interrater reliability for diagnosing major depressive disorder by two trained mental health practitioners as of “questionable agreement.” These field tests confirmed an open secret among psychiatrists that our current diagnostic criteria for diagnosing major depressive disorder are unreliable and neglect essential experiences of persons in depressive episodes. Alternative diagnostic criteria exist, but psychiatrists rarely encounter them, (...) forestalling the discipline’s epistemological crisis. In Alsadair MacIntyre’s classic essay, such crises occur in science when a person encounters a rival schemata that is incompatible with their current schemata and subsequently constructs a narrative that allows them to reconstruct their own tradition. In search of rival schemata that are in conversation with their own tradition, psychiatric practitioners can utilize alternative diagnostic criteria like the Cultural Formulation Interview, embrace an epistemologically humble psychiatry, and attend to the narrative experience of a person experiencing a depressive episode. (shrink)

On the centenary of Max Weber’s “Science as a Vocation,” his essay still performs interpretative work. In it, Weber argues that the vocation of a scientist is to produce specialized, rationalized knowledge that will be superseded. Weber says this vocation is a rationalized version of the Protestant conception of calling or vocation, tragically disenchanting the world and leaving the idea of calling as a worthless remains. A similar trajectory can be seen in the physician William Osler’s writings, especially his essay (...) “Internal Medicine as a Vocation,” in which the calling of a physician is described as both rational and noble. While Osler’s conception of the physician’s vocation has been formative for contemporary medicine, physicians are reporting burnout and leaving medical practice at escalating rates. As physicians abandon their noble vocations, an alternative conception of a physician’s vocation is needed. From the worthless remains of the physician’s rational and noble vocation, the labor of a physician can find grounding in humility. (shrink)

Martial metaphors shape the practice of medicine. Bioethicists who disagree participate in culture wars; public health officials who advocate declare wars on cancer and drugs; surgeons who operate map theaters and fields; physicians who enter graduate training become housestaff officers; nurses who act clinically follow doctor's orders; patients who become ill wage battles against disease. But when we figure medicine as warfare, clinicians become either dutiful combatants or conscientious objectors. Clinicians who serve the mission of medicine are described as loyal, (...) while those who abstain are characterized as disloyal. Disagreement is figured as treason and is punishable by exit from the... (shrink)

ABSTRACT:The relationship between equality and equity has been theorized and described in many ways. Recently, this relationship has been popularly illustrated via a meme depicting three people watching a baseball game while standing on boxes. The meme's analogy, that achieving health equity is the ability to view a spectator sport, is a neoliberal account of health. The analogy defines equality at the expense of equity, characterizes health as individualistic, describes health equity as a static outcome, and implies that the bioethical (...) questions for achieving health equity are about the distribution and redistribution of resources. As the SARS CoV-2 pandemic vividly reminded us, health equity is no spectator sport. Health equity is the intentional removal of obstacles to health and the enabling of human flourishing to assure that everyone has fair and just opportunities for health. That relational and radical account of health equity requires different analogies. This article reimagines and re-illustrates the relationship between equality and equity using an organic analogy of three plants. The analogy calls for bioethics to nurture communal relationships and engage community leaders in pursuit of communal flourishing. (shrink)

Abraham Verghese proposes to renew medicine by training physicians to read the right texts—literary fiction and patients' bodies—with skilled attention. Analyzing Verghese's proposal with reference to Foucault's idea of the "clinical gaze," I find that Verghese conceives of patients as texts that only physicians can read, meaning that physicians become the storytellers of the bodies, lives, and deaths of the people they meet as patients. I conclude that Verghese's project is unsustainable and alternatively propose thinking analogically of physicians as ship (...) captains who maintain therapeutic distance to reopen interpretative spaces for communities outside of medicine. (shrink)

Every July, when new resident physicians arrive at our teaching hospital, a colleague reminds them that “You now work in the train station of the gods. People coming and going all the time. You’ll need to ask spiritual questions.” He can offer this counsel annually because—whether it arrives early, as expected, or in error—every one of us is awaiting her departing train. Every few years, an experienced physician-writer offers counsel on what it means to work in these train stations, to (...) tend to people as they die in contemporary hospitals. The physician-writer often describes the equivalent of train wrecks—harried and heedless deaths—and sounds a call for reform. The call is answered, in part, by... (shrink)