Doctors and Their Patients

A Social History

Edward Shorter

• Publisher: Routledge
• Year: 2017
• ISBN:
  9781351521949
• Edition: 1
• Topic: Medicine
• Subtopic: Public Health, Administration & Care

With every passing year, the mutual mistrust between doctor and patient widens, as doctors retreat into resentment and patients become increasingly disillusioned with the quality of care. Rich in anecdote as well as science 'Doctors and Their Patients' describes how both have arrived at this sad shape.

1
Introduction

IN JUNE of 1979 Dr. David Rabin, director of Endocrinology at Vanderbilt Medical Center, started to have feelings of restlessness in his legs. By that autumn he was walking with a limp, and a year later he was scarcely able to walk at all. He had contracted a crippling affliction called Lou Gehrig’s disease. The disease would have been bad enough, but Dr. Rabin was further horrified by the reactions of his medical colleagues.

“One day, while crossing the little courtyard outside the emergency room, I fell. A longtime colleague was walking by. He turned, and our eyes met as I lay sprawled on the ground. He quickly averted his eyes, pretended not to see me, and continued walking.”

Dr. Rabin sought medical help, traveling to a “prestigious medical center” to consult a neurologist. The man was able to diagnose Dr. Rabin’s condition without difficulty, but what surprised Rabin was the neurologist’s “impersonal manner.” “He exhibited no interest in me as a person and did not even make a perfunctory inquiry about my work.” The neurologist made no suggestions about specific daily activities; nor did he give psychological advice about mustering “the emotional strength to cope with a progressive degenerative disease.”¹

After hearing of this tragic story, one listener responded, “I marvel at Dr. Rabin’s naivete. His account of his experiences .. . indicates that he has simply found himself on the unfamiliar side of the typical physician-patient relationship.” Ordinary people have come to expect this kind of treatment from doctors, she pointed out. Other doctors behaved impersonally with Dr. Rabin, not because they were embarrassed at weakness in a fellow physician, but just because Dr. Rabin “had the misfortune to become a patient.”²

I am observing in a “family medicine” clinic. A woman, thirty-one, comes in complaining of deep, constant chest pain, night and day. It’s not relieved by bending forward or lying down. She has other aches about the neck as well, plus a feeling of tiredness so great that she’s had to stop jogging entirely this week and only went out a few times last week. Stress? Apparently none. Her work is going fine. She says nothing about her personal life. “This chest pain is the major problem in my life right now.”

She has already had a chest X-ray, complete blood tests, electrocardiogram, a barium swallow, and a sigmoidoscopy (examination of her colon with a long viewing tube). She is exasperated at the length of time it takes for the results to come back.

In addition, someone forgot her appointment today and let her cool her heels for an hour and a half in the waiting room. She believes the doctor has lost interest in her case and, as someone in a fast-track career who is accustomed to having things happening, wants very much for them to start happening around her now.

While she’s talking, unbeknown to her, things really are happening. Two senior doctors whom the resident has summoned are phoning around the hospital for the results of the X-ray and tests. The tests show anemia. In other words, she’s losing blood somewhere, probably from the digestive tract. An intense discussion is going on over whether it’s an ulcer.

None of this activity is apparent to her. The resident soothes her. “You can be sure we’re taking your problems very seriously.” The resident wants her to come back for another barium swallow. She is irritated and asks whether it is absolutely necessary. She is tired of being “fucked around” by the system.

As a historian, I am well aware that a hundred years ago her problem would have been diagnosed as “hysteria,” and the investigation terminated. In contrast, these postmodern doctors—those trained in a certain style since the 1950s—are intent upon finding out exactly what’s wrong and fixing it. But she, as patients often do, sees only delays, bureaucratic foul-ups, and impassive clinical expressions.

Something is wrong with the practice of medicine today. Although this young woman is receiving far better medical attention than she would have at any other time in history, she is quite possibly feeling worse. Medical knowledge has rapidly expanded in recent years, but medical care has in certain crucial ways deteriorated. For a whole complex of reasons, doctors and patients eye each other with mistrust. A medical encounter today is very likely to produce an explosion of mutual resentment and frustration. And this tension has quite a direct bearing on whether or not the treatment is clinically successful. In other words, medicine is currently in crisis.

My intention, in writing this book, has been to trace the history of doctor-patient relations as they have evolved alongside the science of medicine. It is in this history, especially that of the last century and up to our own time, that we can discover the roots of the present crisis. I believe we will also find, in following that story, significant insights into what the shortcomings of present-day medical practice actually are.

Doctor bashing would be easy in a book like this: lining up the horrible anecdotes and concluding that doctors have become a lot of heartless brutes. But in recounting the story of the present crisis in doctor-patient relations I want to make sure the doctors tell their side as well. You are a doctor practicing in the pain program of the Mayo Clinic in Rochester, Minnesota. Many patients who have intractable pain you are able to help, with drugs, psychotherapy, or surgery. But some you are not. Their pains are agonizing and unendurable but seem to have no organic cause. What’s more, these patients are constantly firing off letters of complaint about how wretchedly they’re being treated and threatening to sue. One, for example, is a forty-four-year-old woman, separated from her husband, whose pain—which nobody has been able to diagnose—has been going on for about ten years. She has had “many falls, operations, treatment failures, and marital problems.” This time in the clinic she says she “stumbled over some physical therapy equipment,” hurting her arm. Nothing appears on X-ray. She develops many other new problems as well, and complains of “anxiety and depression.” When she leaves the hospital, she secretly takes the X-rays with her, has her new doctor send his bills to the Mayo Clinic, and threatens to sue.³

It’s easy for doctors to be unsympathetic to this woman. Even though she feels genuine pain and believes herself to be physically ill, they see her as suffering from a psychiatric disorder. Most doctors would dismiss her as a “crock,” a pain in the neck, and even the psychiatrists who treated her in Rochester would not have admitted her again to their pain clinic. Doctors officially call it “pain of psychological origin,” but her real problem is the “white knuckle syndrome”: not that the patient’s knuckles are white, but that the doctor’s are, every time a patient like this comes through the door.

Thus, for both sides, harsh judgments of the other come easily. But let us for a moment suspend moral judgments. In the 1980s more than a billion encounters between doctors and patients occur annually in the United States. Three-fourths of all Americans see a doctor at least once a year, and the average person has about five contacts a year with a physician.⁴ Many of these contacts end with anger and frustration on both sides.

What is this consultation like that it so frequently produces anger? One British study shows the main features of a typical encounter. You walk in the door and the doctor asks, “What is wrong with you today?” “What’s hurting today, and where is it?” Then occur the actual history taking, the physical exam, the forming of a diagnosis and organizing of a plan of treatment: these procedures will occupy us in considerable detail in this book. Then the consultation ends, a common way being the physician’s “symbolically tearing off a piece of paper and offering no explanation, only a set of instructions.” Patients often find these highly directed consultations unsatisfactory, because the doctor is so intent upon dealing with the main symptom, or “chief complaint,” that patients don’t have a chance to express what is really on their minds.⁵

Consider this young woman whose “chief complaint” is painful diarrhea. The doctor asks her a number of questions about her attacks and where she feels pain. Each question is precise:

Doctor: Any particular sort of foods upset you?

Patient: At one time I did knock off the fats; fatty foods, you know.

Doctor: Does it make any difference when you have them?

Patient: No, not really. Well, I put a bit of margarine on and scrape it off again....

Doctor: Do you get any other trouble, apart from the pain and sickness?

Patient: Well, I don’t know whether this has anything to do with it. . . . (She begins to cry. The telephone rings.)

Doctor: (after finishing the phone call): You were telling me you’ve had this [vaginal] discharge. How long have you had that?

Patient: (talking rapidly, still crying): I’ve had a D and C [an operation to scrape out the uterus] and I thought . . . and there it was .... He said I should have told you....

(The doctor obviously does not want to hear any more about the D and C or why she’s so upset about the discharge. Even though she is still trying to blurt it out, he changes the subject back to her diarrhea.)

Doctor: I see. Do you get any indigestion, wind or any of that sort of stuff.. .?⁶

Many doctor-patient encounters of this nature add up to a crisis: frustrated patients, unable to express what is really troubling them, and doctors irritated by what they see as an avalanche of trivial symptoms, both blindly caroming off each other to end up later at cocktail parties, venting their anger with amusing stories.

As I shall demonstrate, consultations of this nature were quite unusual in the days before postmodern medicine. We shall follow the story of the massive breakdown in doctor-patient relations from the side of both the doctor and the patient.

The doctor’s transformation began in 1945, with the diffusion of mass-produced penicillin to the civilian population, just after World War II. In the next decade a whole series of antibiotics became available, effective mainly against bacterial infections. It is difficult for us to recall now how dramatically these “wonder drugs” transformed our encounter with disease: pneumonias that had previously swung the balance of life and death were now whisked away; rheumatic fevers that earlier had left patients with permanently damaged hearts now vanished with a few pills; gonorrheas, which once young men gave to their wives at marriage, cursing the couple to a lifetime of infertility, could now be cured with a course of tablets. And the antibiotics were just the beginning. In the 1950s and 1960s came other drugs: medicines for preventing inflammation in the joints and the kidneys, making the arteries larger in fighting high blood pressure or making the blood vessels smaller in fighting shock, causing the heart to beat more slowly or more rapidly, composing the mind, and thinning the blood. Never before had medicine possessed—with a few exceptions we shall read about—drugs that could actually cure disease. After this incredible leap forward in drug therapy, one could more easily list the diseases that couldn’t be cured than those that could, so numerous had the latter become. (Granted, viral infections have remained untreatable, as have a number of diseases that affect relatively small numbers of patients.) Even some cancers, with the exception of those caused by smoking, have in the 1970s and 1980s acquired favorable prognoses (chances for recovery) as a result of this incredible therapeutic revolution.

These stunning changes were not confined to drugs. Becoming disoriented and confused? We’ll clean out the arteries that supply blood to your brain with a scraper. Blood in the stool? We’ll find out what’s wrong with an endoscope. Feeling tired and run down? By the 1980s entire new sciences, such as immunology and clinical biochemistry, have a good chance of figuring out why. Most practicing doctors before World War II had only the vaguest notions of what the chemistry of the body entailed.

The upshot of all these changes was to fill doctors with an aggressive new confidence about their ability to diagnose and cure disease. Postmodern medicine is characterized not only by its ability to diagnose with near certainty what’s wrong with you, but to cure it as well. This is the revolutionary feature: the ability to cure disease, an ability that doctors had never before possessed.

The medical profession now bristles with new self-confidence. I asked a young family doctor, once you succeed in making the diagnosis, do you think you can cure whatever the patient has?

“Oh, absolutely,” she replied.

This is wonderful, right, the ability to cure disease? Indeed it is. But this new medical enthusiasm has had a transforming effect upon the doctor-patient relationship, causing the doctor to be much more disease-oriented and less patient-oriented. Being disease-oriented means that you, the doctor, basically believe the patient has some kind of physical disease, the result perhaps of the invasion of a microorganism (such as a cold) or of a degenerative process (such as osteoarthritis), and that you believe your job as a doctor is to diagnose and appropriately treat that disease. Therefore, encounters with disease-oriented doctors are likely to lack, for the patient, a certain human dimension. Such doctors tend to be perfunctory in history taking (not believing the “history of the illness” to be all that revealing); to be concerned principally with gathering diagnostic data and interpreting it with specialists; and to evidence little personal interest in the patient. It is not that they are ««interested in patients and their personal problems. It is just that there is no medical need to show interest.

But so what? As long as the doctor diagnoses and fixes what’s wrong with you, does it matter whether there’s a little heartburn? The mechanic that fixes your car may be gruff, but at the end the thing runs, and who needs a blabby mechanic? But it does matter, because patients are different from cars: about a quarter to a third of the symptoms that a family doctor sees are not the result of well-defined disease processes. Instead they are of psychological origin. They arise in the mind and spread to the body, from “stress” perhaps or from some disorder of the mind, but not from the usual causes of disease that one learns about in medical school. And disease-oriented doctors are unable to do much for these “psychosomatic” or “psychoneurotic” conditions, because these doctors lack the sympathetic relationship to the patients that is a precondition of their cure.

It is my belief that doctors before World War II focused more strongly on the person than on the disease. Because of this sympathy for the patient, they had far better results treating so-called psychosomatic disease and psychoneuroses than doctors do today.

Two preconditions are necessary for the cure of disease of psychological origin: (1) the opportunity for the patient to explain the symptoms and their presumed origin thoroughly in a relaxed conversation with the doctor; (2) the patient’s implicit belief in the powers of modern medicine, and thus in the doctor’s ability to effect a cure, whatever the doctor does. All of this brings us to the second half of our story, the patient’s track.

In the years since 1960 several aspects of the world of the patient have changed. There has been an enormous increase in the number of symptoms for which patients seek relief. Presumably patients in the 1920s, or in the fourteenth century, felt an itching ankle or a stomach pain as acutely as people do today. What has changed is the patient’s willingness to define bodily symptoms as an illness and to seek help for this illness. Patients in the 1980s are far more willing to rest up or consult a doctor than ever before. And the glut of illnesses created by this willingness has swamped not only ...

Table of contents

• Cover Page
• Title Page
• Copyright Page
• Table of Contents
• History of Ideas Series
• Abbreviations Used in the Notes
• Introduction to the Transaction Edition
• Preface
• 1 Introduction
• 2 The Traditional Doctor
• 3 The Traditional Patient
• 4 The Rise of the Modern Doctor
• 5 The Making of the Modern Patient
• 6 Disease of Psychological
• 7 The Postmodern Doctor
• 8 The Postmodern Patient
• 9 Psychological Disease and Postmodern Medicine
• Notes Chapter One: Introduction
• Suggestions for Further Reading
• Index