We had both just gotten home for the holiday when Dad calmly announced to the dinner table, “Your uncle has had a heart attack.”
An explosion of questions and half-eaten rice erupted from my brother, an emergency-medicine resident, and me, a second-year medical student.
“He’s doing great,” my father reassured us. “They’ve already sent him home from the hospital. We would have told you sooner, but we didn’t know any of the details. It is hard to keep tabs on your uncle when he’s on the other side of the world.”
Our uncle Manouchehr was indeed fine. He had two stents placed at a first-rate Iranian institution and was feeling much better. This was, however, his first extended run-in with conventional medicine, and he was left feeling run down. The next day, we called him via Skype to see how he was doing. There was no lack of suspicion from my brother as to the quality of health care while abroad. He asked to go over my uncle’s prescriptions, and sure enough, two medications that are considered standard of care in the United States—beta-blockers and ACE inhibitors—were missing.
When my brother tried to explain to Manouchehr that he needed additional medications, my uncle let out a long sigh. Manouchehr doesn’t like pharmacy. He doesn’t understand it. He’s fond of telling my brother and me that we are squandering our talents by becoming drug dealers. And while for the most part he is kidding, his jokes are an expression of a very real frustration. In Iran, where my uncle grew up, herbal medicine was practiced in most households and generally held as a point of pride for Persian-Iranians in the face of a bourgeoning Western medical industry. Still, instead of trying to manage this cultural divide, my brother had attempted a hasty justification for his recommendations based on his knowledge of randomized controlled trials, clinical guidelines, and expert consensuses.
Evidence is the currency of contemporary Western medicine. We place an emphasis on epistemology and biochemical mechanisms when explaining disease and treatments. In Iran, the emphasis is placed on healing, a concept intimately tied to notions of spirit and comfort—not morbidity and mortality. Biochemistry, pharmacology, stents, and studies all produced discomfort for my uncle; discussions of RCTs and clinical guidelines didn’t help. All of this came into conflict with his existing beliefs and caused a considerable amount of cognitive dissonance.
These treatments also failed to address the healing that our uncle felt had yet to take place. In my brother’s plan, there seemed to be no attempt to restore order or return his body to its natural state. To my uncle, more medications would only push him farther away from a “clean” state of being.
Manouchehr found an Iranian physician who agreed. His doctor told him that those medications were unnecessary and, in his experience, contributed to his patients’ unease. My uncle’s thoughts were validated by this line of reasoning; he had been feeling more run down than ever since he had started taking medications.
Instead, this doctor prescribed Manouchehr a thyme oil extract to take twice daily, noting that it had been used successfully for centuries to aid in the healing of those with illnesses of the heart. My uncle promptly added thyme oil to his daily regimen and proceeded to ignore his nephews’ advice.
In the first two years of medical school, we spend a lot of time learning through observation. While shadowing a cardiologist, I saw an encounter with a patient who had had a heart attack and was on much of the same medications my uncle was supposed to be taking: a high-dose statin, Plavix, aspirin, an ACE inhibitor, and a beta blocker. He came to his six-month follow-up with an agenda.
“Doctor, how much longer before I can come off of statins? I’m really not a fan of all these pills.” A negotiation ensued. The physician wanted the patient to exercise, and the patient did not want to be on so many medications.
Afterward, the attending and I talked about how this patient absolutely needed to be on a statin–his risk of having another heart attack was overwhelming without the effects of the drug. We could not budge on his statin therapy. On the other hand, his blood pressure was not so pressing. Exercise would both boost his heart health and act as an early warning system in case of another cardiac event. Getting him to agree to start exercising was worth risking a slight increase in blood pressure by ceasing one of his medications.
But why were they bargaining? Didn’t the doctor and patient both want the same thing?
My uncle eventually saw a cardiologist in the States who convinced him to adhere to his medications. When we talked, he described the experience of going to a physician with mixed feelings. On the one hand, he acknowledged the doctor’s immense expertise in the area of physical illness, and on the other, he was left wanting in the realm of healing. He takes his medications because he knows that if he doesn’t he’ll have more heart problems. He made a settlement; he’d rather take the doctor’s medications than risk being stuck in a hospital bed with two very upset nephews.
In the eyes of physicians, this is the logical choice—to be well. Manouchehr now leads a symptom-free life with his five-pill cocktail. He continues his travel and his work as before while minimizing his chances of an early demise. But in Manouchehr’s eyes, a person is not well if they’re on medication. Medications are for sick people. Herbs and natural supplements are augments to a healthy life, taken by healthy people.
It’s clear that this concept of wellness is not unique to my uncle or his upbringing. As physicians, however, we often don’t have adequate time to engage with these beliefs. We can’t examine why someone would rather take a capsule of thyme oil than a capsule of Lisinopril. We can’t explain that aspirin was originally isolated from willow bark or that statins can be found in red yeast rice. Instead, we’re left bargaining, leveraging fear of disease against apprehensions borne of misunderstanding. It’s a quick fix to a big problem, which leaves me wondering—can we do better? With chronic-disease management becoming the bulk of medical care around the world, we are going to have to try.