A Spoonful of Insight Makes the Medicine Go Down

“I feel like a prisoner.” I didn't understand these words, not only because they were spoken to me in Mandarin Chinese, but also because it followed a two-week-long medical workup as well as an hour-long explanation of our team's exhaustive efforts to identify the pathology disrupting the body of the Chinese woman who spoke them.

How could she say this? We had done everything in our power to help her, while she continually blunted our efforts. She refused diagnostic procedure after diagnostic procedure. Worse yet, she would almost daily give us false glimmers of hope by agreeing to undergo a procedure, only to later that day refuse her consent. Felt like sabotage.

She frustrated physicians across disciplines, provoking the same exasperated question with various endings: “Why won't you let me…[perform a skin biopsy, bronchoscopy, pannicular biopsy, lymph node biopsy…]?”

I did not understand how biopsy equated to jail bars. Even the medical interpreter looked quizzical. Imprisonment? Finally, I stopped reeling long enough to take a deep breath and ask her what she meant.

“I want to go home to China.”

Go home when she could be dying? Didn't she want to get answers to her medical mystery? Didn't she understand that she wouldn't get better without letting us first diagnose the problem?

Or was I the one who didn't understand? Had I assumed that I could easily appreciate the cultural framework of a woman who had lived her entire life in China, only now visiting her daughter's family in the United States? In the lofty estimation of my own cultural competence, was it possible that ‘I didn't know what I didn't know’?

Mrs. C was a 63-year-old Chinese woman who presented with fever of unknown origin. She sank into rapidly progressive respiratory failure complicated by liver and renal insufficiency. A reticular, erythematous rash would traipse across her body and then vanish as enigmatically as it came. Her CT scans were a mosaic of bowel, omental, and pannicular inflammation; pericardial effusions; and diffuse lymphadenopathy. Blood counts dropped dismally into pancytopenia while inflammatory markers, including a serum ferritin level greater than 1000, grew to ludicrous proportions. We ordered every infectious lab on our panel, cultured every liquid we could obtain from her, and consulted every specialty available to us. Still the answer remained elusive, which led us to a request for tissue.

Here is where our perspectives diverged.

One culture invades and samples the human body without hesitation. No opening? Then we will create one. The other views such trespasses into an intrinsically harmonious system as sacrilege and asking for disaster. All she needed, her traditional Eastern sensibilities told her, was medicine to gently re-center a perturbed equilibrium. With this notion, she would daily ask for remedies for her illness. Despite her timid temperament, I could tell she was angry that we were not giving her medicines and therapy. I was angry as well. I wanted to bang my head against the wall while moaning, “I don't know what to treat because you won't let me find out what you have!” I couldn't fix her, and yet, I couldn't let her leave the hospital in the event her plague was contagious. Backed into a corner, I felt helpless.

We both struggled to get the other to “listen,” spending hours speaking through an interpreter. I tried to explain how the mystery of life and healing had been beaten into submission via the Cochrane Database, how Harrison's had become the medical bible. She recognized my burning desire to diagnose and treat her, and I finally recognized her view of life and death and the equally burning desire she had for relief from affliction and to return to her home. The therapy she had been begging for was pain and nausea control. By the week after I met her, her third week of “imprisonment,” I provided her with pain and antinausea medication and she provided me an embrace. She left the hospital without the answers I sought but with the peace she needed.

In the end, after much research on and insight gained into the Eastern perspective on medicine, I felt that I and our system had failed her. We had held her in the hospital for three weeks attempting to convince her to undergo our procedures to satisfy our desire for answers. We held her out of fear she may infect others despite continued negative cultures. (My ever-present Western voice reminds me that I still can't say that she didn't have something we have yet to identify, which may, in fact, be contagious.)

I never gave her illness a name or started a therapy that made her “better.” She did, however, make me “better.” She taught me that cultural competence is an active engagement and a lifelong commitment to patients that is grounded in humility. She taught me that what “makes sense” to me may not always be so logical under a different set of assumptions or with a different type of reasoning. She taught me that the “right” therapeutic plan is not always found in PubMed.

As travel, technology, and research advance, the borders between medical ideologies become increasingly fuzzy. Thus, the potential for ethical misunderstanding also grows. ¹ Avoiding medical impasses such as the one described here depends on effective crosscultural dialogue. This requires a detailed, empirically grounded understanding of other cultures' norms of ethical reasoning and discourse.^2,3 As an American medical graduate, I understand Western medicine and its development through hypothetical deduction. I have been trained in disease detection and therapy. However, I am unfamiliar with the inductive method of medicine common to the older generation Asians and the emphasis on balance of the microcosm with the macrocosm. ⁴ In a sense, Western medicine appears to be more active and aggressive, whereas traditional Eastern is more restorative. ⁵ Mrs. C wasn't preoccupied with obtaining a specific name for her ailment, but was more concerned with restoring balance in her life, including controlling symptoms. ⁶ This also allowed her to embrace potential death, a concept I have yearned for many of my other patients to grasp but which seems to be relatively alien to the American worldview. ⁷ Perhaps we have unwittingly locked ourselves up after all—in a prison of trying to control our own fate, to stall death, to understand how to conquer every disease named or unnamed. Perhaps we could learn a thing or two about balance, especially, as the Chinese say, zhong sheng an si—respecting life seriously and accepting death peacefully. ⁸