Lisa Freitag says:

Dr. Lisa Freitag is a former pediatrician in Minneapolis, Minnesota.  She wrote some guest posts for us in 2013, and we are delighted to have more of her insightful presence here. This is the second half of the third (and last) part: Part 3a is here; Part 2 is here; and Part 1 is here. Part 3b has been reposted from its original posting due to technical problems.

According to Arthur Frank, whose academic theories on the doctor-patient relationship began to crystallize in his book about his own illnesses, At the Will of the Body, doctors are not really caregivers. This seems counter-intuitive, since medicine is supposed to be the most caring of professions. However, doctors do not know how to act towards their patients as persons. Frank states “I reserve the name “caregivers” for the people who are willing to listen to ill persons and respond to their individual experience.” (48) His own doctors, he says, rarely did this, instead dealing with him merely as a malfunctioning body in need of repairs. If doctors relate only superficially with others in illness, they seem unlikely to have a template for dealing with themselves as patients either.

These misconceptions are perhaps ultimately destructive to the formation of a human relationship between doctor and patient, no matter which side of the relationship he finds himself on. This is demonstrated well in the opening chapter of Sherwin Nuland’s famous book, How We Die, where he reports his first encounter with death. The patient was a middle-aged man who died of a massive heart attack while the young Dr Nuland was examining him. Nuland goes to great lengths to convince the reader and himself that it wasn’t his fault. He does this, not by grieving at human mortality, but by transferring the blame to the patient. Nuland’s description of the dead man and the destructive life style that brought him to his early death, borders on hatred. Nuland describes the man’s “flabbiness,” his “gluttony,” his laziness at taking a sedentary desk job, and compares this “high pressure boss of large, tough men” to his own 22 year old “boyishness.” Though he admits that these were not known risk factors at the time, these are disdainful words that imply a sinful life. The man was ultimately responsible for his own demise, not because he is mortal, just as Dr Nuland is, but because he lived in wrongness.

Arthur Frank sees illness as a chance to witness the mortality which we all share. Instead of  recognizing, and perhaps mourning, their common humanity, Dr Nuland distances himself by describing the man’s shameful life-style. One can assume that Nuland himself does not do all those naughty things, and can therefor believe he himself is safe from such a death. He spends the rest of the chapter, and indeed the book, describing in detail the ways in which the body can betray its owner, always with the idea that this knowledge, applied scientifically, will prevent death. I suspect that Dr Nuland’s own death will come (came?) as quite a surprise to him.

It is far easier to blame the wrongheaded patient rather than mourn the fact of death. Indeed, we were taught in medical school that mourning is out of place. We were supposed to create an emotional distance between ourselves and our patients. This was called maintaining objectivity, and is, we understood, a necessity, if one is to be a rational scientist. As Frank has recognized in At The Will of the Body, this distancing leads to thinking of patients as merely broken engines in need of repair. The person inside is largely ignored, except as the means which medical instructions will be carried out. The person, submitting to the will of the medical system, becomes a compliant body.

So what is a doctor to do when his own body escapes control and betrays him to illness? He must resent not only the sudden possession of a now-defective body, but also struggle to find a place to shift the blame for its failure. He must either accept that, like his patients, he might be mortal, or work to forget that medicine is not infallible. At the same time, he must willingly subject himself to becoming a body in the eyes of his peers.

All of these things are in operation when I become a patient, though I have, so far, not had a fatal one. I am surprised to find myself unprotected from sickness, and feel angry because I can’t think what I might have done to deserve it. Having at times seen illness as Dr Nuland does, as a sign of weakness in others, I find it nearly impossible to forgive it in myself. At the very least, I have failed to exert proper control over my body. It doesn’t help that I know precisely what has gone wrong, what that failure might lead to, and how painful it is likely to be to attempt to correct it.

Which is why, at the six week follow-up visit after surgery to fix my broken arm–which I honestly considered skipping altogether–I was completely inappropriate. I was annoyed that I was there, reluctantly complying with an unnecessary recommendation. My fractures were healing quite well, due to hard exercise and the help of some very good physical therapists. The orthopedic surgeon seemed inordinately pleased at his success with my operation, as though he still considered my arm partly his possession.

At one point, he told me, as though imparting a special confidence to a fellow doctor, that he liked the outcome so much that he was going to use the same “surgical approach” more often. It seems that he had put the incision on my shoulder in a different spot than usual. This was because he didn’t want to bother moving my unresponsive body between the surgery on my elbow and shoulder. I managed, just barely, to avoid saying what I was thinking, which was that this seemed terribly lazy to me. He looked, briefly, a bit confused by my horrified silence. Then he relaxed. He didn’t say anything, but he might have been thinking, Oh, right! Doctors are terrible patients. There was a small, indulgent chuckle.

I guess I was supposed to display more gratefulness. Or less implied skepticism at his talents. I feel kinda bad about this, but not bad enough to come back, as he wants me to, in another six weeks, so he can further admire his handiwork.

Lisa Freitag says:

Dr. Lisa Freitag is a former pediatrician in Minneapolis, Minnesota. She wrote some guest posts for us in 2013, and we are delighted to have more of her insightful presence here. This is the first half of the third (and last) part; Part 2 and a link to Part 1 are here. We’ll finish Part 3 in the next couple of weeks, between posts from Laurie and Debbie.

People have said, “Doctors make terrible patients,” to me, usually with a little indulgent laugh, as a sort of joke meant to partly excuse a demonstration of un-patiently behavior on my part. Maybe doctors as a group are bad at receiving care; I certainly am. I am a terrible patient.

I curse, I scowl, I second-guess science, and I resolutely refuse to be cheerful in the face of adversity. I resent the whole package of being ill; the discomfort, the weakness, the interruption of better plans, and especially the reduction in status from person to patient. Waiting in a room full of other supplicants for access to the purveyor of all that is holy, creates in me a gnawing and impotent anger. The knowledge that, at a different time, I held this power over others, and believed it to be benign does not improve this anger. While I was working as a doctor, I felt rather put upon, because there was only one of me, and all those people were out there in my waiting room, waiting for beneficence.

Although I suspect that I am not the only doctor who harbors a creeping uncertainty about the truths of the religion that is medicine, very few have ever admitted it to me. I have witnessed very few of my fellows during illness, so I cannot vouch for their terribleness as patients. I cannot assume that my reasons for being a doctor who is a bad patient are typical, nor can I support the hypothesis that doctors universally suck at patienthood. But some of the things I was taught over the years, do seem to indicate that doctors would, in fact, be unlikely to adapt well to the role.

One of the first things we learned in medical school is that doctors do not get sick. Of course, doctors get the flu, or feel crappy, but there are no offers of sympathy, no postponements of work to be done, no allowance for time off. Any display of weakness, or need for allowances is considered inappropriate. Your personal life must not interfere with the important work of medicine.

When I was in my third year of medical school, one of the interns, two or three years ahead of me in training, got stomach flu while on call. After a few hours of vomiting and diarrhea, he thought he might be getting dehydrated. So he started an IV on himself and continued working. Somewhat later, a mother, not recognizing him as a doctor with his scrubs and IV pole, complained that a “patient” was examining her child. The intern was reprimanded for his error, but he was not sent home to recover in peace. He merely heparin-locked the IV while seeing patients, so that it would not be visible.

This was not an isolated incident. Doctors never call in sick. If you get two hours of sleep the night before, or have a low-grade fever, or feel like you might be coming down with something, you go to work. One of my partners worked until noon the day he had surgery on his back, because his procedure wasn’t scheduled until 1:30 PM. The same guy never forgave me for my son’s premature birth, not because I had stupidly failed to recognize signs of early labor and continued working, but because my sudden absence really messed up the schedule.

Thus doctors spend all day examining the bodies of sick people, while not tolerating any sickness in themselves or their peers. The combination of ignoring one’s own body while spending every waking hour attending to the needs of others’ broken bodies, cannot be healthy. This dissonance between realities breeds, I think, a general disrespect for the body and its functions, and a specific suspicion of the person who is ill. Being sick becomes an inability to control the body, a sort of failure of character.

The main thing one learns in medical school is medicine. Tons upon tons of science, all directed at the battle against disease. To keep being a doctor, one must be convinced of having a chance of actually winning. So we forget what that we know all bodies must eventually break down, and concentrate on bolstering the body’s defenses. Many patients these days are offered only optimism, encouraged to hope for a cure, even if one is unlikely. At the same time, doctors often know from experience what the worst looks like. In a serious illness, a doctor must walk a tightrope between hope and despair, remembering past triumphs and failures in similar situations. Suppression of this knowledge can become a necessary component of maintaining the proper optimism.

The refusal to display or acknowledge illness reinforces the popular image that being a doctor confers an immunity to the things that plague the rest of the world. There is some implication that doctors deserve this reward. Doctors themselves seem to accept, if not expect, the benefits of their superiority, from waived parking tickets to large incomes. Apparent immunity to illness is another perk, explained away scientifically by the assumption that doctors supposedly enjoy the very best insurance and preventive medical care. Thus, we can bury quite deeply both the knowledge that we might become seriously ill and the fact that death is inevitable. When another doctor needs medical care, everyone involved is reminded that it is a fiction, and the illusion fails. Neither doctor nor doctor-turned-patient appreciate the reminder.