I am not, in any sense, a healthcare provider. I do not practice medicine, provide healthcare, diagnose patients, or treat patients.

In many ways, my goal is to help patients access actual, licensed healthcare providers.

This is a good opportunity for me to clarify that while I use the term "patients" in my practice, I do so in a rather distinctive way. The patients I work with are not "my" patients but rather they are patients of the Canadian medical system — or, they are persons who wish to be patients of the Canadian medical system, who are encountering barriers in doing so.

No. I critique certain problematic practices in medicine and certain uses and abuses of medical power. I subscribe to the view that all power and authority should be rigorously and continuously critiqued. Critique of medicine is necessary because, historically, what is “ethical” and “good” requires constant and ongoing renegotiation and revision. For example, being gay was a “sociopathic personality disorder” in medicine in the 50s, and later, a “mental disorder” until 1987.

Medicine certainly has a lot of power. As the historian Paul Starr put it in his 1989 text, The Social Transformation of American Medicine, medicine is so important to a given life that the prospect of not getting what one needs from it is, simply put, “terrifying.”

What’s more, medicine’s practitioners decide who is sane and insane, what is normal and what is pathological, whether one is guilty or innocent, whether you suffer or flourish, and whether you live or die.

Power that great must be scrutinized — and BC medical doctors aren’t even allowed engage in public institutional critique.

My critiques about medical practices are sometimes far-reaching and thoroughgoing. If anything, this reflects the value I place in the provision and practice of healthcare.

I am trained as a rhetorical critic in a field known as the Rhetoric of Health and Medicine (RHM). I am also trained in the History of Medicine. I trained at the University of British Columbia and Harvard University. I’ve learned with whom I consider to be the greatest theorists and teachers for this work: Dr. Judy Z. Segal, rhetorical critic of medicine; Dr. David S. Jones, an MD-PhD and professor of the culture of medicine; Dr. Eugene Richardson, MD-PhD and critical global health scholar. I studied with the late MD-PhD Dr. Paul Farmer, a notable humanitarian. I have more recently been generously mentored by Dr. Seye Abimbola, a leading scholar of the decolonization movement in global health.

In past scholarship, I have examined the tension between critique and political practice in global health scholarship, competing visions of progressive healthcare policy, and the limitations of current ethical discourses in medicine. I have a sustained research interest in inter-professional battles over authority in medical practice, the historical deskilling of nursing professions, and the historical epistemology of rheumatologic medicine.

My work with poorsickalone takes up an intervention I made in an academic journal in 2018. In "Ethics for Rhetoric, the Rhetoric of Ethics, and Rhetorical Ethics in Health and Medicine" (published in the Journal of the Rhetoric of Health and Medicine), I argued we need more expansive ethical and moral imaginations in medicine, and new medical ethics practices. I argued that my humanities field—the Rhetoric of Health and Medicine, specifically—can offer a “distinctive and legitimate” approach to medical ethics discourse based on our unique ways of knowing. I called furthermore for a better bridging of what I termed the “health/humanities divide.” This simply means that I believe in the power of the humanities to make meaningful contributions to medicine.

I am often asked how I relate to medical malpractice lawyers, social workers, offices that receive concerns about patient care quality, and more. I take up my role in the professional landscape in more detail in my forthcoming field-mapping article. For now, I can touch on these distinctions only briefly.

Each of these professions plays a critical role for the medically disenfranchised patient. However, many are prohibited, by their respective governing professional bodies, from providing the kinds of support that are most obviously helpful to patients dealing with medical disenfranchisement.

Accompaniment, for instance, the simple, potentially life-altering act of simply going with a patient to an appointment, is entirely outside the scope of practice of most professionals.

Typically, I aim to act where other professionals’ hands are tied. Let’s take the example of a medical malpractice lawyer. Medical malpractice lawyers are typically inaccessible to the disenfranchised patient. The medical malpractice lawyer tends to prefer more anomalous and overt instances of medical malpractice with significant associated pecuniary damages. Said lawyers are comparatively less suited to addressing the ordinary, everyday violences that constitute medical disenfranchisement. The patient, too, is often simply too crushed by their circumstances to seek out legal advocacy.

For entirely different reasons, therapeutic professionals — including psychoanalysts, psychiatrists, psychologists, registered counsellors, or registered social workers providing counsel — are also generally not well positioned to respond to medical disenfranchisement. While therapeutic professionals are willing to hear a patient discuss their traumatic medical experiences, diverse Western therapeutics seem to take a unified and principled stance against the active support of patients on the problem of medical disenfranchisement. Your therapist will likely never take you to the hospital, for instance, even you’re at death’s door and telling them about being turned away.

The refusal to act is principled: there is a belief that such support could undermine the patient's autonomy. Western therapeutic culture actually idealizes detachment from the addict and pathologizes those who allow their lives to become entangled with the addict’s. Any therapist who is moved enough by a patient’s plight of medical disenfranchisement to act is likely to suffer the charge of inappropriate counter-transference.

I am intellectually heavily informed by psychoanalytic discourses. However, on this point, I am at odds with it. I do not believe that the severance of ties with the weak or the addicted is a marker of moral autonomy or self-actualization. Moreover, I believe therapeutic culture (inadvertently) promotes a culture of rugged individualism and the abandonment of the weakest members of society. I believe other kinds of sociality are both more desirable and eminently possible.

Indeed, far from severing ties with the addict, I am aligned with the liberation theologian Gustavo Gutiérrez who advocates for the “sharing of fates” with the addicted and rejected members of our societies.

Social workers are another interesting case. Some are specifically tasked with the treatment of subjugated patients. However, the social worker's professional governing body places strict parameters on how that solidarity can possibly look, and for many patients I have worked with, social workers have had their hands tied and have even, at times, been (generally inadvertently) recruited to the project of gatekeeping. At other times, a social worker’s service of the subjugated patient begins to resemble management and disciplining thereof. The hospital social worker's capacity to alter the dynamic of a patient's care is further impeded by their need to maintain good working relationships with their physician and hospital administrator colleagues if they are to remain employed.

Physicians, who ought to be the shepherd to the destitute sick, are too often the very gatekeepers who prevent patients from receiving care. My theory as to why physicians participate in medical disenfranchisement requires a good deal more space than I have here. For now, I’ll just say that there are issues that are endemic to professionalization itself.

In the cultural theorist Catherine Liu’s recent book, “Virtue Hoarders: The Case Against the Professional Managerial Class,” Liu contends that licensed professionals who command high levels of social, capital and economic capital “hoard” virtue. That is, they occupy elite positions in society and enjoy a sense of esteem that rests on the premise that they earned their comforts and status through hard work, discipline, sacrifice, persistence, skill and other modern virtues.

The problem is that the corollary of this view is the more bigoted belief that disadvantaged persons also deserve their lot — that the poor are directly responsible for their deprivations.

From this perspective, the chasm between the physician — a cultural elite by any measure — and the destitute sick patient, who engages in criminality and suffers addiction, for example, is difficult to bridge.

A physician can be virtuous, well-intentioned, and capable of all manner of good. But that does not mean that the physician, as any member of the professional managerial class, does not unwittingly contribute to the entrenchment of social hierarchies. The critical global health scholar Seye Abimbola touches on the differing degrees of “awareness” that accompany harmful actions in the essay, “Unawareness, or What We Do Not Want to Know.”

In a sense, yes — but not quite. I find the notion of the “patient advocate" tends to take for granted certain questions that need asking, like, "What exactly does the patient advocate advocate?” That is, “What, in a given advocacy practice, is ‘good’?” It’s just as important that we ask, and answer, “What happens when that good comes at a cost?” and “What happens when the patient advocate's idea of what is ‘good’ departs from what the patient wants?”

I "advocate" a number of things. I advocate, for instance, recognition of medical disenfranchisement as a problem in Canada’s healthcare system, and I advocate the ending of these disenfranchising practices. More broadly, I advocate a conception of the ethical in medicine that centers on the imperative of patient enfranchisement. By this, I mean I advocate that medicine becomes a place that uses its power equitably. The dream is that patients who dwell in corrosive disadvantage might, through medical enfranchisement, get a real chance at changing their health and subsequently their lives. I also advocate “accompaniment,” a model for relating to patients that is quite different from traditional provider-patient relations; it’s more of a position of “standing with” than one of “power over.” Accompaniment is a mode of sociality that involves the sharing of fates with the weak.

I also want to stress what I do not advocate. I do not advocate unnecessary healthcare services for a patient, and I do not advocate what a patient wants if I disagree with it based on what I understand about the medicine or the ethics. In cases where a patient and I disagree over what is properly enfranchising, I advocate a dignified relationship with the patient whereby it is my duty to engage the patient in good-faith, full-disclosure, and open deliberation regarding my views.

However the bulk of the friction I experience in my advocacy of patient enfranchisement lays in the cost of the work. Usually, that toll comes in the form of grueling institutional pushback and the seeming indifference of health systems to charges of harm.

Institutions, as Sarah Ahmed has pointed out, don’t do so well with complaints. They struggle to acknowledge and metabolize substantive concerns all the time. Here the dilemma gets personal: I say I advocate enfranchisement, but can I endure, traverse, tolerate, or otherwise accommodate the pushback I encounter? How much pushback can I endure and how much should I endure? When and how should I change tack? Can the institution be made to hear us? What is possible? What can be gained? To what lengths can and should I go with a patient to mitigate disenfranchisement?

Somewhere in the answer to this cluster of questions lies the true character of my “advocacy.” The answers, by the way: I can endure a great deal; I remain flexible and am always ready to change tack; I will go to great lengths to mitigate disenfranchisement; and I don’t think it is possible to know what is possible in advance, but I have seen enough health system transformation in my day that my sense of what’s possible has grown rather large.

There is a well-established crisis of “diagnosis” in medicine. The crisis refers to the difficulties associated with diagnosing patients accurately. By some estimates, over 200,000 patients die annually due to preventable medical errors in the United States alone.

Scholars have posited many reasons for the crisis of diagnosis. To begin with, the spectrum of disease is vast and human pathology complex, while many illnesses bury their own tracks. There is some consensus that the issue is sociological, however, in addition to biomedical. Namely: the volume of cases per practitioner is untenable, while resources for diagnostics are constrained — and resources must, on some level be rationed.

The question arises: “Is medical disenfranchisement any different from the ordinary extraordinary difficulty of accurately diagnosing and treating patients?”

In my experience, the answer is absolutely yes. The statistics on missed diagnoses that we have seen do not meaningfully break down sampled publics by vulnerability factors. While some scholars have done so elsewhere — Keith Wailoo, for example, has shown how black persons are less likely to be adequately treated for their pain, and many scholars have shown that women’s pain is more likely to be dismissed — still too little literature describes how socioeconomically vulnerable patients are treated differently in the clinic.

All this said, there are indeed elements of uncertainty in any medical case, and not all uncertainty can, in the context of patient vulnerability, be attributed to patient vulnerability. In my work with patients, I always stress the ordinary limitations of medicine. I find that once a patient is able to depersonalize those problems in medicine that are not due to medical disenfranchisement, we are more free to direct our energy towards the problems in medicine that are.

The majority of my work occurs in clinics and in the neighborhoods in which patients live. I also do consultations over the phone, over zoom, and in my private office space (location available on an as-needed basis).

I work with people who meet two broad sets of criteria. First, I ask that patients be poor, sick, and alone— that is, that a person need medical care, is under resourced, and is under-supported both by the healthcare system and their kinship networks. Second, I ask that patients provide ongoing consent to working with me. This consent can be withdrawn at any time. That’s about all it takes.