"How Can They Act like That?": Clinicians and Patients as Characters in Each Other's Stories

Abstract

In what may be the clearest, wittiest, and truest essay patient ever wrote about doctors, Anatole Broyard, literary critic terminally ill with cancer, expresses his desire for his physician's recognition. He wants physician who would for my as well as my prostate. (1) Broyard then cuts to the quick of clinician-patient asymmetry: While he inevitably feels superior to me because he is the doctor and I am the patient, I'd like to know that I feel superior to him, too, that he is my patient also and I have my diagnosis of him (p. 45). (2) The pace of storytelling has increased since Broyard's reflections were published posthumously; and both patients and physicians enjoy proliferating outlets to express their diagnoses of each other as people. Yet Broyard's hope that clinicians and patients might find a place where our respective superiorities could meet and frolic together (p. 45) has not come about. Among the stories of clinician-patient relationships that were told during the meetings of recent research project at The Hastings Center on the clinician-patient relationship in cancer care and research, I recall only one about mutual frolic. A man who had received bone marrow transplant described setting up toy basketball net in his hospital room. Any physician who wanted to talk to had to take foul shot first. Broyard would have laughed out loud. But that patient was self-described medical entrepreneur who knew the system and how far he could push. More often we heard about two groups, clinicians and patients, each watching the other, often warily. If the world of clinician and patient is no longer silent world---if it has become filled with stories--mutual observation rarely becomes dialogue. By dialogue I mean talk grounded in mutual desire to recognize and be recognized. (3) In Broyard's colorful phrase, physician and patient would each grope not only for tumor, diagnosis, or treatment, but also for the of the other. This essay addresses the question of what that spirit is. What does each need to recognize about the other to create clinician-patient dialogue? How Can They Act Like That? Issues of care--not care reduced to provision of treatment but care in the sense of mutually caring relationship--are usually marginal to bioethics. In the case studies presented in this journal and others, little is said about whether clinicians and patients recognize each other as Broyard wants to be recognized, and as I believe most physicians want to be recognized by their patients. A stand-in for recognition is trust, which is talked about more often. But trust is generally constructed, first, in asymmetrical terms emphasizing the need for patients to trust clinicians, not vice versa. (4) Second, trust is considered to be worth talking about because it has instrumental consequences for achieving medically defined ends: success of treatment requires compliance that requires trust. Instrumental consequences also underlie whatever need for mutual understanding is acknowledged in discussions of clinician-patient communication. (5) Patients have to understand the medical instructions and advice that clinicians give them, and clinicians have to understand enough about patients to anticipate cultural and lifestyle barriers to compliance. But none of this gets close to recognition in Broyard's rich sense, in which each feels implicated in the other's life story, and feels that other's implication in his or her own story--and believes these stories matter, crucially. The issues of this essay are thus on the margins of bioethics and of what is conventionally constructed as clinician-patient communication. My concern is with clinician-patient relationships (or, properly, lack of relationship) that most observers might shake their heads over, but that hardly seem to merit an ethics consult, much less write-up as case study. …