Exposing the thin line
M R Maithreyi
Robert Klitzman. When doctors become patients. New York: Oxford University Press; 2008. 333pp. $35
After losing his sister Karen in the September 11, 2001 terrorist attack in New York, a devastated brother helps to organise her memorial service and packs up all her possessions. What happens to him over the next few weeks has culminated in the form of the book under review.
It takes three whole months of sleeplessness and disinterest in life for the brother, a psychiatrist by profession, to realise he’s suffering from depression. The irony of his situation sets him thinking about what it means for a doctor to be a patient. His curiosity leads him to 70 physicians, ranging from 25 to 87 years, with various illnesses like HIV, cancer, hepatitis C, and bipolar disorder. These sick physicians divulge things they had never shared with anyone before: disbelief about their illness, a sense of shame and discrimination, and lessons re-learned. “And I’m a doctor, a scientist! But I’m also just a scared patient” is how Charles the internist with HIV describes his experience, exposing the thin line between being a doctor and a patient. The journey from one side to the other is certainly never easy, as Dan, a middle-aged oncologist who had metastases in his chest, reveals: “We doctors wear magic coats… How could it [disease] ever attack us?”
The book traverses his journey to becoming a patient, then going back to being a doctor and interacting with patients. For the most part, the author allows these ailing physicians to speak in their own voice as it “best conveys the struggles and conflicting identities, poetry and pain they described…” What makes one a good doctor? Is it the technical expertise or the bedside manner? For instance, Herb, a neonatologist with heart disease, whose doctor tells him he has a five per cent chance of dying during surgery, realises how the way one conveys a fact is as important to a patient as the fact itself: “If I had been told instead that I had a ninety five per cent chance of surviving, I would have slept better…” It is a lesson he has learnt for the first time in his 30 years of practice. Surely no amount of doctoring can prepare one to be a better patient!
As patients, these doctors discover fissures in the health delivery systems. They see how hospitals are shaped around the doctors, administrators, and business people who run them rather than the patients. They note how procedures and other technological interventions have diminished the amount of time doctors have with patients. They also recognise how acutely paternalistic doctors can be.
Patients open up only when certain responses are preempted by the attending doctor. The cues they provide affirm the possibility of raising certain issues. But it is also true that doctors work against time pressures and cannot devote as much time as every patient may demand. Given such a context, most of the sick physicians in this book modify their own practice to incorporate a more “equal sharing” as against the traditional stance of “doctor knows best”.
The book very effectively brings out the confusions the doctors face as patients. One moment they feel paternalistic attitudes are all around them, the next moment they complain about the treating physicians not being sensitive to their emotional needs. Confusion prevails even in the way they organise their own lives. Should one plan to live or die? Questions such as this assume greater importance. Some of the stories like those of Deborah, the psychiatrist with metastatic breast cancer, dreaming her hair is back; Steven, the endocrinologist with HIV, switching from optimism to pessimism, are indeed heart-wrenching.
One of the criticisms against doctors is that they can be judgmental, especially in psychiatric illnesses stemming from drug and alcohol abuse. The shame and fear of stigma and discrimination leads many of these physicians to hide their own illnesses. It also leads them to improve their communication skills with patients. For instance, they see the usefulness of asking “Do you have a partner?” instead of “Are you married?”; a lesson they were never taught as medical students!
The author describes how “spirituality aided many of these physicians in confronting serious illnesses”. But some of his observations seem rather banal and perplexing like “Scientific training can foster … skepticism and hinder desires to be more religious” or “heightened awareness of these [spiritual beliefs and practices] issues can potentially strengthen the relationships between doctors and patients, improving their experiences as they each grapple with disease” Another time Klitzman writes “Depression may provoke religious doubt and conversely, religious doubt may prompt or aggravate depression.” One is left asking “Just how?”
The book could have benefited from tight editing. Several repetitions make the reading jarring and tedious. Though the illness narratives in the book are specific to the US, they still shed light for Indian readers on approaches towards and ways of coping with disease. There are many issues that readers here can identify with, such as stigma, identity loss, denial, medical errors, paternalistic attitudes among doctors, their vulnerability to self-prescribing, spiritual dilemmas, the role of alternative medications, and so on. Roxanne’s rumination, “Even for me, sometimes it’s hard to get information… So I can’t imagine what it’s like for some patients out there” will surely strike a chord among many.
The book makes a strong case for better training to make doctors comprehend the experiences of patients with greater sensitivity and empathy. If one is ready to overlook some of the shortcomings discussed earlier, the book is worth a read. But it is doubtful whether the book would really help doctors to be better patients and to realistically know what to expect as patients with a serious illness, as Klitzman desires in his Introduction.