Monday, March 15, 2010

NO ONE SHOULD BE ALLOWED TO TREAT A DISEASE THEY HAVEN’T HAD THEMSELVES


There was a fine piece in the NY Times last week about when doctors become patients. You can find it at http://well.blogs.nytimes.com/2008/02/08/when-doctors-become-patients/?pagemode=print.

Here’s the issue: patients and doctors live in two different worlds.

In the late 1970s I taught a community college course called “Philosophy of Health.” One session was spent role playing. People paired off, and for five minutes one of the pair played “patient” and one played “doctor.” Then they switched roles. Finally, we discussed what they'd experienced. Virtually everyone, every time we did it, commented on the polar difference in roles.

A typical response was, “When I was a patient I felt relatively helpless, ignorant and dependent. When I played doctor I felt I needed to look intelligent, competent, and in control. Neither role felt comfortable.”

If such observations surfaced after only ten minutes of play, consider how thoroughly these roles are internalized after they’re enacted dozens of times as a real patient, and over decades as a physician. We become the roles we play, forgetting that this isn’t actually who we are.

I viewed a videotape shot a few years ago, in which actual oncologists role-played patients in a support group to an audience of their colleagues and staff. The only coaching they’d been given was the assignment of a diagnosis. Their play was in three acts. In the first act, the “patients” ad libbed about what it was like to have cancer. After a short intermission they returned to their places, but now in makeup: bald, pale and bruised, pushing IV poles, they expressed the tribulations of treatment. After another intermission they returned again, surprised to find one seat empty. In this third act they spoke about death and dying.

Considering the complaints I hear about how some doctor was cold or impersonal or uncaring, this video startled me: these oncologists played patients with nuances professional actors would have missed.

When we doctors seem dispassionate, then, it’s not because we haven’t noticed suffering. The fact is that we’ve noticed it in detail, but we’re not practiced at dealing with it because we suffer a particular occupational hazard, expressive aphasia. What’s that? We unconsiously but obsessively respect our profession’s taboo against expressing feelings. In short, emotion isn’t germane to science. Though the human condition is probably comprised more of emotion than intellect, medical training coerces us to believe it’s an either-or game. Doc, you better keep your white coat between you and all that messy patient emotion.

The task, though, is impossible. If you make your living sticking your fingers into people’s orefices, you’re emotionally involved with them, period. When you daily wade in suffering, you’re absorbing it like butter into hot toast. Suffering is the given. The question is what do we do with it? Well, repression is one time-honored strategy, but over the long run it's a prime cause of physicians' suboptimal health statistics. As a member of one of our support groups said, “Buried suffering is always buried alive.”

This is why being a doctor is poor preparation for being a patient. Over the years, I’ve known a half-dozen doctors who attended cancer support groups as patients. Every one of them told me the switch in roles blew their minds. The ones I knew in practice were fine physicans, competent and kindly, yet still were shocked by how much they had failed to notice in their patients before they themselves got sick.  The gap between the world of the patient and that of the physician is so striking and so central to genuine healthcare (that is, health “care”) that I’m astonished it’s so under-addressed in medical training. 

I’ve related here before the comment that arises occasionally in our cancer support group, “No one ought to be allowed to treat a disease they haven’t had themselves.” Funny though this strikes us, it actually describes the “wounded healer,” the archetype at the heart of the Hippocratic tradition.

Treatment that doesn’t connect hearts is just plain mechanics. I love mechanics; it works, and it does us good. And it’s exactly half of what we need.

P.S....
I'll be on a radio show tomorrow, March 16, 9-10AM PDT. It’ll be on a community station in Mendocino, California, available live online at www.KZYX.org. I'll be discussing healthcare reform with Dr. James Morone, Chair of the Political Science Department at Brown University, and Dr. Richard Louis Miller, noted psychologist and agent provocateur.

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