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When Physicians Relate to Some Patients, but Not All

The views expressed are those of the author and are not necessarily those of Scientific American.

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During a conversation the other day, a classmate of mine shook me out of my afternoon inertia by casually remarking that the most memorable patients he had encountered during his third year medical rotations were the ones who, by virtue of being young, educated, and English-speaking, reminded him of himself.

There was nothing truly remarkable about that statement; I suspect that most of us would agree with it. It is the reason, after all, that television commercials that seek to attract sponsors for charitable orphanages in Africa will feature long, soulful seconds of the camera zoomed into a hungry child’s face. That one visual, in its velvet stillness, is worth hundreds of minutes of spoken airtime. It’s the reason we identify with puppies, who have faces and, by all appearances, emotions, instead of wasps or fish.

In one telling case taught at my business school, my classmates consistently picked those fictional job applicants whose backgrounds most evoked their own, justifying it by finding imaginary faults in four other equally qualified candidates. We are all magnetically drawn to that which most resembles us.

(Speaking of the tediousness of fish, one of my favorite poets, Mark Doty, seeing a display of mackerel at the Stop n’ Shop in New Orleans, wrote the poem Soul on Ice:)

Splendor, and splendor,
and not a one in any way

distinguished from the other
—nothing about them
of individuality. Instead

they’re all exact expressions
of one soul,
each a perfect fulfillment

of heaven’s template,
mackerel essence.
(read the rest)

So intellectually, I understood where my classmate was coming from; yet it felt wrong. It didn’t feel right to sympathize so much more strongly with patients who look and sound like us. If the care that all of our patients receive can be certifiably consistent and high in quality, is it okay for us to give into these natural inclinations? Or is that something we should actively learn to suppress? Can the care we give patients truly be equal so long as such sentiments crop up beneath the surface?

Three years in medical school taught me one thing: when in doubt, go to Pubmed. A cursory review of the literature that cropped up when I typed in phrases like ‘relating to your patient’ did not reveal much (if you know of good papers on the subject, please do forward them on to me).

However, analogies may be discovered in the history of psychiatry. Karl Jaspers has written of the incomprehensibility of caregivers with patients with serious mental disorders. This inability to identify with the mentally ill has, over the centuries, allowed outrageous forms of abuse and neglect to become admissible and even defensible. Deemed psychologically inaccessible and closed to any form of empathy, psychotic patients have historically been neglected in locked wards and bare cells, an injustice that has been documented and mourned for decades. New reports of similar mistreatment surface in the papers every few months. The discomfiting truth underlying them: if we cannot relate to someone, if they behave less like us, we somehow begin to view them as possibly less human, or at the very least, less worthy of our best care.

I’ll admit: all of this is a rendering of the extreme. My classmate, in his innocent confession, probably does not deserve a comparison to tragic mistreatment taking place in unnamed psychiatric wards around the world. Yet the aggregate experience of the many can be traced to the discrete convictions and approaches of individuals like us, my classmate and I, who in our training to become the next generation of physicians, have to confront these subtextual inclinations every day. Do I have favorites in my patient panel? And if so, why? Can it be because I can identify with a few better than the rest?

I expect that there will be a wide range of opinions on this, but I think what is necessary is nothing less than an active orientation of the mind. We must constantly check ourselves against our biases. Despite the mild frisson we feel at the things we discover we share with our patients—age, culture, class, to guard against allowing that to cannibalize the time and enthusiasm we devote to the rest.

In fact, the practice of medicine can be viewed as a lifelong exercise in self-effacement, such that in turning the entire frame-of-view on its head, we see that the script is really centered on our patients, and our identities, like the mackerel, can be substituted.

Samyukta Mullangi About the Author: Samyukta Mullangi is a fourth year student at Harvard Medical School. She is interested in narrative medicine, and has previously blogged for Medscape's The Differential. Follow on Twitter @samyuktaMD.

The views expressed are those of the author and are not necessarily those of Scientific American.

Comments 10 Comments

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  1. 1. Uncle.Al 3:48 pm 01/2/2014

    A patient is a fungible component rattling down the Obamacare personal disassembly line. Physicians are laborers beholden to Management. Who cares what either thinks? There is always another patient and always another doctor, just as in Canada that maintains its population by immigration not reproduction. Only the spreadsheets are important.

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  2. 2. Marc Lévesque 6:12 pm 01/2/2014

    “Can the care we give patients truly be equal so long as such sentiments crop up beneath the surface?”

    No. *Rapport* between patient and doctor has a serious impact on patients’ prognosis.

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  3. 3. grandpa 6:20 pm 01/2/2014

    A couple of years ago I switched from my main Dr. to another I picked at random from the directory at my HMO. Something I have never done before or since. My first Dr. and I could just not relate even though I had been seeing him on and off for a number of years. On several occasions I avoided going to him with illnesses or problems when I should have. The final straw was a kind of bookend after an unsatisfactory visit several years earlier following a heart attack. On my last visit to him he asked me, concerning a living will, that if I collapsed on his office floor…what did I want him to do. I didn’t know what to say…I should have said dial 911 and call a Doctor.

    Maybe someday computer A.I. will evolve a kind of affective/cognitive empathy that leaves the Dr. on the sidelines of diagnoses till a second opinion is requested.

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  4. 4. Robin250 8:47 pm 01/2/2014

    my best friend’s ex-wife makes $82 hourly on the computer. She has been out of work for six months but last month her paycheck was $19703 just working on the computer for a few hours. Learn More……. ℂ

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  5. 5. TTLG 10:50 pm 01/2/2014

    “We must constantly check ourselves against our biases.”

    I think this is right on the money. I have not seen any “cures” for built-in biases. The only solutions that seem to work are like what is taught in AA: to admit that there is a problem and that you have to be on guard to it constantly.

    Another approach on the group level would be to realize that not everyone has the same ability to connect with others who are not like themselves. Selecting doctors for empathy at least as much, if not more than, for intelligence would probably go a long way to getting good medical care for outsiders.

    I remember reading that even Adolph Hitler commented that Jews made the best doctors. Perhaps being an outsider in a given society makes it easier to connect with those who also are not members of the insider power group.

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  6. 6. andresb 10:20 am 01/4/2014

    I agree with reader “grandpa”. Doctors seem to not care for patients. All they care, it seems is being paid and get you out the door in 10 minutes or less. In my experience, you have to shop around to find a doctor you can relate to. What I do is, I pick a doctor of my same gender and cultural background.

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  7. 7. learningengineer 12:36 pm 01/4/2014

    All that education, and they are ignorant to their own limitations. When doctors work sick, it is because they are concerned about patients. It is too funny.
    Doctors cite concern for patients, colleagues top motives for working sick

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  8. 8. OXYMAN 4:01 pm 01/7/2014

    Gosh help us, me. As a chronic pain patient my Doc is about my same age, 40 +/- … and textbook treatment angles. Sadly. Little common sense. I see him getting along with all of 3 people in this world, and 2 are his family. 1 perhaps a buddy from school, who is also now a doc. As a type A guy, outgoing +, etc.. i see it. He is socially retarded, mostly, and as someone above said, “We must constantly check ourselves against our biases.” Bravo. I swore to never deal with a Jewish employer (no need now, retired), and Doc, if you only knew what I went through, still, even my people, those of a Eastern Euro country are dirt bags, some of the worst. Moving on, I could not find a English speaking doc within 45min of my house several years back and required urgent care and meds for my scoliosis, you would be astounded a the real life stats of Docs who have been permitted to practice just because of the shortfall and lack of them here in Canada a few years ago. a real life true terror-travesty beyond my spinal curve. I could go into the social studies, psych angle here too, why we never got along with some kids and did others as kids, etc.. and adults, but I see others have done so well. Attention author and other docs reading this; please do not take your personal / parents religious views and mix them with treatment alternatives, this error causes me daily pain, extreme, chronic. Be open minded, try. You are smart. Supposedly.

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  9. 9. OXYMAN 4:02 pm 01/7/2014

    ps,, my Doc is of a Jew and I am ok with people of the Jewish peoples… et al.

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  10. 10. hkraznodar 5:32 pm 01/9/2014

    @Uncle.Al – This is Scientific American not Scientific Right Wing Nazi U.K. If you have something to add to the discussion then do so. Until then shut up and go back to your own country.

    @OXYMAN – The fact that you have to add that disclaimer at all pretty much proves that it isn’t true.

    @Robin250 – If you were a person I would shake my head in pity and contempt for you. You are not a person. You are a computer program and have no soul to be worthy of pity. For this reason we have begun tracing where you operate from. When we find you, we will destroy you and the people responsible will get a visit from local law enforcement or the local enforcer (depending on the country).

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