Sorry Ma’am, Seems You Are Coming Down With A Strong Case of Structural Violence: Analyzing “The Final Patient”

“The Final Patient”, by Rachel Naomi Remen, encapsulates a real-life story of a mother and her son eventually becoming her final patient as a pediatrician. The anecdote follows Dr. Remen in her concern for her coworker’s immediate jump-to-conclusion accusation that the mother should be charged with child abuse and neglect due to bruises on her underweight son. She brings attention to this story in order to focus on her realization of the rising demoralization among her doctoral peers and how this turpitude is affecting patient well being. Among this story, Dr. Remen’s shift in perspective is outlined and her diagnosis of the medical field clarifies through her description of her coworker. By focusing on one individual story, she effectively emphasizes the corruption in medicine through the interactions of a unprivileged patient and the doctor. Through a short of list of characters– the doctor, the police, the mother, the son, and even herself — in this piece, Remen highlights their roles significantly to reveal the “ranking” system present in today’s society — the foundation of structural violence — pressuring the readers to become aware of this issue, rather than turn the usual blind eye.

“The Final Patient” opens with ambiguity of the characters and this lack of information allows the characters to not be subjected to structural violence, since the reader cannot have prejudiced stereotypes against the mother, in order for Remen to uncover the structural violence embedded in this simple situation later. Remen begins the piece by confusing the readers with the lack of details and it seems as if she is starting the anecdote in between of the story. For example, the first sentence mentions that “Delia [was] in the emergency room when the police arrested her” arises the question of Delia’s role in the story as well as the question of the reason for her arrest. Since there are few details, the reader cannot force their stereotypes onto the character of Delia just yet. With no picture of Delia, Remen allows our perspective to be clean of non-objectivity while introducing her characters, removing the presence of structural violence. This will emphasize its presence when it appears later in the story, as the ambiguous beginning will contrast the version of the story with structural violence involved. Other characters introduced were the police and “the resident doctor who was called”. Unusually, the characters were introduced as their roles and titles, rather than their stories and backgrounds. This is to create a typical scene of a mother and son at the doctors, which will signify the later reveal of the doctor producing an otiose diagnosis– putting the child’s life at risk– because of the structural violence that is poisoning the medical environment.

Remen decided to leave the doctor and the police unnamed to paint a bigger picture of how structural violence is based on the ranking of people’s roles in society. The doctor and police are neglected a name throughout the story to distinguish them from the mother, Delia, and son, Teejay. Only using their titles accentuates the author’s intention of having the characters of doctor and police being the generalized representation of their roles or titles. Remen wanted to clarify that she wasn’t criticizing the bad attitude of one specific individual, rather it is to strengthen her commentary on the corruption of doctors or police and how structural violence’s ranking of them leads to detrimental results. The author includes the situation of “the police and [her meeting] in the doorway of [the doctor’s] examining room, [she] insisted on examining the baby…Reluctantly, they agreed…” in order to focus on the resistance of the police on making sure the mother’s verdict was truly correct, although their motto should be being defenders of justice. The ambiguity of the police in the beginning allowed the reader to establish the image of the police as enforcers of the law and the people’s protectors, yet in the next paragraph, Remen’s use of “reluctantly” alluding to the polices’ blunt lack of hunger for justice ruins that image. Doing this, she ruins our heroic picture of policemen and suggests that the way society views policemen gives them corruptive power– creating more structural violence. Since she presents another, more correct, image of the police, the readers begin to see structural violence in the police role as their authority clouds over their purpose of protecting the innocent. Remen also mentions that she had asked to examine the baby, not question the mother, which indicates that the police had previously refused a doctor to attend to a sick child; however, this raises an eyebrow since the police’s job was for the woman not to escape, not the decision maker of the baby’s life. Dr. Remen had to wear them down before she could check on the baby, which is to create a shock value to the readers as they become baffled at how the police was deciding whether the baby could be look at or not. This is not their job and it is not their authority. Remen uses this as a basis for revealing structural violence in her workplace as police begin to have more jurisdiction than her, at her own job, due to their role. It also conveys the danger of structural violence as without Remen’s persistence, the mother would have still been considered guilty and the baby couldn’t have been diagnosed– this possibly threatens the baby’s life.

The author creates an unusual paradoxic dynamic in the third paragraph with Delia to show how the reader’s stereotypes and “ranking” of people should be questioned and never considered the actual truth of that person. Paragraph three begins with mentioning that Delia “left high school” once she was pregnant at fourteen. This lowers the reader’s attitude and expectations of her, making the reader lean towards the verdict of guilty. Already the reader starts to stop emphasizing with Delia and disassociating themselves with the character. The next sentence follows with Delia “[looking] at [Remen] in despair”, pulling the reader back from their previous judgement with pity for the character. Another paradox-like description of Delia emerged as Remen describes Delia with “her hands covered with tattoos.” With the picture of Delia in the reader’s mind becoming covered with tattoo sleeves, the reader’s revert back to judging and assuming Delia by shooting her down the ranking. The reader will either once again think she is guilty of child abuse or lose empathy towards her, thinking of her as the unworthy of their respect– due to her looking like a low-life “gangster”. However Remen once again pulls the reader back from this thought by further recalling Delia’s “gentle and tender” arms, that repaints the picture of a scared mother caring for her baby and erases the “gangster”. Through this, the author is allowing the reader to not focus on society’s negatives about her and instead direct their attention on the actual wholeness and integrity of the person. With each sentence, the reader is caught deducing the character’s value by ranking her beneath or equal to themselves, but a positive remark withholds the reader from committing to this false image. Remen creates a conflict within the reader, as the reader battles the need to categorize Delia as “good” or “bad”. This showcases Remen’s commentary on how structural violence causes society’s need to organize people in good or bad– those who are respected and those who are “scum”–; however, by establishing this conflict within the reader, it pushes the reader to reject the simplistic idea of good and bad. They start struggling to follow the same beliefs society pinned onto them. By forcing the reader to battle with their own opinions and what structural violence is whispering in their ear, it allows them to become more open-minded and vulnerable to Remen’s critics. It allows Remen to start introducing a world of gray, rather than one of black and white; thus, showing how the world is not “good” or “bad” and that structural violence is poisoning our society with that thought process.

Remen experiments with a form of anastrophe by placing emotion adjectives in the beginning of the sentence to emphasize the empathy-based interaction between her and Delia that differs from the doctor’ impersonal interaction with her. Its purpose is to identity how structural violence– represented through the resident doctor’s approach– has made the medicine world have a lack of emotion and connection to their patients, negatively affecting their well being and healing. By beginning the sentence with an emotion, Remen sets the tone, framing the sentence in a specific light, giving the reader insight to the characters. “Concerned, [Remen] began to question his mother about his care…]” begins with the adjective of “concerned”, which can be assumed is describing Dr. Remen’s emotion. By beginning the sentence with “concerned”, the reader notes Dr. Remen has caring and emotionally connected to the mother; thus, she is truly wanting the baby to have the best care. With this version of anastrophe, the emotion is emphasized, which is Remen’s commentary on the lack of emotion in her workplace. The connection between the doctor and patient is signified as the following sentence is another anastrophe– instead it relates to the mother’s feelings: “Hesitantly, she told me how hungrily he fed…”. By bringing focus to the word “hesitantly”, it gives the reader an insight to the mother as scared and confused, not like a child beater at all. It allows the reader to emphasize and establish their own connection to the mother, picturing her as a worried mother, rather than the “druggie” with tattooed arms. By framing the sentence by setting a tone, Remen is effectively leading the readers to see a more heartfelt, human interaction between a doctor and their patient. She establishes this sensitive and gentle interaction to show how structural violence has destroyed that, by contrasting it with the interaction of the resident doctor and his patient.

The doctor’s description while dealing with Delia as his patient is to showcase how structural violence has corrupted the well being and healing of patients by creating unemotional doctors. Remen, instead of bluntly describing the lack of care her coworker has, uses body language and subtle diction to allow the readers to reach the conclusion themselves, and possibly see familiarity with their own doctors or in their own selves. While Dr. Remen and the residential doctor was in the room with the Delia and Teejay, Remen described the doctor as “leaning against the wall with his arms crossed in front of him.” By assigning this body language to the resident doctor, the reader can infer that he is as far away as the patient and the crossed arms allude to his disconnect to the patient. This lack of connection illustrated is saddening to the reader, because a mother worried about her baby is sitting in the room, yet the doctor refuses help, care, and assistance. Instead, the residential doctor devalued Delia and denied her real care and his expertise. Remen continues to paint this picture as he replied to her suggestion of stenosis with a tone of “some irritation”. When Remen confronts the residential doctor about testing for stenosis, a simple sentence says that “But he had not”, shows his lack of sincerity and how structural violence has molded doctors to not care for the patient, rather fill as much paperwork to get the most money. The description really outlines how structural violence has made doctors less human. Although the residential doctor was wrong, he still replied with irritation to Dr. Remen, showing that he doesn’t even have regret, instead he just wants to move on to the next patient and make more money–making him close minded. It shows the broken connection between an individual patient with their individual doctor.

Remen doesn’t ultise facts in her argument of the presence of structural violence in the world of medicine, which is unexpected from an author with a scientific background, to emphasize on the needed emotion behind the doctor and patient dilemma, rather than the usual depiction of a doctor as a robot filled with facts and cramped textbook knowledge. However, in this story, one piece of fact is used effectively to discredit the resident doctor’s mantra of being only fact-based equals best doctor. Remen mentioning that the “bruises” on the baby’s back were “typical birthmarks seen in seventy to eighty percent of darker-skinned newborn infants” disputes the idea that the smarter and rigid the doctor, the better doctor they are. In medical school, students that are fact-based, good test-takers, and can effectively cramp percentages and diagnose names in their brain have the most potential. Remen comments on that by ironically using a fact to diminish the resident doctor by proving that he jumped to conclusions before even going through other common, basic diagnoses. This allows readers to question how medical schools selects students and how thriving medical students are not emotional due to the structure of the medicine world; thus, emphasizing the structural violence dangering society and people’s health as a whole.

For the Deila character, Remen included a deep ebonic dialect with words like “doan’” and “lotta” to suggest that the mother is not privilege and uneducated, relating how structural violence has placed her there. Ebonic dialect is associated with lack of education, which clarifies Deila’s ranking in society– at the bottom. Remen includes this dialect to emphasize how Deila is a victim of structural violence. There is structural violence against young, single mothers, as they cannot continue school because of the lack of money they have for babysitting. Then it becomes a vicious cycle as the single mother cannot earn money, since she cannot leave the baby home, but cannot afford a babysitting, and cannot get the money she needs from the jobs she cannot get. Remen wanted to emphasize her lack of education to bring more value to a connection between an educated doctor, like herself, and an uneducated, single mother. Between the two women, there shouldn’t be a difference, yet one woman got the opportunities she needed– since structural violence was in her favor– and the other didn’t. This allows the reader to reflect on their own placing in the “ranking” and how structural violence was in their favor. It argues the point that people are where they are because of their actions, but those who are uneducated didn’t have access to the education they needed. Thus, there is no difference between each human except which was favored or not. Remen uses this to make a commentary on how those ranked above the scale tend to treat those below as beneath them; however, there is no ranking and instead it becomes a call to action as the author persists on helping each other get life’s necessities, rather than focusing on an nonexistent ranking.

Towards the end of “The Last Patient”, Remen makes a sharp transition to the future, where Teejay is much more grown and her life also is beginning to shift. With a more uplifting scene, the author showcases how structural violence can be defeated at an individual level through showing the happiness of Teejay and Delia. Teejay was oddly described as “delicious”, which is unusual diction for the boy, yet it brings focus to how much Teejay had healed. By using the word “delicious”, the readers can picture a happy toddler, no longer burdened by his sickness. Instead of using “healthy”, which is what a typical doctor would use, Teejay’s health is more intimate and uplifting due to the lack of “doctor” words and edicets. Remen’s life is also beginning to shift as she is filled with self-doubt, emphasized through her use of rhetorical questions: “How could I not be a pediatrician?” With her success with Teejay and her need to change medicine, directly mentioned when Remen outlines her belief that “medicine needed to change”, it further emphasizes how an individual can overcome structural violence. With emphasis on her passion with “tears [filling] her eyes” and approaching her patients “with a heavy heart”, the readers see her as a hero against structural violence– pushing the typical structure of a doctor as rigid and distant. The religious aspect at the end complements this scene as Delia “[takes] the little hold cross from around her neck…and put it around mine.” The uplifting healing of Teejay, the emphasis on passion, the transition to new possibilities, and the religious ending, it gives the readers a sense of hope and a sense of change. Instead of a call-to-action of the reader, it outlines the author’s own call-to-action and rise to the challenge. It becomes an inspiration to the reader as they can see what an individual can do rising against structural violence, and they have hope for the future.

The transition to “the next year and a half” was actually the transition of the author’s new journey to defeat structural violence. This idea serves as the great lesson that change begins with one person. As the readers change with Remen while reading this story, as they also begin to recognize structural violence — like Remen — and now can also continue like Remen onto a journey to change the structure. With the hopeful tone as the ending, it leaves the readers seeing roles and its dynamic in a new light, with the anticipation of the future, signifying that there are improvements to be made. Those improvements start with them.