The hair dresser was obsessesed with hair; the artist was moved by art; the architect was inspired by architecture; the lawyer was fascinated by the law; the doctor, however, was wary of doctoring in case it affected her chances of getting into medicine.
Yes, medicine declares its unusualness as a career even in its name; in fact, for historical reasons in its development it has become very difficult to define (and confine) just what a doctor’s role is. What should the main focus of medicine be? What makes a doctor tick? Where do you think medicine begins and ends and other disciplines take over?
“He had no patience with anything except emergencies or serious illness. When a man continued to complain but had no dangerous symptoms, he reminded himself of the endurance of the Greek peasants and the needs of those in ‘very real distress’, and so recommended more exercise and, if possible, a cold bath before breakfast. He dealt only with crises in which he was the central character; or, to put it another way, in which the patient was simplified by the degree of his physical dependence on the doctor. He was also simplified himself, because the chosen pace of his life made it impossible and unnecessary for him to examine his own motives.” (p. 55)
But it rarely is. People, including doctors, are complex, and many forces bear down on the patient-doctor relationship to complicate matters:
- When does a person decide their illness is bad enough to present to a doctor?
- How ill is the patient, really … compared to other ones that need attention & limited resources?
- How much effort should be expended on getting the patient in?
- A doctor is a person too, and prone to the same weaknesses as anyone else is: how much can we expect from her?
- How much time should be spent on diagnosing? How much money?
- Is the patient telling the truth about the symptoms?
- How much intervention is appropriate in the treatment?
- In treating the patient for this set of symptoms, are we really dealing with their health thoroughly enough? Should we delve deeper and advise on other aspects aspects of health?
Ultimately it is this thing called the human condition that makes medicine medicine; that means a doctor is not a scientist (Skrabanek, McCormick, p. 135); that disrupts the simplicity of a doctor’s relationship with a patient; that makes every case different; that makes medicine so fascinating to the public and so attractive as a setting for drama and television series; that explains why so many doctors have been writers and writers have been doctors; that draws the doctor beyond the arrows of these diagrams into a whole universe of political, social, psychological and philosophical issues.
So, how do we cope with the infinite possibilities opened up and actually get some focus?
Aside from your personal motivations for going in to medicine, which might be any of or a combination of things like money, social status, gaining respect, thrill seeking, helping sick people, finding a cure for cancer, saving the human race; aside from those, there are obviously objective models of what medicine should be all about presented to you as soon as you start studying to become a doctor, and then again when you start practising as a doctor. Models such as hospital medicine, community medicine, private healthcare, public health campaigning.
Each model of medicine will involve you into a different set of concerns, but whichever model you find yourself working in, there will always be patients; that is, people whose state of HEALTH is unsatisfactory to them and who are willing to seek treatment. It is actually this word ‘health’ that creates the problems with defining what a doctor does or should do, because health is so relative, and what we take it to be changes over time and with perspective, it changes across social circumstances and with age, with lifestyle and understanding, and even from person to person. One woman’s health is another man’s agony.
What is the generic dialogue that we find, then, between doctor and patient about health?
Patient: “I’m not feeling well. Maybe there’s something that could be done to help me feel better.”
Doctor: “Tell me more about what’s wrong with you, and I’ll try to figure out what’s causing it and see if there’s something we can do about it?”
Overhearing these vague terms, you read between the lines and most of you are possibly thinking … hospital corridors, nurses, doctors, trollies etc.; in particular, some are thinking body, disease, diagnostic techniques, treatment options, tests, doses. Others are thinking body, disease, scalpel. (Surgeons!) Others might be thinking mind, childhood, therapy and rehabilitation; others, lifestyle, nutrition, exercise and giving up caffeine; and others still chromosomes, coffin, research and Nobel Prize.
But, although in different models of health care they vie for position with different forces such as science, doctors, money, politics etc., for the most part patients and their health are, in the theory at least, put at the centre of all medicine; but even there, due to the human condition again, they can sometimes be viewed, in practice, more as specimens, case studies, political victims, statistics, living engines, characters and nuisances than as, simply & “complexly” fellow people with personal health concerns.
And bear in mind that even if you, in your working life, intend never to deal with patients directly yourself at all, perhaps to escape all this human condition messiness, it’s irrelevant for now, because to get through “medicine” (the course, that is) the profession insists that you have to get familiar with the patient in all his or her complexity so that your private motivations are counter-balanced by the socially-politically agreed needs of your fellow human beings as reflected in our current ideas of THE DOCTOR. It is a difficult balance to achieve, but all doctors must at least strive.
We want to avoid the trend in some American colleges that is reflected in this extract from Jonathan Kaplan’s The Dressing Station ( >>>):
“I want you to examine this man’s abdomen,” [the doctor instructed one of the students]. “Tell me what you find.”
“I’m not sure what I’m looking for,” said the student. “Can I see his laboratory results?”
“Imagine there aren’t any lab results,” said the doctor, knowing that every test report includes a computer-generated list of possible diagnoses. “Imagine you’re in the middle of the jungle.”
“In the jungle?” queried the student. “Some sort of tropical disease? I wouldn’t know about those. I’m going to be a child allergist.”
“OK, forget the jungle. Let’s just say he’s just arrived in the emergency room, unconscious, and you have to work out what’s wrong with him.”
“If he’s unconscious then I definitely wouldn’t be seeing him,” said the student smugly. “He’d go straight to the neurologists for a brain scan.” (p. 74)
Specialisation has altered what doctors do post-training, and yet the pre-specialisation training has remained faithful to an older ideal of the doctor. Has something been lost in the tension? A columnist in the Irish Times some years ago argued that it was the fault of medical schools: “The very first task of medical school is the conversion of the brain from a vital ratiocinative organ for analytical thought and speculation into a machine for storing facts – in other words, a cerebral shoebox containing a vast anatomical index, in which you can find the name of every nerve-ending and every follicle, and also, in an unswept and unvisited corner, a small, withering organ called common humanity.”
This case for the prosecution, as it were, suggests that doctors have become a little short on communication skills, a little out of touch with common people, lacking in sensitivity. The essayist, Lee Gutkind in his introduction to Becoming a Doctor puts it like this: “Sometimes doctors are distant and convey disinterest; sometimes they are egocentric and radiate superiority; sometimes they are angry or frustrated and treat people rudely…”
And it is not just outsiders who think like this. Dr Rita Charon, author of Narrative Medicine, writes: “doctors often lack the human capacities to recognise the plights of their patients, to extend empathy toward those who suffer, and to join honestly and courageously with patients in their struggles toward recovery, with chronic illness, or in facing death. Patients lament that their doctors don’t listen to them or that they seem indifferent to their suffering.”
Charon grants that “technically adequate care” or “scientifically competent medicine” may well be provided to patients, but that often they are abandoned by doctors to deal with their illness alone.
Hmmm. I sometimes wonder about this equation, though, don’t you? I often say to myself, case for the defence, as it were “I’d rather have sound medical treatment by a rude, dismissive doctor than a sensitive, caring doctor making a complete bags of my case. I often feel that we expect far too much of doctors and that it is those high expectations that are the problem not the doctors. Would you hear a dying soldier complaining that a doctor didn’t take the time to talk to her gently before she injected the life-saving antibiotic? Maybe pleasant, polite, punctual and practical doctors are a luxury that not many health care systems or situations can afford. There’s always the next patient to be seen. And even acknowledges in Becoming a Doctor: “the truth is, we ask more of our doctors, especially these days, than we do of people in almost any other profession.””
But, like it or not, that is the profession you have chosen. The brilliant doctor who has a problem with rudeness is just not acceptable: he or she has to rein in the rudeness in order to reach the standards expected. Consider it an honour that people regard you so highly that they believe you capable of living up to those expectations. The fact is: You do not have the right to mistreat anyone on any level. Do you recognise this ….
“I will prescribe regimens for the good of my patients according to my ability and my judgment and never do harm to anyone.”
Your Oath does not say, “never do harm to the health of anyone”; it says “never do harm”. And it is not just sensitive ideals that demand this – there are very pragmatic justifications for paying attention to the full humanity and social circumstances of your patient. As a doctor, trying to do your best for the patient, solve the riddle of their health (Nuland) and ‘crack the case’, you will surely want to give yourself the very best possible chance of succeeding, and the only way to do that is to move with your patient as one, in full trust, understanding, agreement and support. Even if it’s just so that you have a better chance of getting them to comply with your treatment plan, then the entire touchy-feely, lovey-dovey, huggy-wuggy doctor thing is worth pursuing. Why do so many attempts at treating patients only go SO far, that is, as far as where the doctor can’t be bothered going any farther because she feels she’s done her bit, the specifically medical science bit, enough to get her off the hook, and would prefer to leave it to the patient, their family, support staff, the nurses and the system to do the individualisation bit – the final push that could make all the difference in the success or failure of all the good work she’s already put in on the science end of things?
So, if you want to improve your chances of being a good doctor, you do need to know how to read your patients, how to understand them, what they might be thinking, how they are likely to react in different circumstances. I don’t go to the extreme that some do in describing what is required of a doctor: Dr Charon, who I mentioned above, talks about helping patients grapple with the loss of health, find meaning in illness and dying, understand their ordeal, honour the meanings of their narratives of illness, and be moved by what they behold so that you can act on their behalf!!! Now, that’s over the top, don’t you think?
Reflecting on medicine via the arts, including literature, drama, visual art etc. will help you ‘exercise the muscles’ required for this kind of attention for patients. It will put you into situations, imaginatively, that otherwise you might have to wait years to get a sense of. It will put you in other people’s shoes so that you get a whole new perspective on things. It will lay down a sense of how things go wrong between people in challenging situations, and help psych you up and prepare you for them. It will bring you to your senses, let me say that again: bring … you … to … your … senses.
Returning to Berger’s analysis of Dr Sassall, we discover that: “After a few years he began to change. He was in his mid thirties: at that time of life when, instead of being spontaneously oneself as in one’s twenties, it is necessary, in order to remain honest, to confront oneself and judge from a second position. Furthermore he saw patients changing. Emergencies always present themselves as faits acomplis. At last, because he was living among the same people all the time, and because he was often called to the same cottage several times for different emergencies, he began to notice HOW PEOPLE DEVELOP. A girl whom three years before he had treated for measles got married and came to him for her first confinement. A man who had never been ill shot his brains out.”
Today, I read from:
Rachel Cusk’s A Life’s Work (‘Forty Weeks’)
Lorrie Moore’s Birds of America (‘People Like That Are the Only People Here’)
John Berger’s A Fortunate Man – WELL WORTH HAVING, THOUGH QUITE INTENSE >>>
Johnathan Kaplan’s The Dressing Station – WELL WORTH HAVING >>>
Mikhail Bulgakov’s A Country Doctor’s Notebook (‘The Speckled Rash’) – WELL WORTH HAVING >>>
Paul Zweig’s Departures (rather difficult to get, I think)
And didn’t have time for:
Vincent Lam’s Bloodletting & Miraculous Cures – RAW & HELPFUL STORIES ABOUT YOUNG DOCTORS BY A DOCTOR >>>
Ian McEwan’s Saturday
Petr Skrabanek and James McCormick’s Follies and Fallacies in Modern Medicine
Donnacha Rynne’s Being Donnacha >>>