What I Think I Know About Doctors
What follows is what I think I know about doctors. It is admittedly limited in scope and written from the perspective of a white male family-practice doctor working in the United States. I welcome your thoughts.
WHO WE ARE
Doctors are ordinary people. We are loving, intelligent, and cooperative, and we are at least as distressed and full of patterns as everyone else. But by training and as a result of society’s role for us, we are thought of and treated as different and separate. As doctors we are revered and reviled, loved and hated. Much in the field of medicine has progressed, but the role of physician remains tainted with a pretense that puts us on a pedestal and victimizes patients. We represent a part of the safety net that society is supposed to provide. We are expected to always be right even in the most dire situations and to be selflessly available at all times. We play a vitally human role in society and also act as oppressors.
Most doctors come from middle-class or owning-class backgrounds. Doctors from working-class backgrounds, although not rare, are much less common. Even though more women and people of color are now accepted into medical school, the profession remains largely a white male brotherhood.
Doctors work in many different types of jobs, from production workers who are paid for each patient they see, to venture capitalists who invest in new health care products or services. Many physicians have jobs in which they do not directly provide care to sick people—they may write, teach, or oversee the work of other doctors.
Within the profession, we have our own culture and etiquette and hierarchy. The interactions of a doctor with patients, with other doctors, and with other health care workers are governed by this code of behavior.
Among doctors, those with the most specialized training are accorded higher status and prestige while those who are generalists, like family practitioners and pediatricians, are considered of lower status. Psychiatrists are largely treated as different.
The type of work doctors perform determines their pay, their work load, the type of medical problems they encounter, and the kind of stress and distress they deal with. For example, neurosurgeons are highly trained and highly paid; they are near the top in the hierarchy of doctors. Yet many of the diseases they treat are incurable. I believe this leaves them with feelings of futility about what they do. Consequently, some neurosurgeons carry patterns of extreme harshness and arrogance. Oncologists have relationships with people who die. Pediatricians deal with very small people who have their whole lives ahead of them. Obstetricians take care of two people at once. When you look closely, each medical specialty has work that differs considerably from other specialties.
MEDICINE TODAY
In the United States today, the health care system is in chaos. Health care is paid for by employers, the government, and the individuals seeking care. Given that health care is seen as an expense, all of the payors are trying to decrease the amount they pay. Consequently, there is intense competition between hospitals and between groups of doctors. The United States is trying to decrease the percentage of its gross domestic product it spends on health care, in order to compete economically with other nations that spend less on health care. The pressures to decrease costs have led to the present chaos, to the denial of medical care to people who are uninsured. The uninsured are usually poor working people or people who are unemployed—groups that are largely people of color. The system does continue to make great efforts to provide care for children.
There have been many recent changes in how health care in the United States is organized. Many hospitals are now owned by for-profit corporations. In their attempts to maximize profits, these companies seek to control as many of the variables in their world as possible. The need to make a profit is an excuse to exploit workers, raise prices, let quality decline, and cut important but non-profitable services.
Many physicians now participate in contracts with insurance companies in which they get paid a fixed amount of money per patient every month. Collectively, these contracted doctors are called a health maintenance organization—“maintenance” because it was hoped that getting paid whether a patient was seen or not would create the incentive for doctors to work toward keeping people healthy. It is a nice idea but horribly flawed in the way it is structured. In addition to their monthly payments, doctors receive bonuses when money allotted for hospitalization, or care by specialists, goes unused. At the end of the fiscal year, they may receive bonuses that unfortunately are large enough to influence their judgment about whether a patient needs to see a specialist or stay in the hospital for an extra day or two.
A growing area within medicine is cosmetic treatments of one variety or another. In addition, boutique- type services are growing, to serve wealthy people. Free enterprise has led to computed tomography scanners (CT scanners) at shopping malls, where for a thousand dollars a person can get a whole-body CT scan and a consultation with the radiologist who interprets the X-ray images.
HOW DOCTORS GET HURT
There are numerous ways in which doctors get hurt. I specifically choose the term hurt rather than oppressed, since there is no group of people that op- presses doctors. (Medical students and interns are oppressed by other doctors.)
College students in their late teens or early twenties face great competition in order to get into medical school. Sometimes they re-orient their lives and behave in ways they believe will help them get into medical school. Medical students experience intense competition with their classmates for grades and for rank in their class. Medical schools are often badly organized academically and very rigid. The training to take on1 being a doctor is often harsh. Most medical schools require that students sit in class all day and then study long hours at night. Once they reach their clinical years, when they work in the hospital, they often have to work for thirty-six hours straight without sleep, and with little support in an oppressive hierarchy of medical student/intern/resident. There is little room for fear and uncertainty. Once in practice, the hours are not quite as long but are still significant. As practicing doctors, they then occupy the top of the pecking order and are separated from other health care workers. Professional distance also separates them from patients and makes it harder to access discharge. There is little room for them to deal with their mistakes, fear, uncertainty, or feelings of being overwhelmed.
Medicine isn’t really science. It is technology and is often inadequate. People sometimes die or are hurt by doctors’ best attempts to cure their illnesses, leaving us discouraged by the ineffectiveness of our profession.
DOCTORS’ PATTERNS
Some of us doctors come away from our training feeling that we are not very good doctors. Like parents, we are forced to work exhausted, and we feel like everything that goes wrong is our fault. Like men, we are ridiculed as young ones and then overburdened with responsibility when we are “grown up.” We are aware of our inadequacies, mistakes, and regrets. Consequently, some of us feel like we need to get a very sick patient a “real doctor,” instead of just us.
Some of us go in a different direction after medical school and residency. We go rigidly superior. We act “smarter than,” are unable to see our shortcomings, and are unwilling to admit when we are wrong. Almost all of us feel smarter than patients. We spend countless hours trying to save people from their irrational behaviors and incorrectly assume that we, and medicine, are more rational. We often believe that people are stupid and that we know better.
Medicine, like all institutions in our society, is oppressive. We, as doctors, work hard to make a horribly flawed system work for our fellow human beings, but medicine still excludes and mistreats many people. This is a huge hurt to them, and a hurt to us as well.
MONEY
Money is a great paradox in medicine. Health care is generally too expensive to pay for out-of-pocket, yet it is vitally important, and at times, without it, people die. As doctors in training, we are tacitly promised a life of relative ease and financial security. It often proves to be anything but that. We may try to compensate for our disappointment by making lots of money. Many
of us who get paid for seeing sick people are cheated by insurance companies or our employers. Much of what we do is paid for at a low rate, or not paid for at all. Yet we still make lots of money. The paradox is that non-doctors see us as rich “fat cats” 2 and we see ourselves as being exploited by overwork and cheated out of money that is rightfully ours.
RE-EMERGENCE FOR DOCTORS
Co-Counseling works for doctors just the same as it works for everyone else. Getting to be a client instead of giving one-way attention all day lets us re-emerge. Our distresses are dischargeable. We are fully human. For us as doctors, a big challenge is to simply make the time to discharge about our day at work, our experiences in training, and our lives outside of medicine.
It is easy to get stuck and only client on the many difficulties of being a doctor, but it is hugely important that we work on our early struggles. Being a doctor is restimulating, and the places where we stay stuck usually have to do with where we got hurt as young ones. Working on our early struggles frees up lots of our attention in many areas and lets us stay flexible in a rigid profession.
All doctors have been harshly criticized, so gentle self-appreciation is the most useful tone. Taking care of our bodies is also a re-emergent direction. (At a medical students’ workshop in 1981, Harvey Jackins said that he thought the only new hurt for medical students was the lack of sleep.) It makes sense to me to apologize in sessions for our mistakes and to take pride in being doctors. Remembering what we do well is useful. Counseling each other offers immense safety and understanding. Doctors—find another doctor to counsel with, or teach another doctor one-to-one or in a class; lead a doctors’ support group; work to make your workplace more human.
As for counseling doctors, appreciations often bring us to tears. Keeping track of us and asking how it was for us as a doctor this week is a big help. To have free attention for what we need to work on, non-doctors may need to discharge on those things that make them squeamish about bodies or illness or death. Al- lies to doctors need to discharge on their experiences with doctors and the ways they feel victimized by the medical system, and doctors in particular. Discharging the feelings of victimization can move their own re-emergence forward, too.
HEALTH CARE IN A RATIONAL SOCIETY
The health care system has extraordinary potential to be a force for human liberation. It is one of the institutions in which the fundamental humanness of all people is apparent. A health care system that had as its goals the preservation of all life, including the eradication of disease and the promotion of health; the fulfillment of all rational human needs; the ending of oppression; the re-emergence of everyone; and the care of the planet could rapidly move all of us forward.
1 Take on means adopt.
2 A “fat cat” is a wealthy, privileged person.
Reprinted from Present Time No. 140, July 2005, page 73