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Commentary invited by editors of Scientific American

When Physicians Relate to Some Patients, but Not All

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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.

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

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