that title just gets me somehow. it's medicine all over.
as long as you stay at home, there's only unrelenting pain - vomiting - being too tired to get out of bed. there are only these things, and suffering. but when you start to wonder what the medical explanation is, then along comes the spectacle of suffering - "the patient presents..." - the patient auditions - the doctor applauds, or boos and hisses, or looks bored (the doctor has a hallway full of other performances to attend, and has been attending all morning, all week). both need to collaborate, or to see the other at least as a collaborator, to finalize the presentation, to organize the illness, to diagnose. otherwise, the doctor might break the cardinal rule and treat without a diagnosis, or might retaliate and write something cruel in the diagnosis box ("axis II [personality disorder]," "somatization," "worried well") which insurance will not pay for. (insurance also will not pay for a blood test, a urinalysis, or an MRI of the brain accompanying such diagnoses.) if the patient presents properly, their reward is not only some kind of medicine to relieve some of the symptoms (and possibly the underlying condition), but also a diagnosis, an explanation, a story with a beginning and middle and therefore, one hopes and expects, an end; a tremendous comfort. a work excuse - well deserved; a week in bed - well deserved; a story.
i see that i'm at the top of the google list if you enter "pity modernity" today - you'd think the anti-postmodernist league or somebody like that would be there instead - i do not like publicity. it's because i cited the paper, which i have not been able to read, since my online library doesn't carry it - i was only able to to quote the pub-med abstract, which i found very tasty. if you only google 'pity', you get the wikipedia entry, which reveals that the notion of pity has been suspect for a long time - it is distinguished from sympathy, empathy, and compassion; pity is a bad thing, and the others are good. but anyway, when boys and girls enter medical school, of course, it is because they "want to help others." they write a little essay describing one or two specific others they have wanted to help. same when they leave; they interview residency programs to specialize in their favorite version, or the version that seems most pragmatic, of "helping others," and they develop a little speech about why their specialty is the helpiest.
once they start taking responsibility for "evaluation and management," once they start writing down diagnoses, they begin practicing pity, which philosophers apparently define as niceness mixed with contempt. leaving residency, they're schooled in pity, and rely on it to get them through the day: hannah arendt's "sentimental distance," which doctors actually congratulate themselves on maintaining without sentiment. the "boundaries." nobody comes right out and says, treat the disease, not the patient, but everybody knows that's Good Medicine. "you have to have That Distance." it's assumed that without it, you'll crack, or, worse yet, you'll be tricked. you'll be naive.
we quote osler - the older guys do, anyway - "listen to the patient. he is telling you the diagnosis" - but that's not seen as truly necessary. there are successful pediatricians and veterinarians, after all, and furthermore, patients lie. your reported pain is "out of proportion to the exam" (drug seeker). you say you were vomiting all night, but you're not vomiting now, and i see on the computer that you had a negative GI workup last year for the same complaint (somatizer). it doesn't help that you obviously don't like doctors, and you used a swear word, and there's coffee on your blouse (axis two). patients are unpleasant, and we don't like to be too closely associated with them, but we are blessed with a technology of detection, so we're doctors. thanks to pity, modernity, and spectacle, we're doctors. thanks for playing. glad you could make us elite.
my psychologist pal tells me he thinks my desire to start a solo-solo micropractice is a symptom of my residency burnout - the need for more control. he has insufficient information - i've been studying and reading and learning about this, pretty steadily, for a year now. i read the witnesses of doctors who really burned out, who were disabled by cognitive dissonance as a result of "wanting to help others" plus probably not "having That Distance" so they were unable to adjust properly to the 15-minute doctor visit. plus i look around me at the personalities of physicians; they have terrible self-esteeem and are anxious all the time; they are afraid of 'missing something' and 'having something bad happen.' they never recover from their sense of inadequacy, and i really think it's a consequence of their work environment, not to mention their training (in an even worse environment). i never liked the setting as a patient or as a patient advocate (i reminisce about spending lovely long hours on the phone telling breastfeeding mothers to fire their pediatricians), so i don't want to spend the rest of my life there.
i also remember lovely long hours, literally at the kitchen table, with folks i knew pretty well, talking about pains and infections and fertility and how to keep out of the doctor's office. that, i can do for the rest of my life. 'family medicine' with its notion of 'the medical home' (the notion, not the program) offers such a wonderful opportunity to actually be a personal doctor, to actually know people well. how would that change the spectacle of suffering?
how would it change the way i present my own (casual) complaints of burnout to my psychologist pal, if he knew how i spent the 35 years prior to encountering the stresses of residency? how much would it speed up my beloved spouse's presentation of "my back hurts, i'm worried i'm throwing another stone" if that was actually all he had to say, because the doctor knew how this all started? if i were my patients' personal doctor in a personal way - if they were my patients rather than the clinic's patients - would i finally figure out why the sickle cell teenager takes so damn much vicodin, and why the puerto rican guy's thyroid levels are through the roof one month and through the floor the next and then back through the roof? and would i finally, finally, finally have time to finally, finally, finally make it clear that it's not the three days after your period that you can get pregnant. and would i have seen the "longstanding domestic violence" before i got the emergency room report in my mailbox.
and could we have a cup of tea while we talk. and if you're really just in a hurry and want somebody to look in your ear, why, we can just look in your ear. i've been there too (it's hard to look in your own ear).
one of the solo-solo micropractitioner fam med docs told me a story about sewing up a kid's hand - it was full of interesting technical details - but her conclusion was that she had to just do it herself because she knew the family couldn't afford to go to a hand surgeon, and the kid wanted to go into the army, and he couldn't fire a gun without the repair being done in this particular way. and she showed me, wiggling her fingers, just how it healed, and the negligible little bit of range of motion loss from just one joint, and how it wouldn't limit him, and finally how he went off into the army, and how the family's coping with that. i might hear a story like that from one of the mega-team high-volume docs i work with. but their stories are usually those of comic diagnostic-surprise punchlines - "turned out there were a bunch of plastic spoons in his stomach!" "turned out she'd had a tubal ligation, so the test was a false positive!" or tragic diagnostic-surprise cautionary punchlines - "but she never told us she was HIV-positive." "and it turned out his father had it, too." and it's that constant element of surprise that freaks them out, maybe even makes them into mega-team high-volume adrenaline junkies who wouldn't practice any other way.
and maybe, when all is said and done, one can't practice any other way. (i have another degree, other than medicine - something to fall back on.) maybe the super-high-volume doctor world will spank you too hard, for spurning their clubhouse. when i was interviewing for residencies, i kept hearing sad sighs that family doctors make less than other primary care doctors, and the most idealistic ones often go broke and have to stop being so idealistic, and finally i asked, in exasperation, "what is 'being broke' for a doctor? how much does a doctor have to make to not feel poor?" because i think doctors make an awful lot, personally. and the person told me, it's not just the money, for most folks. it's that you don't get invited to the best cocktail parties. you're not a member of the club. especially if you take care of poor people, you are somehow tainted by your association with them.
awwww.
no, really, it must be an awful disappointment, especially for those who were born into doctor families and groomed for the elite since childhood, who made the awful mistake of going with the vogue of "wanting to help others" and found themselves locked into being a lower-caste physician. as a solo-solo doctor, i would be just a shadowy name that appears on an ER form once in a while. as one of the micropractitioners said, when a local anesthesiologist takes a CPR class, it's front-page news in the hospital newsletter, but when i publish another article in a national medical-economics journal, it's nothing.
i had not realized, when i entered medical school with the personal goal of subverting the american healthcare system, the implications of being a member of an elite; however, i am greatly pleased to have located the counter-elite (or in my case, the kitchen-counter elite). i entered residency right after one of my mentors, crazy neurology guy, told me, "family practice isn't medicine - it's a cult" and i had replied, "i think i'd be a good cult leader," and i think i'm finally getting back to that...
The idea of a doctor and patient falling asleep together while holding hands has the potential to cause a variety of responses amongst those in the medical field ranging from disapproval to alarm to dismissal as something that can occur only when a doctor has absolutely no other demands on her time. All these responses stem from the fact that as doctors we are trained to see patients as clinical cases first and as scared and suffering neighbours second. --narayan
then again, as i entered residency, and told my advisor why i chose to live near the clinic, in a somewhat-poor, somewhat-dangerous neighborhood, "where my patients live," he laughed and said, "you can never be in the same place as your patients. you're a doctor, and they're not." he used to live in cabrini green - but never in the same place, after all, as his patients. and in fact, nowadays, now that he has kids, he lives in a very different neighborhood indeed - not near the clinic, or the hospital - not near anything, except a church.
can doctors overcome the 'sentimental distance'? should we? can patients? is it too big a risk, or no risk at all? is it a bigger risk not to do so? is it still medicine, or just cult behavior? is there a difference between being a good neighbor and being a good doctor? should there be? shouldn't there?
