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From: (Steven B. Harris )
Subject: Re: ALL READ...Steve Harris
Date: 05 Oct 1995

In article <44rrjj$> janaki@gwis2.circ.gwu-
edu (Janaki C Kuruppu) wrote:

   >>As a 4th year med student, recently emerging from the
third-year clerkships, and the non-life that that entails, I find
myself at the curious point between lay-person and
official-physician (with the MD and everything!)  As such, I have
only in recent weeks/months had time to sit at the computer and
read the net (as i used to do in my former life as a
non-professional worker)...

  >>It seems that the problem lies in the fact that physicians
speak to one another in a much different way than they do to
patients, and on the internet, physicians address lay-persons in
a similar manner that they would use with colleagues.  The way
that the physician communicates with the patient simulates, in
many ways, the way a parent talks to a child---as the all-knowing
authority.  In this Judeo-Christian culture of ours, this stance
is associated with our image of God, and, I think, herein lies
the difficulty some folks have with hearing a physician
communicate in plain language.  Doctors, in the minds of many,
aren't supposed to be human.

   >>So the question is:  should physicians talk with their
patients in the exam room on a more person-to-person basis, or
should physicians posting to the internet stay in character as
the God-like figures that at least some in the lay community seem
to want (i.e. the Marcus Welby-type)

janaki kuruppu MS4 (MD in 7 months and counting)<<


    Comment: Good questions all, Janaki.  And the answer is that
there isn't a single right answer.  And that's the problem, too.
With patients, in a medical practice, the way you have to talk to
a patient is the way the patient wants to be talked to, and that
differs really drastically from person to person, according to
personality, cultural, and age factors.   As a doc you're going
to find people still from the era where "doctor knows best," and
you're going to find other people (especially smart long-term
sufferers from rare diseases they've studied long and hard) who
know enough to make their own medical decisions, and only need
you sign off on their ideas, and to write them the prescription.
(In fact they may know more than you do about their disease;
don't let it bother you too much.  Start reading).  You'll find
people who think doctors are Gods because of previous experien-
ces, and you'll find people who hate doctors' guts because of
previous experiences, and don't really want to be where they are,
which is in front of you, half-naked and sick.  And all levels of
people in between.   You're going to find people who are mentally
a few fries short of a happy meal, and you're going to find a few
others who are probably by most measures more intelligent than
you are (hopefully not TOO many of these, but you'll find them).
You'll find Lefties who think that the government should pretty
much decide the nitty gritty issue of health care, and you'll
find Righties who figure such things should be between the head
of the family and God Almighty.   And libertarians who'd like it
if *everyone* would butt out of personal decisions but you and
them-- and they're not too sure about you.

    Now, when you first see a new patient in your office or at
the bedside, you've got a few minutes to start figuring all this
out (which is why you'd better let the patient do most of the
talking at first), and if you fail in your social estimation of
what your patient expects of you, you are going to find your
social interaction with you patient sliding very rapidly
downhill.  But that, along with the science, is what makes the
practice of medicine endlessly difficult: it takes everything
you've ever learned about everything in the world to do it, and
even THEN you'll screw up all the time, and never get it perfect.
The problem is certainly enough to keep you interested for a
lifetime, which is why I recommend it as a profession to bright
people as a career, even if The Powers That Be do end up paying
us less than middle-level janitors one day <grump>.

    As for talking differently to different people, some of this
is what you do all day long in social interactions, of course--
each person reads other people, and adapts themselves somewhat to
the person they are with at the time.  Some people are better at
this than others are, to be sure.  Women, I verily believe, are
better naturally than men at it.  A few doctors are terrible at
it, and we call these "radiologists" (just kidding).

   The PROBLEM comes when you as a doctor are talking to a lot of
people at the same time, for then you run into the politicians'
classic public speech problem: you cannot please everybody if you
have to do it all at once.  You will note that there isn't just a
"bi-stable" way that doctors operate-- one way among themselves
and one for patients.  There are AT LEAST four major social
situations: how you talk to other doctors; how you talk to other
medical personnel (nurses, pharmacists, respiratory therapists,
etc); how you talk to patients; and finally, most sacred and
difficult of all: how you talk to patient's *families*.  The last
is by far the worst problem, because you are dealing with a lot
of different people who have a right to expect something from
you, but who may be of different ages and totally different
outlooks, all of whom probably lack critical information about
how much suffering is going on (only the patient really knows),
and who may well be fiercely protective, and far more anxious and
worried about the problem than the patient is.  That is why you
will observe that "talking to the family" is the one ritual in
medicine in which there is almost no humor, and the one that all
doctors, from residents to attending physicians, prepare themsel-
ves for yogicly, as though it were a trip into another dimension.
Which, believe me, it can be.

   Here on the net it isn't quite that bad; but you have observed
quite rightly that we have many of the same problems.  I am, as a
physician, "talking" to many different people here at once.  It
is a sure thing that some of them are not going to like where I
am coming from, particularly as I refuse to put on my "formal
family face" for talking about medicine offhand in my free-time
on my computer at home (so there).  Worse still, there are many
ways that I couldn't put on my formal "family face" even if I
wanted too:  exchanges here in print, even with emoticons ;-),
lack most of the social information which allows us to lubricate
our exchanges with people in real life.  Without that exchange,
which we as face-communicating primates need, we tend to degener-
ate into flame-wars.  Heck, this happens in ANY subject discussed
on the net, and when we move to emotionally charged subjects like
medicine, there is surely going to be Hell to pay. :-(

   I've made no secret of my political outlook here (I'm a
libertarian, but not an anarchist), but it's important to
remember that I'm not in "face the patient's family" mode here,
and won't ever be.  If I was a doctor taking care of Hugh Rodham,
stroke victim, it would surely be grossly inappropriate to lobby
his daughter Hillary about health care reform (and I trust on
behalf of my profession that that didn't happen).  But it is
surely kosher for me to do such arguing here on the net.  Don't
hold me to the same behavior here as you would if I was your
personal doc.  It's not fair.

   It's no secret, then, that I would in general like people to
be more involved in their health care, and would like government
to bow out. (Bill Clinton may have gone to Oxford, but that
doesn't make him smarter than I am, and it surely does not mean
he ought to decide about my medical care and where my kids go to
school, etc.  Even if he was smarter than I am, he doesn't have
either the information or the vested interest that I do).  My own
favorite patients are savvy, moxie, feisty folks who take their
pills on time, but don't hesitate to quit taking their meds and
call me up if they don't like what their medication does to them.
My favorite patients give me stuff to read and ask questions.
They don't let their diseases get them down, but simply forge on
ahead through life, right over the top of nearly every
disability.  They do complain, and they do keep trying new
things, but they don't whine.  They do sue, but never over
trivia.  They are adults.  I treat them as adults.  Perhaps
that's why *I've* never been sued.  Or perhaps I'm just lucky--
who knows?

   Naturally, I cannot have all my patients like this.  But I can
lobby for it, a bit like the little boy or girl making up a
Christmas wish list.  And if I rub some people the wrong way
doing this lobbying, remember what the situation is.  I'm here
really on as an "exhibit" and zoo specimen of what one
species of modern internist is like-- I'm not really here as the
personal doctor and advocate which I would be if you came to see
me personally for a consultation.  Remember this, and remember
that I'm generally said to be in person a nicer guy than I appear
in print, and we'll all be a lot calmer and happier on this

                                Steve Harris, M.D.

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