The Doctor And The Silenced Patient

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.

Ben Jonson on Doctors

A few weeks ago, I had made note here of a brief excerpt from Molière’s Love’s the Best Doctor, which rather pungently satirized doctors. Today, here is another master of comedy–Ben Jonson–on doctors. (A personal reminiscence follows.) As an added bonus there is some skepticism directed at the cost of medicine, the products of the pharmaceutical industry, and the legal system. (Sort of.)

From Volpone, Act One:

CORBACCIO: How does your patron?

MOSCA: Troth, as he did sir; no amends

CORBACCIO [deaf]: What? Mends he?

MOSCA: [shouting]: No, sir. He is rather worse.

CORBACCIO: That’s well. Where is he?

MOSCA: Upon his couch, sir, newly fall’n asleep.

CORBACCIO: Does he sleep well?

MOSCA: No wink, sir, all this night.  Nor yesterday, but slumbers.

CORBACCIO: Good! He should take

Some counsel of physicians. I have brought him

An opiate here, from mine own doctor –

MOSCA: He will not hear of drugs.

CORBACCIO: Why? I myself

Stood by while ‘t was made, saw all th’ ingredients,

And know it cannot but most gently work.

My life for his, ’tis but to make him sleep.

VOLPONE: [aside]: Ay, his last sleep, if he would take it.

MOSCA: He has no faith in physic.

CORBACCIO: Say you, say you?

MOSCA: He has no faith in physic: he does think

Most of your doctors are the greatest danger,

And worse disease t’ escape. I often have

Heard him protest that your physician

Should never be his heir.

CORBACCIO: Not I his heir?

MOSCA: Not your physician, sir.

CORBACCIO: O, no, no, no,

I do not mean it.

MOSCA: No, sir, nor their fees.

He cannot brook; he says they flay a man

Before they kill him.

CORBACCIO: Right, I do conceive you.

MOSCA: And then, they do it by experiment,

For which the law not only doth absolve ’em

But gives them great reward; as he is loath

To hire his death so.

CORBACCIO: It is true, they kill

With as much license as a judge.

MOSCA: Nay, more;

For he but kills, sir, where the law condemns,

And these can kill him too.

Possibly irrelevant aside: In my time here in the US, I have been misdiagnosed precisely twice. These occasions still remain the only two such instances in my life thus far. In the first case, I was living in Harlem and sought treatment at a doctor’s office that promised walk-in consultations. A brusque, cursory check-up later, I was presented with a diagnosis that seemed wildly off-base. Despite my protestations, I was quickly shown the door. Shaken at this treatment, I made an appointment with an Upper West Side physician who was on the money. In the second case, I was living in Fort Greene, Brooklyn, and desperate to secure a doctor’s appointment quickly, wandered over to Myrtle Avenue and sauntered into a rather dingy looking clinic. I was only a few blocks away from the considerably more well-heeled DeKalb Avenue. The doctor conducted a rushed examination, pronounced his diagnosis, and once again, I was ushered out the door quickly. I was diagnosed correctly a week or so later after I had sought a second opinion.  The common element to these encounters was that in each case I was seeking medical help in what might be termed a ‘not-so-fortunate’ neighborhood.

Excerpt from: Ben Jonson, Three Comedies, Penguin Classics, London, 1985. (ed. Michael Jamieson) pp. 60-61

Molière on the Modern Healthcare System

There are times, when overcome by irritation at our modern medical system, which is expensive, run by insurance companies and all too often, populated by doctors who seemingly aspire to ever greater heights of corporate efficiency even as they resolutely neglect their bedside manners and care little about outcomes while ordering an array of expensive and unnecessary diagnostic tests, I descend into bitterness, muttering dark imprecations about how far the two professions that I admired as a child–journalism and medicine–have fallen.

At moments like those it is best to comfort oneself with a little Molière on doctors; he seems to have anticipated the modern, insurance-company run medical system too.

From Love’s the Best Doctor, Scene Two:

LISETTE. What do you want with four doctors, master? Isn’t one enough to kill the girl off?

SGANARELLE. Be quiet. Four opinions are better than one.

LISETTE. Can’t your daughter be allowed to die without the help of all those fellows?

SGANARELLE. You don’t mean to suggest that doctors do people in?

LISETTE. Of course they do. I knew a man who used to maintain that you should never say such and such a person perished of a fever or pleurisy but that he died of four doctors and two apothecaries.

SGANARELLE. Be quiet! We mustn’t offend these gentlemen.

LISETTE. Upon my word, master, our cat fell from the housetop into the street a while back and yet he got better. He ate nothing for three days and never moved a muscle. It was lucky for him that there aren’t any cat doctors or they would have soon finished him off. They would have purged him and bled him and –

SGANARELLE. Oh, be quiet, I tell you! I never heard such nonsense. Here they come.

LISETTE. Now you will be well edified. They will tell you in Latin that there is nothing wrong with the girl.

Enter DOCTORS TOMÉS, DES-FONANDRÉS, MACROTIN, BAHYS

….

DR. TOMÉS. Well, while we are talking, what is your opinion of the controversy between Dr. Théopraste and Dr. Artimius? It seems to be dividing the whole faculty into opposing camps.

DR. DES-FONANDRÉS. I’m on Artimius’ side.

DR. TOMÉS. Yes, so am I. Of course his treatment, we know, killed the patient, and Théopraste’s ideas might have saved him, but Théopraste was in the wrong all the same. He shouldn’t have disputed the diagnosis of a senior colleague. Don’t you think so?

DR. DES-FONANDRÉS. No doubt about it! Stick to professional etiquette whatever happens.

DR. TOMÉS. Yes, I’m all for rules – except between friends. Only the other day three of us were called in for consultation with a man outside the faculty. I held up the whole business. I wouldn’t allow anyone to give an opinion at all unless things were done professionally. Of course the people of the house had to do what they could in the meantime, and the patient went from bad to worse, but I wouldn’t give way. The patient died bravely in the course of the argument.

DR. DES-FONANDRÉS. It’s a very good thing to teach people how to behave and make them aware of their ignorance.

DR. TOMÉS. When a man’s dead he’s dead and that’s all it amounts to, but a point of etiquette neglected may seriously prejudice the welfare of the entire medical profession.

Hail to the Mighty Nurse

When I was a mere nine years old, I underwent a tonsillectomy, a minor operation that surprisingly enough, in those days, required general anesthesia. My mother spent as much time as she could with me in the hospital, but my constant companions otherwise were the military hospital’s nurses. I might not have been a teenager, but I was still, mysteriously enough, old enough to develop crushes on many of the nurses who did the rounds and attended to my many needs. They wore impossibly starchy uniforms, as befitting those serving in the armed forces; they were prim and proper; they were firm, kind and efficient. I wasn’t sorry to say goodbye to the hospital ward but I did feel more than just the passing pang on waving goodbye to my merry band of temperature-taking, brow-stroking, bedsheet-smoothing caretakers.

Some thirty-five years on, nurses don’t cease to impress. My daughter’s entry into this world was most proximally brought about by the deft handiwork of an obstetric surgeon, but it was considerably and significantly facilitated by a hardworking and attentive group of nurses. From initial admission to prep work to recovery, a nurse was always there, providing expert, experienced care, offering words of advice, caution, and sometimes gentle reprimand too.

My wife and I spent two nights in a maternity ward after the birth of our daughter, and from the time we entered its rooms to the time we left, we were in the care of its nursing staff. I described my anticipation of my firstborn as a mixture of excitement and terror, and the most active factor in the mitigation of that terror was the maternity ward nurse. I always expected fatherhood to involve a great deal of on the job training; I didn’t realize that my first and most visibly accomplished teachers would be a group of nurses.

They knew how to handle newborns with just the right mix of firmness and gentleness; they were champion swaddlers and they knew how to teach its moves to an utter novice like me (I still haven’t mastered the really, really snug wrap, but I’m getting there, keeping their finished product as an aspirational goal); they knew how to change diapers with ease and minimal fuss (and they expertly shepherded me through my first diaper change disaster too); they were, in all the important ways, my hand-holders through my first trepidatious steps through the valley of fathering.

After we left the hospital to return home (but possibly even before) I wondered about how many families the experienced nurses had seen entering their wards with their newborns in tow, how many lives they had kicked off, how many anxious parents’ queries they had answered, how many anxieties they had smoothed over, how many bumblers they had turned into quasi-competents, able to approach the task of rearing a child with just a little confidence.

The world of medicine has often not taken adequate care of these indispensable components of the medical system; doctors have often not acknowledged how their work would be impossible without their assistance; and more than one reformer of the medical system has sought to underwrite their vision via a diminution of their role. They are often invisible, unacknowledged, and unappreciated. Be nice to one the next time you see one or need one.

Note: Support nurses unionizing!

Taylorism and the Doctor’s Office

From this vantage, distant point in my life, childhood meetings with doctors, whether at home–they still made house calls–or whether in the doctor’s clinic, appear as encounters with quasi-avuncular figures, benevolent, mostly-solicitous contacts with a wise, ostensibly caring person. I experienced my share of childhood illnesses, suffered from minor ailments, and almost always looked forward to meeting the doctors who treated me. Consultations took place in their office; preliminary wait in a reception, and then entry into the sanctum sanctorum; I sat on a stool next to the doctor’s desk; the doctor was nearby, walked around to his desk to examine me, and sometimes for more extended examination, moved me to an adjoining recliner. While the waits in the office were sometimes onerous, once told the doctor would see you, you got just that – a ‘meeting’ with the doctor. The doctor’s consultation space seemed made for healing.

The times, they’re a changin’.

To visit a doctor now is to experience a cold, unrelenting blast of Taylorist air, a journey through a land dotted with toll-collectors, each aspiring to rapid and efficient quota completion. You make an appointment and wait in the reception like you always did.  Then you are brusquely asked for your insurance forms, and made to fill out–just like at every other doctor’s office that you’ve been to before–a pile of horribly photocopied forms that ask for details on your medical history, whether you’ve understood your privacy rights, and a host of other legally required disclaimers. Then you wait again. When called in, you don’t meet the doctor. Rather, you are ushered into a small consultancy room, cold and bare, while an assistant screens you by conducting a preliminary examination. (You might have to wait a bit before the assistant shows up.) This preliminary examination over, you are left alone again, sometimes clad in a paper gown.

Then, the doctor–whose voice and form can be dimly discerned as he rushes about in the corridors outside–shows up; clearly in a whirl and a tizzy combined, he is brusque, efficient, and keeping an eye on the clock and his production schedule, his throughput. He reads the pre-examination form quickly, asks a few rapid questions–more often than not, not listening too closely to the stream of information a patient can provide on his body, his ailment–dispenses a quick, snap judgment, and leaves. A battery of tests is ordered; pharmaceutical prescriptions written; and you are told that the ‘assistant’ and the ‘receptionist’ will tie up loose ends. You change, head out the door, are reminded by the receptionist that the co-payment is due, and then, it’s all over. You emerge, blinking, into the sunlight, feeling not so much healed, but as if you had been trussed up, placed on an assembly belt, and had several pounds of flesh withdrawn – by the insurance company, by the doctor’s clinic.

The doctors maximize movement through their clinics; the tests ensure expensive bills can be sent in for insurance claims; the prolific prescriptions pad pharmaceutical profit accounts. 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.