“One of the penalties of an ecological education is that one lives alone in a world of wounds. Much of the damage inflicted on land is quite invisible to laymen. An ecologist must either harden his shell and make believe that the consequences of science are none of his business, or he must be the doctor who sees the marks of death in a community that believes itself well and does not want to be told otherwise.” – Aldo Leopold
Complexity is too often seen as a threat, a barrier to be overcome, not as a source of a robust, resilient, self-ordering system. The history of 19th and 20th C. medicine has largely been one of parsing this complexity, by organ system and disease, advancing through an ever-finer specialization to explore pathophysiology and therapeutics. This process is the medical equivalent of pioneers carving settlements of narrow domestic order from the wilderness. But intense focus comes with risks — namely a fundamental loss of perspective. Just as quiet suburban streets must be recognized as dependent on fundamental natural systems, the forces encouraging increasing medical sub-specialization requires a countervailing awareness to remain grounded in a wider biologic reality. Human health, shorn of the broader perspective gained from an integrative ecological sense,
is at the brink.
Emergency Medicine embraces this liminal space between a seemingly chaotic and complex world and the ordered flow of hospital floors and ICU’s. We deal in uncertainty and complexity of condition, of age, of acuity, of volume. We take care of patients undifferentiated by time, patient age, gender, organ-system, severity or origin of disease. Whether suffering from gunshot wounds, strokes, environmental stressors, or the health disparities engendered by structural racism, all patients are ours, transcend traditional organ-based specialty care, and come at hours not of our choosing.
Wilderness Medicine (WM) is the practice of resource-limited medicine under austere conditions. It is practiced in remote areas, in the developed world after natural disasters (e.g., after the 2011 Japan Earthquake/Tsunami), but also as a daily course of business in many regions of the world (from rural Alaska to Nepal to Africa). We provide critical care for patients in settings where most physicians have difficulty simply caring for themselves.
One gift of providing care outside of our well-resourced, state-of-the-art academic medical centers is that WM providers are forced to have a wider lens on the ultimate sources of and constraints on human health. We practice in demanding environments outside of the carefully-controlled setting of the hospital. In doing so, we gain perspective into how clinical staff approach decision-making under extreme conditions of uncertainty and complexity. We use these hard-won insights to improve outcomes at home.
COVID-related individual and systemic stresses recreate at home the systemic and resource-limited considerations experienced in remote sites — or as a routine feature of developed world hospitals — and provide us all ways to better understand methods to more effectively deliver healthcare.
Magnificent complexity (whether ecological systems, global warming, or human health) is often governed by subtle, fundamental guiding forces. Awareness of these forces is often granted by perspective — perspective allows us to see the forest as well as the trees — and then the planet on which the forests depend. Wilderness Medicine is powered by an appreciation of the complexity of fundamental natural systems, which allows us to explore and expand perspectives to better address human health.
N. Stuart Harris - MD, MFA, FRCP Edin. Chief, Division of Wilderness Medicine, MGH Department of Emergency Medicine. Associate Professor of Emergency Medicine, Harvard Medical School
Next steps for Medicine:
1) Expanding access to care.
Wilderness Medicine provides critical care for patients under-resourced settings.
Our skills and technology allow diagnosis and treatment of patients outside of hospitals. We have, as a goal, to pre-empt hospital care. We develop tools and training to help keep patients out of the hospital. This care is oftentimes not just more cost-effective and capacity-building, but often provides better quality and more humane care. For reasons of economy, infection control, patient autonomy, and familial support, more home-based care is the future for medicine I would wish for my patients and myself.
This noted, acute stabilization through emergency medical care can make the difference between life and death, and can best guide later care. Emergency Medicine promises to care for “anyone with anything at any time.” The expertise of Wilderness Medicine promises to address the missing dimension: “anyone, anywhere with anything at any time.”
A new vision worthy of the technology and human talents of a global 21st C is overdue: expert health care is a portable intellectual and artistic talent — not an architectural phenomenon.
The future essence of academic medical centers (AMCs) must not be measured by the capacity of our buildings, but the reach of our human expertise and talent capable of delivering care to the patient. We should bring care to the patient, not force the patient to come to us.
Fully realized, AMCs must be recognized as a tool, not a destination — a means to an end, not the end. To fulfill our moral responsibility and medical potential, AMCs must embrace their ability to extend expert care to ANYWHERE on the globe. By continuing our overly-exuberant focus on concrete infrastructure (often subject to rising sea levels), rather than on best utilizing human talents and vital natural systems, we are increasingly poorly-positioned to serve our patients in the future.
2) Respect for limited resources.
Wilderness Medicine teaches “essential medicine” — the archetypal interaction between a caregiver and a patient. We teach that care has to be guided by listening, careful history, and an astute physical exam.
By stripping away features that many view as essential to modern medical practice (labs, computers, CT scans, and a ‘clean, well-lighted space’), WM fellows learn to focus on the essential in medicine: an empathetic human relationship between doctor and patient.
The strategies we teach for efficient use of limited resources are durable and transferable from the wild to the bedside. WM teaches efficient, patient-centered care. We go outside to learn to be better doctors inside.
We foster innovative technologies. Our experience in ‘extreme’ locations allows novel insights into fundamental life threats (like hypoxia) and provides expertise in therapies (like inhaled nitric oxide — used to treat high altitude pulmonary edema) that provide unique insights into potential treatments for novel viral (COVID) pandemics. Going outside makes for more innovative, diverse and resilient medicine inside.
Experience with complex, unpredictable systems strengthens disaster response. It increases our ability to care for patients under demanding conditions (resilience) and so strengthens the entire medical system. As Hurricane Sandy taught Manhattan, AMCs are one disaster away from Wilderness Medicine.
In the midst of the pandemic, fellow emergency physicians gave evidence of being profoundly disconcerted with even the distant prospect having more patients in need than we could care for in Boston. My colleagues' surprise and discomfiture were understandable. It was a reality many had never been forced to consider, even as resource-limited care is more the rule than the exception for the majority of the world’s population.
Experience with resource-limited care informs the aptitude and comfort with which we provide care under the demanding conditions of a pandemic and teaches empathy for patient populations existing in less privileged locations around
the world.
3) Recognition of the critical role of climate change for human health.
After millennia of slowly graded impacts, our population is altering the biosphere’s ability to compensate. These changes are having direct health impacts.
Emergency physicians are the first to respond as climate change negatively impacts health through increasing heat injury, psychological stressors, and changing disease patterns. To address the degree and severity of change, we must look outside the hospital to anticipate and adequately respond to the inevitable stresses ahead.
WM advocates for rational risk awareness and mitigation. Climate change is already impacting human health. The stresses and patient suffering will worsen. Working to care for a sick patient on a high-altitude glacier makes plain the impact of environmental stresses on our patients and our own health. Guided by this awareness, we advocate for rational, apolitical, non-partisan, data-driven policy. We recognize that the least affluent of our patients contribute the least to climate change, and yet will be most negatively affected by it. We advocate for environmental justice.
‘Black swan events’ are too often entirely predictable if regarded with sufficient perspective. The historic weather patterns that have brought us largely stable food and water sources are being altered. Extreme weather is occurring more frequently: 100 and 1000-year weather predictions are being revised. Drought-induced starvation that leads to forced migrations are occurring now and are likely to become more common. Climate change refugees from Syria lead to mass migrations, medical humanitarian crisis, and then to dangerous instability in European democracies and increased international security instability — with attendant costs. The data indicate increased climate instability with negative health impacts, and point to potentially devastating future “black swan events,” from changing weather patterns altering food and water availability (storms, loss of glaciers that provide Asian drinking waters, etc.) to equatorial areas becoming so heat-stressed as to become inhospitable for habitation.
A functioning biosphere is the source of all human health — and yet has no central federal source for funded cross-boundary research. Understanding complex systems requires more than myopic specialization.
4) A respect for the complexity of language.
The superpower of bedside clinicians is one we completely take for granted: narrative.
We are a narrative species. We make sense of our lives, become who and what we are through the stories we’ve been told — and tell. We become Americans, Buddhists, Christians, and physicians through the stories we tell. Even as our populations increasingly walk through their lives with eyes adhered to small glowing screens, storytelling (even in 140-character bites) drives us as individuals and as a species.
Medicine exists at the intersection of science and story and so is the most human of the sciences. Similarly, diagnosis is the intersection of science (physiology, anatomy, lab and imaging results) and story (history of present illness, past medical history, social history, etc.).
The ability to solicit and listen to a patient’s story is at the apex of high-quality care. Narrative is both the unparalleled diagnostic engine of medicine and an extraordinary (and safe and cheap) means of therapy. When at the end of Chekhov’s Misery, the sleigh-driver has exhausted all hope of making human contact to help share the unbearable pain he has endured through the recent death of his son, the sleigh-driver finally is forced to turn to the one being who will listen — his horse — and healing begins. The act of sharing one’s unbearable pain can be a profound gift. Care-givers heal simply by listening and by bearing witness.
The ferocious complexity of language is a system beyond our ability to comprehend. Operating below conscious control, our storytelling mind distills facts and feelings into an actionable narrative. This process is unimaginably complex and must be recognized as at the heart of our ability to comprehend complexity — and yet it is fluidly accessible to an unschooled 4-year-old child.
Story is our innate self-righting mechanism. Place a human in any condition, however brutal, and we will use story to make sense of our world — as has occurred from the Gilgamesh to the Torah to Cormac McCarthy’s The Road. While clearly inherent in biologic capacity —it is wired in our cortex — the interplay between the biologic and cultural aspects of language only make it only more complex. And yet despite this innate, incomprehensible complexity that exceeds any designed technology by orders of magnitude, facile wielding of story remains the tool of choice from small children to national leaders for us to make sense of our complex existences, ascribe value, make effective decisions, and create plans to lead
to our futures.
Young doctors become real doctors when they are capable of listening with distinction. When they are able to appropriately recognize the individual human being next to them, gather thousands of external facts, provide proper weighting to a few key details of history, and using the power of narrative, create a history and exam that results in an assessment and plan — a story with an beginning, middle and end that justifies a path forward. It is so innate in us as an organism, it goes unnoted,
but it is our central power as expert clinicians.
Only the extraordinary complexity of narrative rising from the unconscious depths of the human mind is capable of rendering this feat. Physicians dismiss medical care in the absence of story as ‘veterinary medicine.’ This is not unsympathetic to the care of non-human animals or their providers, but a painful recognition that bereft of the knowledge and empathy engaged through another person’s story, our care and treatment are much more simplistic, inefficient, and less human.
Physicians craft narratives each day to tell their patients so that they both understand and are motivated to alter their behavior. This power isn’t only one of diagnosis and treatment at the bedside, it has huge ramifications for the translation of ANY scientific data into action. We would love to believe, but know that we are NOT, a data-driven species. Data bereft of story are barren dust blown off fertile fields. Evolution has provided us with the alchemy to turn data into understanding and action — storytelling. This is as true in our post-atomic age, social-media-driven world as it was under the hot sun of Mesopotamia 6,000 years ago.
Doctors do this with special ability. Every day we communicate arbitrary, complex scientific data to patients in human, storytelling form. Without this power, the import of a positive troponin (indicating injury to the heart muscle) or elevated H1C (indicating poorly controlled diabetes) would be meaningless to patients. That burning of fossil fuels has driven the atmospheric carbon dioxide levels from below 300, to above 400 parts per million (ppm) in little more than a century is no story — and yields no meaningful response until it is made one.
Just as a physician is responsible for communicating the coming vascular failures (failed kidneys, early strokes, decaying limbs) from wildly uncontrolled diabetes (and the telling A1C lab value that portends this future), so too physicians must be the storytellers to make clear the health impacts of global data streams provided compelling evidence of a changing climate. The health impact of the atmospheric CO2 continuing to rise beyond the current 417 ppm is a story not being effectively told at present. Physicians are the scientists to provide this critical public service by breathing story into complex scientific data.
A well-told story dissolves unproductive complexity. Terabytes of data don’t tell us who we are, or what our aspirations are. Human judgement derived and transmitted through storytelling allows us to focus on the essence of good medical care — a caring, empathetic, human interaction and an elegant ordering of abstract scientific data in human form to protect our biosphere.
5) Medicine grows from ecology
It is a very simple statement: the totality of human health depends on a functioning biosphere. It is obvious — and very poorly reflected in our medical education, bedside care, or federal funding priorities. Just as the complexity of language undergirds high-quality medical care, the complexity and elegance of ecology must be recognized as at the root of human health.
The reductionist, sub-specialization of medicine appears to recoil from the universality and ferocious complexity of ecology. Medicine takes some apparent pride in how we have subdivided care by organs and diseases (as the organizational flowchart of the NIH bears witness). To look at this chart, the act of considering humans as an ecologically-placed and integrated organism who are much more complex than the sum of their parts is a rare — and largely unfunded — exercise.
We sub-specialize through residencies and multiple fellowships into more and more fractionated visions of care for a part of a human being (e.g., the joke about hand surgeons focusing on the middle phalanx of the middle finger — of the left hand — has origins in truth) and operate with the bizarre assumption that by dissecting human beings using this microtome of pixelated care that a unifying narrative will result — as if, grammarians, each expert in only verbs or adjectives or nouns or adverbs, could provide insight into Lear’s suffering on the moor.
From this state of fractured care, to then suggest that we expand the scope of medicine to include an awareness of ecological forces outside the hospital’s walls is ambitious — and long overdue. In our exuberance for myopic ‘expertise,’ we lose sight of the single source of all human health — a functioning biosphere.
Physicians must recognize and become comfortable with the larger complexity (the biosphere) on which life depends. Just as a brain or kidney doesn’t operate in isolation without relation to a vigorous self-regulating, autonomous, self-directed organism containing it, so too human health depends on a vigorous vital, autonomous, and stable biosphere.
As humans approach the carrying capacity of our biosphere, we are newly forced to this awareness to best guide and achieve health outcomes. Rather than funding health research as if human health was a bland post-mortem kidney sloshing in a cooler, separated from its source and function, we need to ground care in a larger ecological consideration. Just as kidneys have a limited cold ischemia time before they are non-viable for transplant, human health separated from its larger context has a finite limit, beyond which, permanent injury is inevitable.
Using an ecological lens, no physician or policy maker can be surprised that climate change will negatively impact human health outcomes; or that antibiotic resistance is growing and that the twilight of effective antibacterial therapy is upon us. At its essence, antibiotics function by evoking evolutionary forces. Resistance isn’t a surprising side effect; it is an ecological inevitability.
In moving from an individual patient, to systems, to a biospheric view of human health, we are moving towards recognizing conditions as they are.
We are at such a time in human history and biospheric stress that a change must come. To continue to ignore the pre-existing ecological context in which we all exist will doom our species to continued stresses and ‘surprises’ that would otherwise have been anticipated and mitigated.
Health viewed through an ecological lens provides an escape from our arbitrary academic silos and allows us to appropriately embrace the fullness of the Earth’s interconnected living systems of which humans are such an interesting part.
We are creatures of ecology. What a bizarre thought to think there could be “man” and “nature.” This ancient, false dichotomy between ‘man’ and ‘nature’ has led us to the brink. We are nature. No rational thought leads to reproduction. Nature churns below our conscious awareness late at night, stands by soccer fields on weekends, cares for aging parents, paces through our ED’s on overnight shifts, and types orders into our computers.
To address the primary threats to human health in the days ahead, a competent physician must be as comfortable understanding the Keeling curve as the Starling curve. We don’t have the luxury of saying “I’m a doctor, that’s outdoor stuff. That’s not my department,” anymore. Humans deserve an ecological approach that accurately addresses their health needs. To see humans not as distinct from or even evolved of nature, but as a continuing fundamental cog in a larger and complex whole is critical to safeguarding human health.
6) Willingness to challenge outdated healthcare infrastructure
As noted above, American medical care and research funding is overwhelmingly fragmented. The huge power of federal research funding for human health is largely relegated to an outmoded organ or disease-based system.
In distinction, Emergency Medicine has the luxury and responsibility of caring for the undifferentiated human, ‘anyone with anything at any time.
The NIH, still largely locked in structures based on the political landscape of the 1960s (immediately after the passage of the Civil Rights Act and before the academic practice of Emergency Medicine), lacks a dedicated federal research cost center with the capacity to fund acute care for the entire human being. It has even less capacity to fund multi-disciplinary explorations of how deeply human health will be impacted by an increasingly stressed biosphere. Locked in an ossified, Vietnam-era federal funding hierarchy, the NIH acts as if Emergency Medicine still doesn’t exist.
Even as emergency departments have become the diagnostic and acute treatment center of American medicine, to look at the federal budget, Emergency Medicine is nearly invisible. This even as daily American clinical practice speaks to a very different reality: have a heart attack at your cardiologist’s, a stroke at your neurologist’s, a gunshot wound at your surgeon’s, or an imminent delivery at your OB’s, and the response will be universal, “Quick, call 911 and get this patient to the emergency department ASAP.” This even more true if you have acute hemiparesis at your cardiologists or chest pain at your neurologists. The emergency department is where America’s generalists and specialists send their patients when they need acute answers and treatment.
As a medical researcher in 2020, I can go to the NSF for grant support to study carbon flux in the Alaskan permafrost, and to Alaska Native Health funding sources to study the acute effect of depression and substance use on Native Alaskan communities (not mentioning they are suffering physical and psychological trauma from the destruction of their ancient villages due to melting permafrost), yet there is no meaningful cross-specialty awareness or mechanism to address the direct, devastating effects of a rapidly warming arctic landscape on the health of Native Alaskans we work with — or the impact of these Arctic changes on health in the continental U.S. 1960’s ICBM silos were dismantled; unnatural medical silos
live on.
Our reliance on structures based on 1960s realities is a dangerous anachronism. Our current Defense Department isn’t focused on winning the war in Vietnam, it has pivoted to the present and future threats — and is frankly much more forward-thinking and integrative in planning for the inevitable acceleration of impacts due to climate change. We as a nation and species deserve a similar update in our federal medical funding structures.