System failure: We need a reboot to better handle intersectionality

In medical school, physicians learn how to diagnose and treat medical conditions. We learn about all the different presentations and revel in catching a complex or rare diagnosis. In essence, we learn to categorize disorders based on a cluster of symptoms and match them with appropriate treatment plans.

Of course, you want this quality in your physician. This system works well until you enter independent practice and learn quickly that patients rarely present with a single medical condition that fits nicely into categories. This is very anxiety-provoking to perfectionistic-learning physicians. The term “medical complexity” is adopted to describe patients who do not fit neatly into categories. In the documentation, you may see, “Ms. A has a history of multiple medical problems (MMP) and presents with chest pain.” Many physicians are uncomfortable with ambiguity and dislike the unexplained or unknown. I have witnessed many jargon-filled explanations given to patients when something is unknown.

Why is this? Many reasons, likely, starting with the historical trope that physicians are omniscient. In addition, there is a place for this. Patients, rightfully so, are also uncomfortable with ambiguity. It is wholly unsatisfying to have an unclear diagnosis. Many patients look to their physicians to instill hope and give answers. Other members of the treatment team also look to the physician to make a treatment plan. Imagine if you said to your team, “Well, I have no idea what is going on, so let’s hold off on a plan.”

How, then, do you appreciate complexity? What if a patient has two or three acute medical conditions? The term for this is “intersectionality,” and it spans beyond the physician-patient interaction. We also struggle with this concept when trying to find our identity within the medical field. In the past decade, there has been a shift toward better acknowledgment of the experience of minority cohorts within the medical community. More support exists now for Women in Medicine, for example, than did previously. This allows more opportunities for mentorship, promotion, and career satisfaction. Patients also benefit from seeing physicians that have diverse backgrounds and experiences.

While I am in support of these movements, I cannot help but think we are using the same categorical thinking that we use when we learn how to diagnose. We can make sense of someone if they fit into a single category, but what if they fit into more than one? Many find themselves in this position, and there does not seem to be room to live in numerous spaces. Very little data exists regarding how intersectionality affects the lived experience, but I have to wonder whether rates of burnout are higher in the intersectionality group. Anecdotally, my experience as a female physician and physician with a disability confuses many. Not only do I have to navigate gender bias, but I also have to navigate the world of accommodations. In addition, mentorship is difficult, and I have often been told, “I have never dealt with this situation before.” How can we do better to support individuals with “complexity?”

One could take an evolutionary stance and argue that we are hard-wired to categorize in order to find our tribe. This may be true to some extent, but reductionist explanations rarely appreciate complexity. Embracing this realization earlier in training would allow medical students to better handle ambiguity and see both patients and colleagues as unique individuals with diverse experiences. Even if you have seen an asthma exacerbation one thousand times before, the circumstances for this patient in front of you are unique. Learning how to appreciate their personal circumstances may allow you to consider a more individualized treatment plan. Most importantly, the personhood of the patient remains intact. Obviously, we still need to learn diagnostic categories, but a more nuanced approach is the update the system needs to reboot successfully. We are long overdue for an upgrade and may even find that we like the new version.

Marley Doyle is a psychiatrist.

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