THE DIAGNOSTIC EMBRACE
Mahala Yates Stripling, Ph.D.
Western Social Science Association
San Diego, CA
April 27, 2000
I’m going to talk about how a doctor relates to a patient, and how a patient relates to a doctor. We are all patients, and many of the ideas I will discuss apply equally to all of the helping professions. Consider that ever since the invention of the stethoscope (French physician René Laenecc in 1816) modern medicine has faced a predicament. That is, the technology that may enhance a doctor’s ability to diagnose and to treat has also distanced him/her from the patients themselves. Reflecting on this situation, some of us may even remember a doctor making a house call to our home. It was invariably an intimate encounter in which the doctor offered a sympathetic touch to a fevered brow. With an equal amount of compassion, he would also listen to the patient and family, knowing that giving them the opportunity to express fears and concerns was part of the art of healing. Indeed, the doctor did not merely assess the signals of illness such as skin pallor and heart flutter. Nor was the patient presented as a simple catalogue of symptoms.
Of course, over the last two hundred years technology has increased, and, consequently, the emotional distance between a doctor and patient has as well. In this regard, French Philosopher Michel Foucault in The Birth of the Clinic adds to the understanding we seek of the doctor-patient relationship. Foucault, in fact, looked back over two hundred years since modern medicine was first established in the very late eighteenth century. He saw how the gradual use of technical procedures, including using machines in labs to analyze blood, saliva, and urine, continued to diminish the once intimate doctor-patient relationship. Now, the human anatomy was seen as body parts (organs, muscles, bones), and it had become a symbolic spacerather than humanisticupon which the clinician gazed: to see, to learn, to name. Long gone were the days when a doctor would lay his ear upon the chest of the patient to be reassured by the lub-dup, lub-dup of his heartbeat. New diagnostic tools (x-rays, CAT scans, and MRIs) seemed to replace the need to palpitate the flesh to determine either the wellness or humanness of a person.
Besides modern technology, more recently in this country managed care’s cost cutting and time limitations add to the dilemma. They all reduce the doctor’s intimate encounter with a patient in which, formerly, seeing, hearing, touching, smelling, and even tasting could be powerful diagnostic indicators. Furthermore, the very method of training doctors can be called into question, sharing the blame for distancing doctor from patient. Medical schools, it is widely reported, train doctors in a clearly abusive system where techniques such humiliation, threat of failure, overwork, sleep deprivation, and endless rote memorization dehumanized them. One generation into the next, medical students are turned into unquestioning carbon copies of their teachers, and a doctor’s impoverished self-reliance translates into an attitude of not caring. This so-called paternalistic method created doctors who were expected to dominate their patients by treating them more like timid, submissive children who should be seen and not heard. However, when a doctor dominates, often a patient’s rights are marginalized. A doctor, in fact, often must learn how to care, because you can’t give what you don’t have. In sum, there is no wonder, then, that when patients become reduced to the symptoms of their diseases, and when doctors cannot emotionally commit to their patients that Americans have become disenchanted with healthcare.
I have two stories to tell you today--actual medical case-histories, that will, in fact, illustrate my points. The first story , ‘Brute, describes a raw young doctor who is the product of the abusive system I have described. He has a surgeon-warrior temperament coupled with a professional arrogrance that has isolated him from human emotions (as seen in Shelley’s Frankenstein and Hawthorne’s Rappacini’s Daughter). The story is told by Dr. Richard Selzer, now a world-famous doctor-writer. He is looking back twenty-five years earlier to his residency when he does not have the maturity to contain his frustration. The second story, although now told by the more mature mid-career Dr. Selzer, depicts a very different relationship between a doctor and his diabetic patient. It describes the outcome of a confident doctor’s trusting relationship with his patient.
Listen, now, as I enacted the story Brute. It is a case-history being hotly debated at medical school conferences across the country since it shows the abuse of power, the violation of trust, and the failure to act for the sole benefit of patient. You will hear an extreme case in which the doctor has both physical and emotional control of a patient who is dehumanized and reduced to a series of visible technical signs.
Brute from Letters to a Young Doctor
Listen: It is twenty-five years ago in the Emergency Room. It is two o’clock in the morning. There has been a day and night of stabbings, heart attacks and automobile accidents. A commotion at the door. A huge man is escorted by four policemen into the Emergency Room. He is handcuffed. At the door, the man rears as though to shake off the men who cling to his arms and press him from the rear. Across the full length of his forehead is a laceration. It is deep to the bone. I know it even without probing its depths.
The split in his dark flesh is like the white wound of an ax in the trunk of a tree. Again and again he throws his head and shoulders forward, then back, rearing, roaring. The policemen ride him like parasites. Had he horns he would gore them. Blind and trussed, the man shakes them about, rattles them. . . .
I am tired. Also to the bone. But something else . . . Oh, let me not deny it. I am ravished by the sight of him, the raw, untreated flesh, his very wildness which suggests less a human than a great and beautiful animal. I begin to cleanse and debride the wound. At my touch, he stirs and groans. Lie still, I tell him. . . . Hold still, I say. I cannot stitch your forehead unless you hold still.
. . . And so he strains and screams. But why can he not sense that I am tired? . . . Hold still, I say.
You [blankin’] hold still, he says to me in a clear fierce voice. Suddenly, I am in the fury with him. Somehow he has managed to capture me, to pull me inside his cage. Now we are two brutes hissing and batting at each other. But I do not fight fairly. I go to the cupboard and get from it two packets of heavy, braided silk suture and a large curved needle. I pass one of the heavy silk sutures through the eye of the needle. I take the needle in the jaw of the needle holder, and I pass the needle through the center of his right earlobe. Then I pass the needle through the mattress of the stretcher. And I tie the thread tightly so that his head is pulled to the right. I do exactly the same to his left earlobe, and again I tie the thread tightly so that his head is facing directly upward.
I have sewn your ears to the stretcher, I say. Move, and you’ll rip ‘em off. And leaning close I say in a whisper, Now you blankin’ hold still.
. . . And I grin. It is the cruelest grin of my life. Torturers must grin like that, beheaders and operators of racks. . . .
Even now, so many years later, this ancient rage of mine returns to peck among my dreams. I have only to close my eyes to see him again wielding his head and jaws, to hear once more those words of which the whole of his trussed body came hurtling toward me. How sorry I will always be. Not being able to make it up to him for that grin.
Just who is the titled brute in this story? The patient? The doctor? Perhaps it is both. A doctoras do other professionalshas a great deal of power. When a patient puts his trust in a doctor, he is often put at great risk. In fact, Michigan State University Medical School Professor Dr. Harriet Squier easily sums up the situation in Brute in an email message to me:
There was NO healing in that story. Perhaps he cured the man’s laceration by sewing it up, but big deal. He potentially caused great harm to that patient. [As in William Carlos Williams’ story, The Use of Force], possible psychological harm was done by treating the patient like an animal rather than like a thinking, feeling person. In fact, Selzer uses animal imagery to describe the patient. There was no reason at all to brutalize the patient. The intern could have waited until the guy either calmed down or passed out. There was no need to inflict his frustration and hatred onto the patient. To produce medical students who actually want to relate to patients, you must preserve their humanity, their ability to feel and reason, and the sense of their own attributes, skills, and identity.
Clearly, the intern in Brute, who was the product of an abusive medical school system, exhibits an impatient intolerance for human life. He has a lot of power in controlling what happens to his patient’s mental and physical state. And, the reality of the medical profession--as others--is the possibility of cruelty in the absence of compassion. The doctor in Brute, acting incompetently out of both lack of experience and confidence, has not put his patient’s needs above his own. He has, in fact, violated the first tenet of the Hippocratic Oath, first, to do no harm. He has not learned the wisdom of compartmentalizing feelings that may be harmful to a patient. Ironically, while a doctor may sooner learn to control his revulsion at a patient’s unsightly rashes, oozing pus, and smelly wounds, he easily disavows this human connection. Brute illustrates how this disconnection can be magnified through basic human insecurities and stress.
Clearly, doctors who have had no special training in building their own confidence are more likely to abuse power, and at the heart of medical mistakes is a failure to communicate. While some mistakes are purely technical, the worse kind involve what is termed a failure of will, or mistakes that happen even though a doctor knows the right thing to do but doesn’t do it because he is distracted, or pressured, or exhausted (Hilfiker 376).
Medical mistakes happen for other reasons as well. You may have recently heard about the doctor who carved his initials in the belly of a pregnant woman in the delivery roomwith the greatest arrogance, he said he wanted to sign his work. This shocked many of us since doctors aren’t suppose to make mistakes, are they? But the truth is grim, as reported by Associated Press writer Lauran Neergaard:
In the United States, an estimated 44,000 to 98,000 people die each year as a result of medical mistakes. Those mistakes cost the nation $8.8 billion yearly. This ranks high with other leading causes of death. Here is the yearly estimated number of deaths:
|Medical mistakes: 44,000
Motor vehicle accidents: 43, 458
Breast Cancer: 42,197
It’s like a jet crash every day of the year. While to err is human, Pennsylvania anesthesiolgist Danae Powers believes,
There’s a conspiracy of silence in medical institutions. You circle the wagons. People get sick and suffer the consequences of the fact their physicians weren’t able to talk openly and honestly about what was wrong and what needed to be fixed. (qtd. in Neergaard).
In fact, the report goes on to say,
Errors encompass all facets of care: the wrong drug. The dizzy patient who fell when left to hobble to the bathroom alone. The Pap smear that showed cancer except the busy doctor forgot to check the results. The infection caused by the nurse’s unwashed hands. The botched surgery. (Neergaard)
It shouldn’t surprise patients that doctors, who are human, do not practice medical perfectionthey are not gods. However, the closed climate of medical institutions is intended to keep doctors from openly discussing their mistakes.
Poor doctor-patient communication adds to the problem, as illustrated in Dr. Joyce Allman’s medical mistake study, which delineates several rationale for not discussing mistakes:
Fear of embarrassment
Fear of patient reaction
Fear of litigation
Loss of self-esteem
Censure by peers
Might be thought incompetent
Unknown lie is better than truth (204)
In fact, in a case history cited by Dr. Allman, a humbled doctor confesses that sharing mistakes with a patient is essential. Cited as Case History #15, the anonymous doctor, who had practiced for four years, talks about a year-long relationship with a mid-50s patient. He had chronic medical problems that included having an aortic graft and an artificial heart valve, and he was now on blood thinners and pressure medication as well as diabetic medications. In spite of it all, he led an active life and at a bimonthly checkup complained of fatigue and weight loss. During the examination the doctor found him pale with an enlarged spleenbut nothing else that pointed to what was going on. Routine blood work showed that he was anemic and had a very high sedimentation rate that suggested either an infection, or with his presentation, an underlying malignancy.
The doctor and patient talked and then began an involved workup, yet no diagnosis was made. Later, the doctor discussed the case with a colleague, who suggested getting blood cultures to test for an infected heart valve. For reasons beyond explaining, the doctor did not follow up and with his patient slowly deteriorating referred him to an oncologist whose blood cultures were positive. Profoundly embarrassed and ashamed for missing something obvious, simply and inexpensively tested for and relatively easy to treat, the referring doctor was nonetheless extremely relieved and told his patient he had goofed. Even though not feeling ethically obligated to do so, the doctor felt that he had a close enough relationship with them so that there wasn’t even a question of not telling them. He further added,
I also felt it important to be forgiven by them, not to be absolved of negligence, but so that I could continue to work with people and not feel I was being dishonest or covering up. At first, the patient was going to see another doctor in the [clinic] I worked at, but he changed his mind and continued to see me until I left a year and half later.
I also told colleagues about this mistake, something I have done in other instances because I feel the need for others to acknowledge my errors and tell me that it’s okay to be human and make mistakes. Often, they then share their mistakes and I can then go on, though almost humbled by the experience. Sharing mistakes, especially when they can have profound effects on people’s lives, is essential. If one cannot do it on any level, I think burnout, depression, substance abuse, and suicide are potential hazards. (Allman 153-55).
When doctors did unburden themselves by talking about their mistakes, they most often did so to another physician (29%); signficant other (18%), and patient/family (16%). The mistakes were most often errors in evaluation and treatment (16%), casting a spotlight onto the problem of doctor-patient communication (Allman 205). In light of Dr. Selzer’s confession in Brute, written in atonement and as a release, it appears the culture of silence is being broken. In fact, as reported by New York Times reporter Robert Pear, President Clinton plans to call for a nationwide system of reporting medical errors, somewhat like the system the airlines use to report aviation safety hazards. Of course the American Medical Association and the American Hospital Association vehemently oppose this action (Pear 8A).
While the first story I told you was about abuse of power, the second case-history narration describes a very different relationship with a patient. After many years, Dr. Selzer became remorseful for breaking the faith, as described in Brute. He did, however, in telling the secrets of the priesthood, reveal in the medical profession the possibility of cruelty in the absence of compassion. In the next story, the proper use of his power reveals a relationship of trust and details how medical professionals may join the forces of healers and humanitarians. It is years later. Now a mid-career surgeon, the once abusive doctor is confident and humanistic. In his essay, The Exact Location of the Soul, Dr. Selzer invites us into the operating room where he is to operate upon a young diabetic woman. Though treating his patient for many years, he was unable to trim away enough swollen blue leather, that is her putrid diseased flesh. The doctor writes:
At last we gave up, she and I. We could no longer run ahead of the gangrene. We had not the legs for it. There must be an amputation in order that she might live--and I as well. It was to heal us both that I must take up knife and saw, and cut the leg off. And when I could feel it drop from her body to the table, see the blessed space appear between her and that leg, I too would be well.
On the day of the operation, the surgeon who is no longer afraid to connect--to feel the pain of his patient--watches as drugs are administered and the tense familiar body relaxes into narcosis. He uncovers the leg and sees an unexpected sight:
There upon her kneecap, she has drawn, blindly, upside down for me to see, a face; just a circle with two ears, two eyes, a nose, and a smiling upturned mouth. Under it she has printed SMILE, DOCTOR. Minutes later I listen to the sound of the saw, until a little crack at the end tells me it is done.
Hearing this very different type of case-history, allows us to focus with the doctor not on the pain of the rotting leg and the horror of such gross infection, but on the beauty within, revealing the trust that lies hidden in the patient’s body. There is a mutuality of understanding--a trust relationship--in which the patient justifiably reposes confidence, faith, and reliance in the doctor. The doctor, in turn, remains fiercely connected and loyal to the patient’s trust and confidence.
Daily, professionals witness pain and suffering, joy and transcendent spirituality. These matters are at the heart of human experience. Doctors and nurses--and other professionals--are often privy to the most vulnerable and intimate moments of their patients’ lives, with medicine becoming a window to look at the human endeavor. A medical professional, for example, is within twelve inches of every patient, listening with a stethoscope. He is close both physically and emotionally to the patient. At last, Dr. Selzer offers an understanding of this viewpoint, in his examination, or diagnostic embrace, of a patient:
There is something deeply moving about the human body waiting to be examined. Lying or seated, the body has surrendered whatever defensive or acquisitive posture it may have had and presents itself in an attitude of supplication. Palpitating the abdomen, the doctor may glance up to see the trust that glows deep within the eyes of the patient. Sparks of it will leap forth to ignite him. For it is trust, not gratitude or worship, that animates the physician. To palm a fevered brow, to feel a thin, wavering pulse at the wrist, to draw upon a pale lower lid--these simple acts cause a doctor’s heart to expand. His own physical condition is altered by the presence of the patient. It is the sublime contagion of the diagnostic embrace. Add to this the possibility of the grace of healing, and there is no human contact more beautiful.
The sublime contagion of the diagnostic embracethe grace of healing. Selzer’s words so eloquently translate into an understanding of a patient’s trust balanced with the doctor’s understanding. Achieving a better doctor-patient relationship is exactly what the medical humanities in partnership with clinical medicine teaches. Both doctor and patient may need to modify the traditional dominant-submissive roles. Physicians who learn how to expresss humility are not afraid of telling their patients that there is much about their illnesses they do not understand; but, that, together, through open communication, they have a better chance of learning more.
Much of my work involves lecturing, writing, and educating in the field of the medical humanities, which includes proposing a new doctor-patient partnership. The students in my classes who are in or entering medical professions (after extensive reading, writing, oral presentations, and discussions) learn better communication skills as well as how to balance scientific study with ethical awareness and empathy. They learn that in taking a patient’s history, listening (i.e., trying to catch, understanding, and interpret every word said) is different from passive hearing. In this regard, in a recent Chronology Richard Selzer sent me, he wrote:
In a former incarnation I was a surgeon, and a good one, although I made my share of mistakes over the thirty-five years in which I labored in that vineyard. A few people died at my hands, a few others were maimed. I did the best I could. Truth to tell, no honest surgeon could say otherwise. I was much beloved by the patients because I knew that what they wanted more than anything was to be listened to, and so I did. Besides, I found it most interesting. I posed not, nor did I pontificate. (My emphasis; 5 January, 2000 letter to Stripling)
Here and now at the Western Social Science Association meeting, contemplate the need to continually assess your doctor-patient relationship. As highlighted in the two stories, Brute and The Exact Location of the Soul, the best doctor may fall midway between scientific detachment and rampant empathy. Healing in the first story was replaced by possible long-term damage; in the second story, a diagnostic embrace connected a caring doctor and trusting patient.
Secondly, remember that doctor in Latin means teacher. Many of us, who are teachers, can easily correlate the doctor-patient relationship I have described to that of teacher-student. We have the same concerns for preserving the humanity of our students, sustaining their ability to feel and reason, and instantiating their own sense of attributes, skills, and identity. Consider, too, that we are also subject to the imposter syndrome or having that inadequate feeling that we can never know enough. Therefore, it behooves us all to embrace the teachings (i.e., the ways and means) of other professions. Oddly, many scholars treat interlopers from other disciplines as if they were engaged in a war for territory, as if interdisciplinarity were a zero-sum game (Wissoker B4). But, interdisciplinary knowledge will serve all of us well.
For example, although I am a Medical Humanities rhetorician, in my pre-med classes I use Communication skills, History, and World Literature to build a learning community that creates a model for compassionate doctoring. Its goal is to humanize and to create, through discussion and sharing, the necessary balance between empathy and restraint, between the scientific method of learning and humanist thought. The students, who are dedicated, bright, and competitive, have learned to listen and to assess important relationships through accessing various viewpoints. They have also learned compassion, as well as to not violate certain taboos. That is, according to Richard Selzer, in their professional lives they must learn to suppress such things as erotic impulses until they become taboo, unthinkable. In like manner, they need to overcome a natural revulsion for certain ugly facts of the flesh: pus, ugly rashes, wounds, and smelly things. In the end, they also have learned how to compartmentalizefor they will soon go from pronouncing death into a minor consult. Now, they are also able to gaze upon that physical misery and not find it ugly, but find it frail and vulnerable, and therefore beautiful. In particular, that is what Richard Selzer has tried to write about and to teach us: the beauty of ugliness (Stripling 151).
As we, personally, reassess what our relationship with our doctor should be, we can also reflect on the fact that doctors are human beings who sometimes make mistakes. Entering the new doctor-patient partnership, more responsibility falls on the better educated patient to communicate, just as it does on the more humbled doctor to listen--not just dole out scrips. And, it absolutely does matter how we as a society view our medical professionals. For, the doctor-patient relationship, though mediated by technology, elaborate procedures, and sophisticated pharmacology, is irreducibly personal, individual, and fraught with the ethics of care and responsibility.
As we enter the third
millennium, let’s lift our spirits by reaffirming our shared humanity in the new doctor-patient partnership. With improved communication, a better system for reporting medical errors, and the implementation of Medical Humanities curricula, we don’t need to make a Faustian bargain: technology for humanity.
Allman, Joyce Lankford. Bearing the Burden or Baring the Soul: Physicians’ Self-Disclosure and Boundary Management Regarding Medical Mistakes. Doctoral Dissertation. University of Oklahoma, 1995.
Foucault, Michel. The Birth of the Clinic: An Archaeology of Medical Perception. Trans. A.M. Sheridan Smith. New York: Random, 1994.
Hilfiker, David. Mistakes On Doctoring. Ed. Richard Reynolds, M.D. and John Stone, M.D. New York: Simon, 1995. 371-382.
Neergaard, Lauran (AP). Like a Jet Crash Every Day of the Year. The Times-Picayune No. 28 (20 February, 2000): A2.
Pear, Robert. (New York Times Contributor). The Fort Worth Star Telegram 22 February, 2000: 8A.
Selzer, Richard. The Diagnostic Embrace. Down From Troy: A Doctor Comes of Age. New York: Morrow, 1992. 160. Recorded Books narrated by Sam Gray, 1995.
- - - . Brute. Letters to a Young Doctor. New York: Simon, 1982. 59-63.
- - - . The Exact Location of the Soul. Mortal Lessons: Notes on the Art of Surgery.
New York: Simon, 1974. 15-23.
- - - . Letter to Dr. Mahala Yates Stripling. 5 January, 2000. [Chronology]
Squier, Harriet, M.D., M.A. Email conversation between Michigan State University Medical School Professor Squier and Dr. Stripling. 10 March, 1998.
Stripling, Mahala Yates. ’The Tending Act’: An Interview with Richard Selzer. The
Journal of Medical Humanities 17.3 (Fall 1996): 147-164.
Wissoker, Ken. Negotiating a Passage Between Disciplinary Borders. The Chronicle of
Higher Education (14 April, 2000): B4.