Unheard by Dr Rageshri Dhairyawan: A Book That Should Be Required Reading in Medicine

Reflections from the Pedantic Zebra Book Club

This spring we read ‘Unheard: The Medical Practice of Silencing’ by Dr Rageshri Dhairyawan. Here’s what we learned, why it matters for Long Covid and ME communities, and what’s next for the Pedantic Zebra Book Club.

There is craft to this book - it’s that simple - and art. It is a fine thing to see ‘Unheard: The Medical Practice of Silencing’ by Dr Rageshri Dhairyawan in print. One can feel the care, compassion and dedication that it has taken to come into being. And it’s five stars from us.

Medical silencing is something all too familiar to those with Long Covid and ME. In fact, we probably have a doctorate level understanding of this pernicious and dangerous practice in medicine.

Yet, the read evokes a striking sense of camaraderie - so many illnesses are silenced in similar ways. The stories that Dr Dhairyawan narrates about people with sickle cell and AIDS and endometriosis, especially those from minoritised backgrounds, are hauntingly familiar.

But, why is there craft to this writing? Well, it achieves something that is extraordinary in that it deals with a deeply traumatic subject in a way that is approachable and gentle. One can feel the precision of each sentence and each issue discussed.

We are aware that not everyone with Long Covid and ME has the spoons to read the full text. One of the aims of the Pedantic Zebra book club is to make educating ourselves more accessible. So we will go through three essential takeaways here for ease.

The Transformative Power of Naming

Language is powerful. Naming is powerful. What Unheard excels at is clearly delineating key processes that occur when silenced. To know what a problem is, one has to be able to internally recognise it and externally communicate it through language. When trauma and injustice happen to us in the consulting room, we often experience this emotionally but sometimes cannot bring it into words - to conceptualise it.

Even knowing the words silencing and gaslighting can begin to give us our power back and undo some of the trauma because we recognise the fault is not with us. It is also vital that those on the authority end comprehend these concepts too, if things are to change.

Throughout the book, Dr Dhairyawan weaves in important concepts from other thinkers and academics gently and accessibly. It is clear she’s done her research and that medicine benefits from a wider intersection with the humanities. So let’s go into some examples:

• Medical Silencing: the act of suppressing, ignoring, or invalidating a patient’s voice, experiences, or concerns often leading to misdiagnosis, inadequate care, or professional marginalization. This can occur through a dismissal of symptoms; the doctor interrupting or rushing; or the overreliance on test results and not engaging due to ‘normal’ results.

• Testimonial Injustice: a form of epistemic injustice in which a patient’s credibility and voice is unfairly downgraded due to prejudice about their illness, ethnicity, appearance, gender, or age.

• Ideal Patient: a patient who is compliant, emotionally controlled, humble to medical authority - traits that align with healthcare norms and often increase the patient’s credibility and likelihood of being taken seriously.

Other key concepts which are worth knowing and exploring are disease prestige, the knowledge gap, untitling and testimonial smothering - but we will leave the book to go further into those.

Who Gets to Be Normal? Power, Privilege, and the Somatic Norm.

The history of medicine has reflected discriminatory societal gender norms and that doctors are too often white, male and from privileged backgrounds. Throughout the text, ‘Unheard’ deals with this gnarly subject well and extensively:

In essence, women have been systemically under-researched, doubted, under-investigated and under-treated. Their ability as knowledge-producers has been discredited. The androcentric, racist and ableist roots of Western Medicine have silenced the voices of women, particularly the most marginalised, and led to a lack of knowledge about their own bodies. Dr Rageshri Dhairyawan.

The concept of the ‘somatic norm’ is bought to light too. A process widely discussed by sociologist Prof. Deborah Lupton. It refers to the implicit standard of the “normal” or “ideal” body, which is typically assumed to be white, male, able-bodied, and adult. A dangerous default which shapes medical research, diagnosis, and treatment practices, often marginalizing those who do not fit it.

This is highlighted in the book with the #ILookLikeASurgeon campaign, started in 2015 by Dr Heather Logghe, as a response to the stereotypes of surgeons as older, white and male. Clarifying that it isn’t just patients that have to deal with being unheard in medicine - internal gatekeeping and patrimony are serious issues too.

The Hidden Curriculum: How Medicine Teaches Power Over Patients

Whilst Dr Dhairyawan gives advice and recommendations for individuals at the end of the chapters, she is clear that actually the responsibility for change and action should be from those in authority. One of the most shocking aspects of the book is how ingrained the process of medical silencing is in education. How essentially specialness, separateness, and superhumanness is part of medical conditioning.

Not only are healthcare systems not designed to encourage or incentivise listening, but medical education teaches doctors to doubt patients and imbues them with a sense of hubris - this is a wall to better understanding. Dr Rageshri Dhairyawan.

This is chapter two - ‘Devalue: Why Doctors Don’t Listen.’ If you are interested in dipping into this issue more deeply. It details how the empathy and idealism that medical students start with turns what Xi Chen describes as “medicine’s hidden curriculum of brutal pragmatism… a reliance on derogatory humor towards patients.”

We would hope that this book is a catalyst for doctors to recognise this process and for medical schools to teach silencing and gaslighting. As without naming and recognising the problem, it cannot be resolved.

From our time as students, we are taught to keep a distance from patients, to listen selectively and with a degree of scepticism. This outlook is even ingrained in the language of medicine and contributes to power imbalances in the doctor-patient relationship. Dr Rageshri Dhairyawan.

Narrative as Intervention: What Medicine Must Take from Unheard

‘Unheard’ is a masterclass of narrative non-fiction. It draws from personal and medical experience, from historical and social science theory - in a way that is gentle and incisive. It clearly unpacks and conceptualises key processes that have lurked under the surface for too long. It is refreshing and potent that this book has come from a medical professional. Although it is striking that it came to be because the doctor was placed in the position of the unheard patient.

Does the book have any shortcomings? Not many, to be honest. I would have quite liked an index, so it was easier to revisit key concepts. What remains vividly though is something that Dr Dhairyawan recognises in the book. It is the extra effort she has had to invest in herself in order to be taken seriously as a doctor - as a person who is petite, female and from an ethnic minority. In essence to be the ‘ideal doctor’, as we are often pressured to be the ‘ideal patient’ or the ‘ideal scientist’. One can feel the control and precision in the voice and structure of the text. I just wish this pressure and stricture didn’t have to be the case.

But, it is important to realise that silencing isn’t a rhetorical exercise, it can be a matter of life and death, of trauma and medical abandonment. We know medicine is a behemoth, an oil tanker that, like the banking system, is a complex structure where no one is really in charge. What is needed is more than a tokenistic recognition of ‘Unheard.’ It needs to be part of the medical syllabus, in healthcare staff room coffee tables and for it to start a conversation at the top levels of power to initiate change for the better.

A Conversation with Dr Rageshri Dhairyawan

The exciting news is that we will be talking to Dr Dhairyawan about some of these concepts on our livestream on Thursday 5th June at 7pm, on our Facebook and Youtube channel. Or if you are reading this is the future it will be available as a recording on YouTube, Substack and at longcovidadvoc.com or as audio on our podcast. So many choices!

This will be an opportunity to talk about more specific issues that people with Long Covid and ME face in medicine in relation to silencing. We will also discuss the problem when listening turns to toxic empathy, what structural issues need to be addressed we might even have time to discuss medicine and AI - will it help or hinder?

If you have any questions to ask or thoughts on the interview do let us know in the comments! You can subscribe to our YouTube and toggle notifications if you need a nifty reminder.

Up Next in the Pedantic Zebra Book Club

Our next book in the Pedantic Zebra Book Club, which we will be reading (or listening) to, from June to September, is ‘Who Wants Normal? The Disabled Girls’ Guide to Life' by Dr Frances Ryan, Guardian columnist and general super advocate for disabled people.

There are numerous accessible ways you can take part:

• Read or listen along at your own pace.

• Catch up with our Friday takeaway on social media.

• Follow the #pedanticzebra

• Listen or read along, together in spirit, not in person on Friday nights at 8pm. A little something for the diary even if we are housebound or bedbound.

• Watch out for our article breakdown of the main themes.

• Join the discussion on goodreads

We will leave the final words to Dr Dhairyawan:

This points to an uncomfortable thread that runs throughout this book. For people who have been historically silenced to be truly heard, those who have benefited from their silence will need to give up some of their power. Whether they do this remains to be seen, but I hope this book provides a clarion call as to why this is essential to improve health equity. Dr Rageshri Dhairyawan