“The Upstream Doctors” – An Accompanying Essay

The following is an excerpt from an accompanying essay I wrote for the TED book, “The Upstream Doctors,” by Dr. Rishi Manchanda. 

At the end of almost a decade spent in teaching hospitals and clinics, most (we hope all) physicians have honed their clinical acumen by focusing on the care of the patient who is right in front of them. Perhaps this is as it should be: as patients, we don’t want our doctors (or nurses or social workers) distracted by “outside” considerations such as the suffering or concerns of other patients not there in the exam room or, heaven forfend, by abstractions such as the extra-personal social forces that place people in harm’s way. We want the doctor focused on us, by bringing expertise and attention to our specific “illness episode” and even to our minor aches and pains. That’s what we want: laser-like focus, to use another term from the medical profession, on our own “chief complaint.”

Or do we? What if most of our aches and pains and many of our serious ailments come largely from those outside forces and abstractions? What if we want to prevent disease or complications of it by altering our risk of poor outcomes (not just death, but predictable or unforeseen complications of the chronic conditions and growing infirmity that most of us will one day endure)? What if we acknowledge that we live not only in bodies but in families, homes (mostly), neighborhoods, and cities? What if our lives outside of the clinic or hospital are often difficult and even, for some people and at some times, almost unendurable? What if our clinical diagnoses are not our chief complaints?

Dr. Rishi Manchanda’s TED Book, “The Upstream Doctors,” addresses all of these questions with clarity and vision and humility. His vision is informed by long experience, illuminated by the experience of his patients, and solidly buttressed by a great deal of data.

About Paul Farmer

Paul Farmer, MD, PhD, is Chief of the Division of Global Health Equity at Brigham and Women’s Hospital in Boston. A medical anthropologist and physician, he is also the Kolokotrones University Professor, Harvard University; Chair of the Department of Global Health and Social Medicine at Harvard Medical School; and a founding director of Partners In Health (PIH), an international non-profit organization that provides direct health care services and undertakes research and advocacy activities on behalf of those who are sick and living in poverty. Dr. Farmer’s work focuses on community-based treatment strategies for infectious diseases in resource-poor settings, health and human rights, and the role of social inequalities in determining disease distribution and outcomes.
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