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.

Gus Fring: Breaking Bad’s Management Consultancy Guru

Yesterday, while writing on the corporate deadliness of The Wire‘s Stringer Bell, I noted in passing, some structural resemblances between that character and Breaking Bad‘s Gustavo ‘Gus’ Fring. But, in many ways, Gus goes well beyond Stringer in bringing the corporate to the corner. In particular, in his channeling indiscriminate violence into murderously well-directed and precise outbreaks of mass murder, his attention to the crystal meth manufacturing process, his deference to the men of science, his marriages of the industrial engineer, the accountant, and the factory foreman to the military general and the assassin, Gus outdoes Stringer. Gus builds his empire by an energetic, quietly confident, and slick union of corporate manufacturing schedules and assembly line management with the trade of the traditional drug dealer and thus imbues the brutal, paranoiac violence of the perennially threatened drug trade with a strategic shop-floor vision.  Stringer is merely a dealer; Gus owns the means of production, the machinery, and the workers.

Gus is modern in a very particular way: he facilitates his projects with the precision, efficiency and sterile beauty of technology, relying all the while on the powers of science and its practitioners to sustain and realize his vision.  It is never too subtle a point in Breaking Bad that some of Walter’s initial allegiance to  Gus is underwritten by his acknowledgment of the scientific and technological excellence of the manufacturing unit Gus has put together. Morally corrupt scientists in hock to those who facilitate their deadly work; think, perhaps, of German scientists in the employ of the Third Reich; science and efficiency, in the service of perversion.

Gus is thus too, a classic bureaucrat, deploying science to bring about the most desired and deadly of outcomes. He conspires, arranges, sets up the blade and makes it fall; and yet, while he is a wheeler and a dealer, he remains smooth, never greasy, mannered, never affected. Interestingly enough, Gus is entirely desexualized, and even here, his sexual austerity sets off the rigor of his management style. His attention to careful detail and his measured responses, conquer, or at least keep under control, the awesome, murderous brutality of the cartels. That management style ensures that one of Breaking Bad‘s most floral and lurid moments–the mass poisoning of the Mexican cartel–possesses a curiously contained edge. For the true genius of the mass murder of the cartel’s top leadership did not lie in Gus’ use of poison, his deceit, his willingness to expose himself to deadly risk, it lay in its logistical details, in Gus’ planning for the aftermath: the medical supplies, the doctors, the getaway mechanisms. Amateurs talk tactics, professionals talk logistics. Indeed.

In Gus Fring, we were brought face to face with a business talent par excellence. When he finally meets his match and is killed, we recognize it was because for a brief, fatal moment, Gus allowed his anger to get the better of him, to let passions rule where dispassionate calculations had always held sway.

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.