Tuesday, November 24, 2009


I admit I entered medical school with a few surreal fantasies.

One concerned patient contact. Recall photos from Sunset magazine’s 1960s kitchens: perfectly coiffed and composed chefs in dove-white aprons conjured never-fail souffles. I imagined myself like that in practice—the white-coated scientist who, floating above worldly concerns, dispenses cures to ever-grateful patients.

It didn’t take extensive ward experience to reveal that image as not only arrogant, but impossible. I learned that the juice in this career I was taking on lay in precisely the opposite direction, getting fully into it with sick people. Each successive year I found myself more enthralled with people’s stories: the meanings they made of their sicknesses, the coping strategies they crafted, the lessons they learned.

At some point I completed my leap across the chasm. Whatever medications or advice I supplied, it often felt in essence like I was operating a high-tech turnstile, patching folks up so they could return to their same-old same-old. Now, having chosen to have no medical responsibilities, I can listen to people fully, without physician filters in my ears, and I love it. Of course, I’ve noticed that my role has changed, from objective scientist to, well, friend.

That’s why I got rattled when a psychologist buddy sent me a column from one of her professional journals. Written by the journal’s resident ethicist, it responded to a query from a Dr. T.

Dr. T. is a psychologist in a small town, and also happens to sing with a band. One of her clients is Ms. G., a woman in her eighties with cancer. During one of their sessions together, Ms. G. leaned over, placed her hand on Dr. T.'s, and said, “It would mean so much to me if you sang at my funeral. Would you do that for me?”

Touched, Dr. T. wanted to say yes, but a little voice inside her said that might constitute what’s called in psychotherapy a “dual relationship,” defined as contact outside the office. I’m your psychologist, say, but what would it mean if I also played tennis with you? How might that affect our therapy’s dynamics? Can we go to the movies together? Can we date? You see where I’m going. Dual relationships can be hazardous, especially given the perceived difference in power between the two people. Are our transactions outside the office by genuine mutual consent, or is one of us simply acceding to the other’s power?

Listing several potential issues, the ethics columnist advised Dr. T. to think about it carefully before answering Ms. G. One issue he explored was confidentiality: is it alright with Ms. G. for her friends and relatives to learn, as they will, that she was seeing Dr. T. for psychotherapy? Another was consistency: how will Dr. T. respond to future requests to sing? And what about transference and countertransference?

My psychologist friend and her partner, who together have a century of experience counseling people with cancer, wrote to the journal that they disagreed with the ethicist’s advice. They said he failed to note Dr. T’s commitment to the client. “In this situation,” they wrote, “you enter into the relationship wholly or not at all.”

I agree with them. As Wavy Gravy famously observed, “We’re all bozos on this bus.” Sometimes the most stainless chefs need to get a little butter and chocolate on their hands. I’ll be in Ms. G’s shoes soon enough, and when I am, whom would I like around me, those who love me unconditionally or people behind starched aprons?

How would you answer Ms. G.'s request?

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