Doc in a Box [Commentary

Abstract

Doc in a Box, a novel by San Francisco Bay neurologist Robert A. Burton, is a redemptive tale of a physician, Dr. Webb Smith, who loses his way mightily, both personally and professionally, only to discover what matters most about life and doctoring. The title, in addition to summoning up dreadful images of Jack in the Box managed care models, also alludes to the good doctor's sense of entrapment, of being “boxed in” so to speak, by his interpersonal relationships, money worries, and work. In this excerpt, Dr. Smith has hit bottom. His medical license suspended for an act of compassion toward a patient, Dr. Smith is employed illegally at a clinic where few questions are asked so long as the bills are paid. Craving expiation in the form of someone he can “fix,” Dr. Smith instead encounters a completely uncommunicative patient with headache and his demanding wife. For exhausted, overburdened residents, the excerpt provides an easy entry point into the frustrations of a relationship with a perceived “difficult” patient. Told exclusively from the physician's perspective, what we first encounter is a sympathetic (albeit confused and lost) physician, trying to do a good job with his patients, only to be faced with the patient and family member from hell. Residents quickly smile in recognition at the monumental passivity of the patient and the entitled, confrontational attitude of the spouse. It is easy to feel sympathy for the beleaguered, boxed-in Dr. Smith. But is Dr. Smith the only character trapped in this web of substandard, McDonaldized medicine? Point of view is indeed a marvelous thing. Usually without prompting, learners quickly start to be curious about the other characters in the story, the almost pathologically taciturn patient and his “hawk-like” wife, with whom they initially feel less affinity. What could have happened to make a man so hopeless and helpless? Are there other ways to understand the aggressive tenacity of his wife? As learners imaginatively explore the landscape of these so-called problem patients, they begin to surmise that husband and wife may be as trapped and desperate as Dr. Smith. The patient has been imprisoned by headache for twenty years, almost a life sentence. As for his wife, who might not display a bit of temper after having been relegated in perpetuity to the thankless role of ineffectual but solely responsible caregiver? Together, husband and wife are trapped in a co-dependent relationship organized around the patient's suffering. Other dimensions of the boxed-in metaphor also become illuminated. Once a resident commented, “I can really relate to that man.” When asked why, she responded, “I've been captured by headaches too.” This evocative language gave rise to an innovative alternative story about how wife and doctor might join together to emancipate the walled-off captive. We may also wonder how prevailing social ideas about gender affect the interactions of doctor—patient—spouse.* Trapped in a traditional female role of caregiver with no reward and great frustrations, the wife struggles to expand its parameters by manifesting certain characteristics traditionally associated with men (aggressiveness, protectiveness, confrontation). For this violation of the wife's own gender-based box, the two males in the story join in fantasizing about her being bludgeoned to death by the reflex hammer! At this point, having identified the experience of entrapment shared by doctor, patient, and family member alike, residents can profitably revisit the story. They have not lost their compassion for and identification with Dr. Smith. They still acknowledge that his inclination toward kindness and his awareness (albeit fleeting) of peering into his patient's soul are efforts to free both himself and his patient from the confines of their highly constricted and unsatisfying options. But through reflection and imagination, the story has become more complex, richer, and multi-layered. By recognizing the suffering of all participants in this doctor—patient—family member encounter, learners can conjecture different endings built upon their common predicament. They explore alternative strategies of limit setting with the wife, restructuring the encounter, and expressing empathy and compassion toward both patient and spouse. They speculate about how to extend the system through referral to a counselor or an alternative practitioner. In a bold vision, they can even imagine Dr. Smith disclosing his sense of failure before his patients leave the room, the wife experiencing for a moment the relief of surprised silence, and the first halting words of the patient. Out of enslavement, shared possibilities of liberation emerge.