The Language of Medicine
In this chapter and the one that follows, we convey to you some important notions about communicating with patients. We attempt to do so in simple English. We intend no disrespect for the often elegant, always parsimonious, and usually dispassionate language of medical science. Indeed, we were tempted to adopt a tone that was more traditional. A slew of possibilities for chapter titles came to mind—Facilitating Effective Communication Skills in the Doctor–Patient Relationship, Interviewing Skills for Health Professionals, and so on—but we refrained.
The reason we refrained has to do with the often unappreciated impact of language in the actual conduct of medicine. Let us illustrate this with a truism: The bulk of communication between doctors and patients occur in language. We “speak,” of course, in many ways, but usually in words. Therefore, giving some thought to the words we doctors and patients use to talk to each other may not be entirely trivial. Consider the doctor–patient relationship by means of simple analogy: Imagine a collaboration similar to that between a pair of mountain climbers. Their goal is to reach the top (develop an effective healing partnership). The route to the top is never entirely known in advance and requires ongoing cooperation and communication as the ascent proceeds. (The doctor–patient relationship is a process that evolves collaboratively over time.) In this analogy, we might add that one of the climbers is far more experienced in this sort of mountaineering; he has been on many similar climbs and thus often acts as an authority and guide. (The doctor has experience and expertise the patient expects, and on which the patient relies.) Still, the climbers must tackle the mountain together, and their fates are fundamentally intertwined as they make their way up a sometimes treacherous and uncharted mountain face. Finally, these two climbers—whose roles are collaborative, although not isomorphic—are bound together by critical linkages: ropes, pitons, mutually understood signals, and other means of communication. In the doctor–patient relationship, our ability to talk with each other becomes our essential arsenal of ropes and pitons. We are linked not with hemp and metal, but with words, empathy, respect, and mutual trust. To succeed, we must be able to communicate; we must be able to talk to each other and listen to each other. This is difficult at best. It becomes even more so when a person is ill, frightened, and in pain. However, it becomes impossible only if doctor and patient cannot speak the same language at all! There is no substitute for it. No CAT scan will ever be able to compensate. Thus, we are not speaking here about niceties in “the bedside manner”; we are talking about the success or failure of patient care.
A young doctor, Dr. Miles, is trying to tell his patient that he has inoperable, metastatic cancer. Dr. Miles is white, middle class, and 27 years old. He is very committed to being the best doctor he possibly can. The patient, on the other hand, is a bit weary and worn down by life. His name is Ignacio Chavez. He is 58 years old, widowed, of Hispanic origin, and barely surviving financially on a small Medicare disability pension.
Some doctors would be able to communicate with Mr. Chavez in a meaningful way. Given the mixed degree of formal education in these skills that we provide, it is remarkable how often doctors manage to do so empathically and well. Alas, this is not so with Dr. Miles. Instead, we witness a painful series of halting stammers, equivocations, and bungled opportunities. Our young, bright doctor suddenly seems reduced to jargon and pathetic mumbles:
“You have a primary CA,” he says. “There may be metastases, little pieces of it, in your vertebral column. I mean, in your spine—you know, your backbone.”
Our patient, in turn, does not complain or protest. Rather, he nods and stares blankly, trying to be polite, pretending that he understands. Inside, he is also terrified, confused, and profoundly alone. These feelings emerge only later, with his family, if he is lucky enough to have a family. Or perhaps they will not come out at all. Our morning rounds end thus:
dr. miles: Well, then, Mr. Chavez, so now you understand why I need to do the test on your spinal fluid.
mr. chavez: That’s the one where you stick a needle into my back and take out some fluid?
dr. miles: Right! It won’t hurt much. Now roll over on your side and tuck up your knees to your chin.
mr. chavez: (No verbal response, silently assumes position as instructed.)
Our young doctor performs the lumbar puncture, collects the samples, and places a small Band-Aid over Mr. Chavez’s skin.
“By the way,” he adds, on the way out the door, “you’ll need to lie down for at least another 8 hours, and you may get a headache.” Eight hours later Mr. Chavez is still lying on his bed, obedient and alone. He stares at the ceiling saying nothing. What is he thinking? It is difficult to know. His expression gives nothing away.
Is young Dr. Miles insensitive and callous? Is he hopeless? Of course not. He simply has never learned to speak with patients effectively. Not only has Dr. Miles not been trained adequately in communication skills, he has, concurrently, been socialized into a frequently dehumanized system and inculcated with biases and narrow perspectives that have actually caused a deterioration in the native compassion and empathy he originally brought with him to medical school. Like most of us, Dr. Miles went into medicine because he wanted to take care of people. What happened? The answer is complex and multifaceted. One symptom of the problem shows up in his bungling when he needs to communicate. He reverts to a highly abstruse “technical” language that confuses the patient and leaves Dr. Miles feeling more than a little uneasy. On the other hand, it is this very language that Dr. Miles knows will score points with his attending physician on rounds. Quite a predicament!
It is often said that students like Dr. Miles learn 10 000 new words in medical school. This strikes us as a conservative estimate. Yet, too often, they still cannot talk to patients and, furthermore, do not know how to listen. Certainly the problem does not lie in mastery of a very precise technical jargon. For example, students learn that many anticancer agents, such as several that will be tried on Mr. Chavez, cause alopecia, ulcerative stomatitis, and desquamating intestinal enteritis. How different these words sound, if one says: These drugs may cause my patient’s hair to fall out and his mouth will become filled with painful, open sores. His intestinal lining may slough off and he may bleed into his gut; the blood may come gushing out of his anus. He could bleed to death.
Despite the popular accusation, we personally do not believe doctors fall back on excessively technical language with patients to appear pretentious, smart, or to lay verbal smokescreens. More likely, the problem occurs because young doctors are not helped to cope with the emotional impact of their work. On the contrary, they are encouraged by older house officers or professors who use similar defenses to twist language so that it denies the harsh emotional realities of what patients really face and doctors really do. How could a doctor so trained then be expected to communicate effectively with a suffering patient? In truth, it is impossible to imagine an effective doctor–patient relationship emerging from an educational system that does not fully acknowledge the feelings of the doctor, let alone those of the patient.
The biopsychosocial model, which forms the central theoretical foundation of this book, is a quantum leap forward in the right direction. It yanks the feelings and relationships in a patient’s life out of the clichéd realm of “bedside manner” and plants them where they should be—in the hub of scientific medicine itself. The education of future physicians must also include helping students to understand the biopsychosocial forces that they themselves experience so intensely; after all, they are half of the dyad and live in that emotionally intense crucible as surely as their patients.
One final observation about the structure of our medical language: Repeatedly, we have been struck by the propensity of all physicians to gravitate in their speech toward highly action-oriented verbs. Listen to a group of doctors talking on work rounds. They talk about “doing an LP.” They say they need to “get a urine sample.” They talk about “ordering a PA chest film.” The words imply action, doing something to someone. They deny any notion of interaction. In one sense, this is perfectly logical. We doctors must constantly do things. We stick needles and cannulas into people’s bodies; we withdraw fluids and tissues. Sometimes we cut bodies wide open to take out organs or even put them in. The active tone of our language thus reflects the active nature of so much of what we do. Yet, the procedures we “order” are seldom as one-sided as they at first might seem. For example, take a simple procedure: A doctor “orders” a barium enema. Yet, those of us who have observed a patient undergoing this procedure—much less endured it ourselves—appreciate how active the patient must also be. A day in advance, she is purged with harsh laxatives. She is then deprived of food. During the X-ray procedure, she must consciously squeeze her anus shut to keep a huge volume of fluids in her colon while she assumes awkward, embarrassing, and painful positions on a cold X-ray table! So the test we “ordered” is not so simple a matter as our language initially led us to think.
Imagine how different medical rounds would sound if doctors spoke like this: We need to get Mrs. Jones to our radiology technician in the morning for a really good upper GI. Or: Mr. Smith and I are going to go to the examining room at 11:00 so we can do a careful neurological; it’s critical.
To some, these distinctions doubtless seem idle—the ruminations and quibbling of an obsessive lexicologist. Yet we argue the opposite. We think it is the language of doctors, perhaps more than any other aspect of their behavior, that betrays the difficulties they so often have dealing with powerful emotions. Over and over, physicians’ choices of words reveal not only their awkwardness when they hear strong emotions in their patients, but also their limitation to seeing the doctor–patient relationship as an interaction that involves both doctor and patient (not to mention the patient’s family).
The Power of the Doctor–Patient Relationship
A highly respected, technically gifted, humane orthopedic surgeon once made a terrible mistake. He had treated an elderly woman for many years for an arthritic condition caused by diabetes. She was very attached to him and trusted him implicitly. There came a point in her illness when the surgeon decided she would have to have her left leg operated on. She readily assented and, in due course, the operation was performed. Then, while she was in the recovery room, a tragic error was realized. The wrong leg had been draped. The surgeon had operated on the wrong knee. After considerable personal anguish, he waited for her to stabilize postoperatively and then entered her room to tell her the truth.
“Mrs. Fenswald,” he began. “I have to tell you that I have made a terrible mistake. Through a series of blunders, I operated on the wrong knee.”
Mrs. Fenswald initially looked shocked, then pensive. For a moment, the two sat together in silence. Then, Mrs. Fenswald replied.
“You know, Dr. Jones,” she stated, “I am obviously sorry that this has happened, but I’m really not that worried. You’re such a good doctor. I’m quite sure that the other knee will get better anyway.”
This vignette, from Dr. Reiser’s book Patient Interviewing: The Human Dimension,1 is at once heartening and highly disturbing. Certainly it describes an iatrogenic catastrophe, yet it also dramatically underscores the power of the doctor–patient relationship. It is this relationship that Balint2 has referred to as a “drug” for which “no pharmacology … exists yet”. Whatever the metaphor one chooses, and there have been many eloquent ones throughout the years, it seems indisputable that the doctor–patient relationship is one of the most powerful human dyads that exists. It is as old as history, and it exists in every culture, however “advanced” or “primitive.” Despite much current lamenting about the erosion of that relationship and the demoralization that has resulted, the dyad remains, in many respects, as durable and potent as ever. If one wishes anecdotal confirmation for this, witness how often people speak in disenchanted, even enraged tones about medicine in general, yet refer in glowing terms to “my doctor.” As Balint2 points out, however, this powerful drug is not without its side effects. If the strength of the relationship can cure, it also can occasionally cause great harm, and lesser disasters occur all the time. Patients who are treated rudely and unempathically by their physician may not die from the experience, but most assuredly they will suffer. Conversely, those who feel truly understood can sometimes face great pain, uncertainty, and even death in comfort and with serenity. If one thinks about it for a moment, it is the very power of the doctor–patient relationship that explains why so many Americans are currently, and most appropriately, angry with their healers. If doctors were not so important, it is unlikely that people would be so disappointed and angry.
Two final points about the doctor–patient relationship deserve mention. First, neither party is ever without conflict about being part of a relationship that is so intense and important. Doctors are, understandably, ambivalent about the power invested in them and the responsibility that goes with it. Almost without exception, patients are equally ambivalent about allowing someone to be so crucially important to them. Second, although we often talk about this relationship as though it were terribly mysterious, a scientific explanation that can account for some of its incredible power is both desirable and possible. Engel’s biopsychosocial approach, explicated more fully in Chapters 2 and 3, points to such an explanation. As he observes, illness almost always evokes feelings of helplessness. Such feelings can, and often do, cause patients—although they are, in fact, full-grown adults—to feel very much the way they must have felt when they were a tiny, helpless baby. Being a patient can make one feel totally dependent again, like an infant forced to rely on his parents for emotional succor and even for survival. Hence, the power of the doctor–patient relationship may derive in part from its symbolic connection to the earliest stages of life. This, of course, can be regarded only as a hypothesis, but it represents how one can use the biopsychosocial model to think scientifically about matters consigned previously to the realm of “art” and “intuition” alone. As Engel points out, people who feel that such considerations are beside the point, completely miss the point. Perhaps scientifically informed inquiries will eventually lead to the elusive pharmacology that Balint2 laments still does not exist.
Doctor–Patient Dyad 1: The Student as a Person with Something to Offer
Medical training, from its first months to well into the house staff years, often seems diabolically contrived to make students feel they are engaged in an interminable rite of passage. They sometimes fear they are doomed to feel eternally inept, incompetent, and foolish. Students probably take little solace in reassurance that mastery and even wisdom eventually do come. For long years, medical training feels too much like a harrowing twilight of incompetence in the face of overwhelming responsibilities and stress to permit students any optimism about the distant, promised dawn.
Clichés do not mollify students on this point. It is often more helpful to suggest to these students, especially to those just beginning, that they actually have something to offer their patients.
To begin with, and at the very least, students can offer their unbiased presence. There is some irony here. Very often, precisely because students have not yet grown excessively encumbered and narrowed by an exclusively biomedical viewpoint, they can actually interact with patients in some important and therapeutic ways that may be overlooked by their more medically jaded mentors. Students often dismiss this advantage as mere naiveté, “being a nice person”—the bone students toss to patients in view of being able to do anything “real” for them. All this, they complain, is accompanied by the “fraudulent” donning of the white coat, and what at times feels like the endless exploitation of patients as “guinea pigs.” Reassurance alone does little to assuage most students’ anxieties about these matters.
In fact, however, students are in an ideal position to approach patients from the perspective of the biopsychosocial model. Ironically, students may be the most free to see their patients as parts of a total system—from mitochondria to ministers, from white blood cells to wives. The students’ relative freedom to learn and apply the biopsychosocial model to patient care can be an invaluable asset. This is one important reason why students, despite their relative technical inexperience, so often form relationships of such tremendous richness with their patients.
Students are usually curious. They are curious about the body and the mind, and about the ways in which the two interact. Although they fear asking something “dumb” on rounds, students in fact are encumbered by far fewer stereotypes than their mentors. Furthermore, their curiosity can be channeled and trained. With guidance, it can be honed from diffuse fascination to an astute capacity for accurate and detailed observation. The great diagnostic value of such observational skills is discussed more fully in the next chapter.
Students occasionally find themselves mocked for their compassion by only slightly older peers. More egregious, perhaps, is the widespread folklore that depicts medical students as cut-throat, narrow-minded, and compulsive—survivors of the “dog eat dog” competitive system of premedical training that got them into medical school. Actually, nothing could be less true. Students rarely begin as the ruthless, conniving gunners they are sometimes made out to be. If they finally end up that way, it is because they are made to fit that caricature by powerful, even irresistible pressures for social conformity that beset them during their medical training. Medical schools are inundated with so many qualified applicants; it would behoove them to admit the intellectually superior, morally outstanding, and deeply sensitive male and female applicants.
Students can and frequently do bring a capacity for concern and compassion to their patients. It is vital to a patient’s well-being. This is one of the ironic reasons patients, especially at training hospitals, so often refer to the medical student assigned to them as “my real doctor.” One student, for example, had this experience when he was still a freshman. He was working with a middle-aged woman who was dying of cancer. At a certain point, surgical removal of her ovaries seemed desirable as a palliative measure. The woman refused. Finally, the chairman of the department of surgery attempted to prevail on her.
“Not until you get permission from my doctor!” she insisted. Ultimately, there was the whimsical spectacle of a prominent surgery professor being given “permission” by a freshman medical student to perform the operation. The incident cuts deeper than whimsy, however. In fact, this woman needed to trust in a doctor–patient relationship, and the task fell to a junior medical student bedecked in his starched, uncomfortably new, “fraudulent” white coat.
Like patients, students have different styles. Some students are more assertive and action oriented; some, by nature, are more contemplative and slower to act. Some tend to respond on an emotional and intuitive level; others rely on logic and cognition. There is plenty of room in medicine for such a variety of styles. One of the major tasks of medical education is to assist students to learn what their own style is and to help them adapt it flexibly to a growing variety of complementary and divergent styles in their patients. Engel gives an example of this in Chapter 3, where he discusses the “Type A” physician taking care of a Type A patient. Engel’s reference to Type A refers to its correlation to coronary heart disease reflective of research at the time. Research since then has shown limitations of describing complex human experiences within such narrowly defined parameters.
Finally, students quickly bring to their relationships with patients something very special and important—a deep sense of responsibility. From the outset of medical training, a sense of responsibility is pounded into students. By the time they graduate, this sense has penetrated their very being. One can work at many jobs and leave the work behind at 5:00 pm when the whistle blows. Many chores and obligations can be hung like hats on pegs in a closet when the work week ends. This is not so for physicians, particularly during the training phase, when there is a felt sense that one is a physician 24 hours a day, 7 days a week, hypervigilant to digital stimuli in the environment as the pager beckons. Being a doctor is an all-consuming role that carries burdens as well as privileges, but should be contained within a structured set of duty hours to avoid the high risk of burnout and allow for nurturing of other meaningful roles within the context of personal interests, family, community, and so on.
Ironically, this deeply ingrained sense of responsibility—certainly among physicians’ most noble traits—seems to be formed in part from the very same pressures in training that also promote callousness, dehumanization, and despair. To give only one example: There is no doubt that the rigorous, even brutal, on-call schedule of typical house officers, in which they are up all night every third night struggling with the suffering and pronouncing on the unquestionably dying, is a process that forges in some way the deeply internalized sense of responsibility that good physicians feel. Such a sense, of course, is not restricted to physicians, and many other individuals in other vocations also possess it. Yet, it remains one of the most important gifts medical students, even the greenest students, have to offer their patients.
Doctor–Patient Dyad 2: The Patient as a Person with a Problem
“It is more important to know what kind of patient has the disease than what kind of disease the patient has.” —Sir William Osler.
A group of junior medical students and their preceptor found this out. They were conducting an interview at the bedside with a 58-year-old man who weighed 430 pounds. When the group of 7 entered the room, they found the huge man poised on the edge of the bed with almost gelatinous precariousness. Panniculus plunged pendulously to his knees. His nightshirt was mostly unbuttoned, and his pajama bottoms had slipped down below his thighs, exposing pubic hair and genitalia. Still, he beckoned the students in with a hearty laugh and showed no obvious embarrassment. His wife, a heavy-set woman herself, wore thick glasses and labored at a piece of crochet work in her lap. She blushed faintly when the group entered. She had been sitting opposite her husband. Now she hurriedly pushed her chair up against the far wall, nearer to his head yet out of his line of vision. She then proceeded to watch the interview very intently but said nothing.
The student who was conducting the interview tried valiantly to ask open-ended, empathic, and appropriately leading questions—ones that would encourage the patient to open up about why he was, figuratively, eating himself to death. From the medical chart, the group knew the patient had been gaining weight since his retirement as a truck driver 10 years before. His obesity had not gotten out of hand, however, until 4 years previously, after his 24-year-old son committed suicide, leaving behind two young children. The patient mentioned none of this spontaneously. Rather, he seemed to prefer to joke cavalierly about politics and the like. Several times he said he “loved to swim.” He planned to go swimming with his wife that summer, but caustically referred to her as “a hunk of blubber in the water.” At one point, the wife started to interject something about the son’s suicide, but he quickly cut her off. Despite the obvious drama of the events, the interview itself left a sense of boredom among the students. The patient managed to stonewall everyone. Students yawned, looked at their watches repeatedly, fidgeted, and dreamed about dinner. The preceptor stifled a yawn. When the interview finally ended 5 minutes early, all departed with a sense of relief.
The group then huddled. What had “gone wrong?” Their main data came from detailed observation and, above all, the students’ ability to heed their own feelings. (This second matter is discussed further in the next chapter.) As the students conversed and conjectured, the preceptor encouraged them to delineate strictly observable data. A number of things stood out. For one, the patient seemed utterly oblivious to even the most basic amenities, apparently betraying no shame for exposing his genitals. Furthermore, he appeared mysteriously indifferent about several catastrophes in his life: his obesity, a serious urinary tract infection, and finally his son’s suicide. Then there was the wife, who never said a word, except once—only to be cut off—who sat neither in nor out of the scene, vigilantly overseeing every nuance but never plunging in.
The students’ ultimate formulation is discussed later in this chapter, under “Feelings.” Here, simply observe that the biopsychosocial components of this man’s illness were overwhelmingly obvious. This had not, incidentally, seemed so obvious before the group went to the bedside. In fact, the student who selected the patient had originally thought he only wanted the preceptor to decide whether the patient was “pickwickian”—a descriptor to describe obesity hypoventilation syndrome. He had also anticipated a discussion of the pros and cons of gastric stapling procedures in the treatment of obesity.
By the end of the interview, however, it was abundantly clear this man, with kidneys inflamed at the parenchymal level, was also shockingly emotionally disturbed. And—most troubling—he seemed to be reacting to all the tragedy with complete noblesse oblige and jocularity. Finally, this dying, infected morbidly obese man had a wife and an extended family. Somehow they had to be part of this morbid process too.
As one student exclaimed, “This man is eating himself to death! Why isn’t anyone stopping him?” Clearly the answer to this question lay in an understanding of the forces that went beyond parenchyma and calories alone.
Empathizing with the Patient’s Anxieties about Meeting the Doctor
Typically, beginning students are so apprehensive about their own shortcomings and inexperience they, understandably, focus largely on themselves. Will they “blow” the interview? Will they miss getting that arterial puncture? Will the patient complain about them looking so young? Although such apprehensions are inevitable, it is often helpful for students to draw a conscious parallel: As apprehensive as the student may be, imagine how anxious the patient may be. The patient doubtless expects to see a young doctor, a concerned person, but one in a hurry, who will ask many questions. Will this young person approve of him? The last one got impatient when he could not recall the exact date his symptoms started, when he did not stick to the “important” details of his left lower quadrant pain. Will the student become physically disgusted by the smell from his infection? What will he think of the urine drainage bag dangling there below the sheets? If students can empathize with the enormous apprehensions a patient has about meeting a new doctor, some of their own self-consciousness may decrease. Furthermore, the appearance of anomalous reactions in such a setting can also be telling. As Engel pointed out in Chapter 3, patients who are not anxious, who immediately take the offensive, or who do not even seem to care are revealing important information about themselves.
Erik Erikson3 was one of the first to state what now seems obvious—that development and change do not cease at puberty. Rather, people undergo major developmental changes throughout their adult life. Since Erickson, important research has been done by Levinson4 and Vaillant5. Much of this pioneering scientific work has also been incorporated into an excellent, timeless book by Gale Sheehy6 titled Passages. It is extremely useful to familiarize oneself with this body of literature. Most students are young. Most of their patients are older. Although empathy, rapport, and understanding can bridge most gaps, students are helped immeasurably when they has some cognitive handles to help them understand what developmental issues a 40-year old, a 60-year old, or an 80-year old faces. Will the 50-year-old woman whom I am about to interview suffer from the “empty nest syndrome?” Will the high-level executive who is 48 and in the hospital for his first myocardial infarction be asking himself what he has really done with his life? People are almost always more complex than the paradigms we invoke to describe them. Nobody progresses predictably through locks in a canal. Nevertheless, there are normative stages that have now been well delineated, and, when applied flexibly, they can be very useful. Knowledge of them can be especially valuable to students who wish to form an empathic alliance with their patients—people so often different from students in background and age. Still, even during the early, often awkward moments when doctor and patient are trying to form a bridge, they have the most critical element of all in common: Despite differences in age, socioeconomic background, and life experience, both are human beings. Both know what it means to suffer; and whether either one admits it, both know, deep down, what it means to fear loneliness. Psychiatrist Harry Stack Sullivan once said, “We are all more human than anything else.” This is true. A 25-year-old woman medical student raised in Massachusetts may be very surprised to discover how much she can understand about a 70-year-old Filipino immigrant dying of prostatic cancer—how much more than she might have imagined she possibly could. Our human capacity for empathy can be awesome and sometimes even a little frightening.
The Patient Has a Life
Even the most isolated, down-and-out skid-row derelict has a life. He must have a place somewhere where he hangs out, and usually there are people he hangs out with; moreover, there are assuredly things that matter to him—maybe just a soiled snapshot or a tattered address book. Above all, everyone has memories and a past. Everyone had a mother and father—once. Everyone also has a future—hopes, aspirations, dreams, as well as illnesses and fears. Even our most anonymous patients have a life. Students should never forget that hospitals are very artificial environments. Hospitalized patients are stripped of their clothing, their wallets, and their jewelry. Favorite pipes and pictures are gone. We dress them in gowns and tell them to lie down flat. We isolate them from so much that makes each of them a person. Why we do this routinely to people is both curious and complex. In some ways, it seems necessary. Sometimes one wonders, though, if we perhaps do it also to protect ourselves emotionally. Maybe it is just too wrenching and frightening to see people so very sick in the full torrent of their humanness, and to think: They could be us. Whatever the reasons for our rituals, remember that the supine figure you see on a gurney under a sheet has a life, as surely as you or I. It is always worth inquiring into, for it is virtually impossible to treat someone inhumanely whom one understands, and sometimes our understanding itself can help immeasurably.
What do we do about feelings? In medicine, they are all over the place. Patients have them and we have them. Generally, we do not talk about them much. When they erupt, their occurrence often seems awkward, even guilt-laden: Witness the savage nursing station humor of house officers complaining on admitting night about getting another “hit.” Similarly, patients may erupt suddenly into uncontrollable sobbing or rage. What do feelings have to do with medicine? Are they “scientific?” Engel addresses this question in Chapters 2 and 3 and concludes persuasively that understanding the feelings of doctor and patient is essential and amenable to scientific study.
Allow us to take the whole matter one step further. We propose that doctors who understand feelings—both their own and their patient’s—are better doctors. They are better because they are able to comprehend what is truly important and therefore can provide more effective help. Empathy for our patients’ feelings and insight into our own are not frivolous “window dressing,” as some have made them out to be. We go even further: The failure of contemporary medical education to help students integrate their affect with their intellect may prove to be its greatest failing. Our profession is littered with casualties: doctors who are addicted, alcoholic, and divorced, or deeply depressed, disillusioned, and alone. For rare individuals, the apparent opportunity to deny all emotion may seem a welcome relief, but it is a dangerous denial—and one most of us do not welcome anyhow. For the vast majority of us, being in touch with our feelings and coming to peace with them is essential to our well-being. Patients who are not in touch with their feelings are thought to be more vulnerable to disease. We believe doctors, too, are at greater risk and for the same reason. We cannot continue to treat ourselves, much less our patients, like insensate machines. As educators, we have an absolute and urgent obligation to help physicians identify and cope with their feelings—in their patients and in themselves. We risk great peril if we do not achieve in this area.
Feelings Are Useful
Feelings provide us with vital clinical data. To begin with, feelings are, biologically, very old, both phylogenetically and ontogenetically. They are the essential matrix for human bonding and socialization in our species, as essential to life as protoplasm. Phylogenetically and ontogenetically feelings originate first in lower mammalian forms and in infants. Ideas became attached to them later in evolution and development with the emergence of the neocortex. They are, in fact, essential. On a more day-to-day basis, each of us must come to grips with our own feelings if we hope to be effective as well as satisfied professionally. Above all, clinicians who are in good touch with their feelings possess a most wondrous and reliable diagnostic tool.
Let us return, at this point, to the case of the 430-pound man cited earlier. Recall that the students saw how many biopsychosocial influences were affecting this man, yet the situation remained very puzzling. Where were the feelings? He did not seem depressed, when he should have been. Where was the anxiety? After the interview, the students sat around a conference table yawning, cracking cynical jokes, and saying they wanted to knock off early that day. The preceptor began to write a list on the blackboard, a list of feelings the students were having. Among the feelings: hopelessness, despair, remoteness, and boredom. Above all, the feeling tone among the students was unmistakably dysphoric. Why?
It began to dawn on the students that they were having the feelings the patient should have been having. This discovery led to an interesting notion. The notion goes as follows: This man’s entire family never recovered from the suicide of the 24-year-old son 4 years before. Instead of grieving or feeling depressed, the family’s feelings seemingly went underground. In some complex way, the depression was hidden and then divided up among the whole extended family. The father ballooned into morbid obesity. The mother’s voice became stifled. The students could only speculate about the family’s many children, including the surviving children of the suicide; but, by the end of the discussion, a lot more was known. Using the data of their own feelings, the students were able to construct a decent, testable hypothesis to explain the bio-, psycho-, and social sequelae of this tragedy.
Transference and Countertransference
Transference and countertransference, two rather lofty and formidable-sounding words, have suffered over the years from misuse and overuse. The terms originated in psychoanalytic theory, where they have specific definitions and applications. The concepts are nonetheless very useful, even if the argot has grown confusing. Rather than adding to the mess, consider a definition that is brief and intentionally quite simple: All human beings transfer things—feelings, attitudes, and expectations—they once had toward important people from their childhood, typically parents and siblings. Such transfers are probably ubiquitous, but often become highly prominent in the doctor–patient relationship, especially as it develops over time. Sometimes such transferences are problematic; often, they are not. Usually, however, it helps if they are understood. Some kinds of psychotherapy deliberately foster and then examine transferences as a major focus of treatment. This usually does not occur, however, in the typical doctor–patient relationship. Here is an extremely simple example of transference:
A man of 36 grew up in a family where he felt his father was harsh and critical of everything he did. When this man, now an adult, began to develop signs of chronic obstructive pulmonary disease, his physician (a man his father’s age) counseled him to stop smoking. When the patient did not do so, the physician admonished him about how really important this was for his health. The patient exploded angrily and berated his surprised physician for nagging and belittling him, and not appreciating his efforts to stop.
This is transference. The patient acted as though the doctor was his father. In turn, the physician found himself reacting
Countertransference, strictly defined, is the reaction of a doctor to his patient’s transference. In this case, the doctor had a reaction. He found himself disgruntled with his patient. He complained to a colleague about the patient’s stubborn ingratitude, and especially the patient’s unwillingness to let him be of help. This is countertransference; the doctor actually felt toward his patient like a disgruntled father. Many transference–countertransference reactions are far more complicated and subtle. Furthermore, it is quite possible for a physician to have his own transference to a patient. A physician’s transference is considered countertransference among contemporary views. For example, if a young man is treating an older woman who reminds him of his caring mother, he may form a positive countertransference to her.
Students often quite properly protest the hazards of pseudopsychologizing. Sometimes students correctly assert feelings are straightforward and belong in the present. One student expressed the skepticism well: “Just because I was bored and grumpy today doesn’t automatically prove that I’m having some kind of countertransference to my patient. Maybe I’m just in a bad mood. Maybe I was on call last night and didn’t sleep. Maybe I had a fight with my wife.”
Quite true! Yet it is still surprising how often these straightforward feelings can also originate in response to a person’s transference. Of all his patients that day, for instance, why did the students get grumpy with this one? In any event, the most important skill involves being aware that transference often does occur. Patients are especially prone to developing strong transference feelings toward their doctors. Knowing that such feelings can and do happen, and having some notion that they might be transference, is more important than definition and jargon.
“Frequent flyers,” “bounce backs,” and “train wrecks.” Let us be truthful. At some point, the most well-intentioned among us may conceivably use these denigrating terms or their equivalents, outrageous as that is. Thus, it is impossible to conclude a discussion of feelings in the doctor–patient relationship without talking about the frustrated, angry feelings medical students and house officers inevitably experience in the training hospitals where they spend so many crucial years. Typically this training occurs in large public hospitals, Veterans Affairs hospitals, jails, and city wards. Students are told they will have to take a lot of responsibility in these settings and see a lot of “pathology.” Both statements are true. Frequently, however, students and young doctors are also assailed by a grim, raw, desperate, even hopeless side of human existence for which they were hardly prepared. Their sensibilities are shattered and overwhelmed by the seemingly endless procession of overcrowded wards, inadequate equipment, and haggard and overworked staff. Into these nightmarish environments flow severely ill people—people who are not just medically ill, but burnt out physically, crushed psychologically, defeated by life itself. In they pour like an interminable deluge—cases of hopeless alcoholism, drug addiction, brain damage, knife and gunshot wounds.
What one witnesses in these settings is not all of medicine or indeed all of life, but it is what young doctors may see day after day and night after night. Sometimes a benumbed feeling of nihilism sets in, even in the most sensitive of us. Very few of us can forebear endlessly or be so saintly that we never once call a patient by a disparaging label.
Still, we must ask why. As difficult as things may get, when we find ourselves using disparaging language toward our patients, we must ask why. Reflecting in this way provides insight that often helps. When we have a strong aversion toward a patient, usually something specific has gone wrong, beyond the general frustrations. Somehow, doctor and patient are failing to understand or empathize with each other at all. This is not always easy. Sometimes it may feel nearly impossible. Some patients are very far gone. Nevertheless, we have repeatedly seen instances in which a student or house officer expressed revulsion for a patient, not from nihilism, but because it seemed too painful to feel otherwise. The anguish seemed just too deep to bear and the reward for recognizing such feelings too miniscule, far too remote. Similarly, over and over we have witnessed patients suffering in these settings. More than a few are rude and hostile because underneath it all they are too terrified to hope, too frightened to reach out just one more time, to show their humanity, only to have it crushed again.
When you call someone a “train wreck” ask yourself why. It is almost impossible to loathe someone you understand.
Denial of Death
In Chapter 3, Engel observes that much of what we call “art,” “intuition,” and “bedside manner” are actually essential to the proper understanding of patients. He argues persuasively that, in this area, we probably have not been scientific enough. Yet, there is a widespread mythology that such matters are not amenable to scientific scrutiny. This mythology, coupled with our failure to effect such study, has had a disastrous effect on medical education. Engel believed this narrowness has evolved from the scientific model of Western medicine itself, which for centuries has been based on reductionism and the Cartesian mind–body dualism.
Yet could there still be another level to the problem? Why has modern medicine seemed so entrenched? At times, so stubborn? We personally suspect it has something to do with our inevitable proximity to what is most disturbing, mysterious, and impenetrable in life itself. Doctors are present when life is born. We are there when sane people go mad. We are there when death comes. By the nature of what we do, we are, inevitably and inexorably, tangled up with our patients in the crucible of life’s most painful and agonizing questions. Above all, as mortal human beings ourselves, we doctors must nonetheless confront daily the most unimaginable yet undeniable truth of all: We all die. Without doubt, when we confront this reality in our patients, we are forced to make certain unavoidable inferences about ourselves. In Dr. B. J. Miller’s TED talk on what really matters at the end of life,7 he astutely identifies dying and suffering as the most apprehensive aspects of death—a necessary suffering that unites caregiver and care receiver whereby compassion is suffering together. This is where healing happens.
Centuries ago, before medicine was based on science, doctors were priests, shamans, and medicine men—witch doctors. Although they were endowed with the special respect due to those who have commerce with the ultimate mysteries of life and death, they were also lonely and set apart. In Keniston’s words8, they were members of a “feared and powerful guild.”
Times have changed. Centuries have passed. Although some have wondered if a field can change so rapidly and constantly and still call itself a science, modern medicine is based indisputably on science and the scientific method. The dazzling technology that now surrounds us is not, in itself, dehumanizing. It is a monument to science and to the scientific method itself.
Yet for all of this, some things have not changed. People still die. Although we have advanced with astounding alacrity and success scientifically, we remain inevitably just as helpless, frightened, and befuddled as ever by mortality. For all our knowledge, we, too, remain deeply uncertain and alone.
We do not like this one bit, of course, and attempt with all our might to deny it. Probably the shamans and witch doctors did too. The causal connections our ancestors invoked had to do with angry gods and dangerous alignments of pathogeneses that originated in immune complexes, anaplasty, and genetic markers. We are much closer to the truth. We are being more scientific, but the ultimate riddle still eludes and torments us. The most unbearable truth has not changed. Maybe we doctors, if we are to become truly wise and at peace, must learn to accept that our intimate involvement with life’s greatest mystery—death—commingles dramatically with the triumph of our advancing technology and expanding knowledge. We can do more and we know more, yet control of life’s ultimate riddle remains beyond our grasp. We remain the descendants of shamans, and perhaps we should accept this and be proud.
Possibly, then, we can free ourselves and our students from the shackles of a narrow, dehumanizing view of people—a view that both denigrates science and ignores the existential curse and blessing of our calling. In the future, we will learn more and more about how people regenerate and degenerate, how they come into being and how they die. We will keep advancing on the truth—humane scientists, scientific human beings. However, we will all die, and our work has to do with this too. The renal failure in room 407 is you, me, all of us. If we are to achieve our ultimate stature as the noble professionals we can be, we must strive to study and learn always; but, we must realize that the very nature of our calling puts us in the eye of the hurricane. We deal with life’s most inevitable, ineffaceable truth: our mortality. This is as true for us as it was for our noble shaman predecessors, who rubbed herbs in their hands, sang incantations, and searched for answers from dim and distant stars. We are closer, but still we search. By the very nature of science, there will always be this excruciating paradox. As doctors, the farther we push back the ocean of our ignorance, the more we will find ourselves still standing at the very edge of an unutterably beautiful and terrifying shore.
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