In Confessions of a Medicine Man: An Essay in Popular Philosophy (MIT Press, Cambridge, MA, 2000, pp. 109-110) Alfred I. Tauber writes:
Health care providers have to listen, respond, and generally account for the subjective experience of a patient’s complaint. So much of our discontent can be traced to the too little time the physician spends with a client, and how poorly a true dialogue develops. Focusing upon the clinical narrative, the patient’s rendition of the disease experience offers crucial insight to the physician, both as scientist and empathetic, that is, ethical, healer. Beyond obtaining information that may be important in tending to the patient’s particular physical needs, a patient’s own description of the illness presents the physician with the problem of suffering, and the profound disruption, uncertainty, and pain that disease imposes. To ignore this aspect of illness is to deny the patient’s fundamental humanity and relegate them to the status of object.
In an older post titled Taylorism and the Doctor’s Office I had complained about the slavish devotion to efficiency and throughput maximization visible in the work of the physician; an important component of the dissatisfaction I felt then, one not fully articulated, was that my physicians, my healers, were simply not listening to me:
The patient, meanwhile, many of his questions unanswered, his possible inputs to the diagnostic process ignored, returns home, disquieted by the experience, disillusioned by the wonders of face-to-face contact with a fellow human being, and supposedly a healer at that.
This is a real frustration with serious consequences. As a patient, I have a great deal to tell my doctor about my personal experience of the illness: this is how it feels on the ‘inside’; this is how it affects the way I move, the way I relate to my body; these are the kinds of things I want to do and cannot do; this is how I now see myself in relation to the world and my body. I see these as important inputs into the healing process; I see them as descriptions of my dis-ease, a tabulation of the ways in which I am no longer whole and long to put back together again. My illness is not just a set of physical markers; it is an impairment of my being in this world, and I am best placed to report on a very particular aspect of that fractured relationship.
Because I consider myself a good observer, and a good reporter, I come to each doctor’s visit with a sense of anticipation: I will place these reports and descriptions at the service of my doctor, and he will combine them with his expert physiological, medical, and scientific knowledge to produce the optimum healing package. Together, doctor and patient, interacting with each other, will move to a new co-anchored state of being: the doctor becomes a better doctor by healing, by having his skills honed on this new ‘challenge’; I will return to good health.
But my doctor has no time for such niceties; he cannot be bothered to listen to his partner; he cannot wait to hear the ‘other side’ of the story; he is only concerned with test parameters, visible observations, and quick slotting into categories (and the submission of an insurance claim for payment.) To listen to a patient will interfere with the most efficient ‘best practice,’ the one recommended by the management consultant group in charge of his clinic or hospital.
The patient’s experience of the illness falls by the wayside; it is the least important part of the modern ‘healing’ process. And with that assessment, the patient becomes just as marginal, ready to be objectified.
2 thoughts on “The Doctor And The Silenced Patient”
It is not the fault of the doctor, at least not completely. About half the money in medical care goes to Insurance and management. Dr Alex Lickerman (Happiness in this world blog) has started a primary care. For a reasonable monthly fee (much less than what I pay for insurance) he or his assistant doctor can listen to the patient for more than an hour. You may want to read his opinion about primary care. He is in Chicago. There may be a similar service in NYC.
The problem outlined is the central problem in medicine, and the problem with medical ethics. The trouble is: your doc. is ideally trying to use language in two very different ways when he is having a conversation with you.
Primarily, he is using language to gather information about your immediate complaint in a way that will allow him to correlate your information with statistical data at his disposal. I don’t mean that he is running the numbers, but he is at least plugging your words into a series of models constructed of weighted risks and likelihoods.
Ethically, he is obligated to do his best for you in carrying out that process.
However, what’s best for you is not inherent in that process. To find out what’s best for you, he would have to find out what use you have for your health. He can then advise you based on your valuation of health re: the outcomes his diagnostic and treatment algorithms.
So ideally, he is not just cross-examining you, he is trying to build a picture of your attitude toward being in the exam room, and your attitude toward the problem that brought you there. The second use of language is ideal, but it is not an ethical imperative.
When the information gathering is all that’s happening, it feels adversarial, disrespectful, and a little empty. ‘Cause it is.