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Terror and mystery always interfere with a person’s ability to care for herself.

A person becomes a patient out of fear, not merely often but clearly always.  What the patient fears is death or some concomitant of death—pain, mutilation, dependence, rejection or abandonment.  No comfortable person becomes a patient; even the most seemingly healthy and comfortable person who becomes a patient has anticipated death or its concomitants, or has tapped her real buried fear of death whether she knows it or not.  So there is no “routine” clinical encounter for any patient.

I have defined the patient by his emotion, fear.  I extend the definition:  the patient is not rational.  If a person successfully could deal with his problem, identify and solve it, that person would have no cause for fear, would have no reason to submit to being a patient.

It does not matter if the patient is fully aware of what I have just outlined, he is fearful nonetheless, and irrational.  When I am a patient I am so, and I know it.  (I am also fearful and irrational when someone I am close to is a patient, and then I cannot serve that person as a calm and competent clinician.)

Whether consciously or not, each patient will be fearful and irrational not only toward death, but toward the clinician she seeks to trust.  No patient can afford to trust a clinician initially.  A patient may seem to trust even too much (as he may seem to fear too little, or seem to perceive and understand more than should be expected), but all that is likely to be a test of the trustworthiness of the clinician, often more difficult for the clinician to overcome than the more straightforward challenge of disease.

The most convincing examples are from your own experience as a patient (but about these you will be emotional and irrational) or from your own experiences as a clinician (of which I hope you will not be too afraid or too intellectually incompetent).  We are each clinicians sometimes, attending to someone who is sick or afraid.

For now I ask you merely to consider some general type of patient behavior that are selected with some logic from an infinite spectrum of unique persons in unique circumstances.

Because I have described the patient as afraid and irrational, out of a sense of fairness and balance I will imagine with you the most healthy, competent and independent patient.  Why did he come to the clinic?  Why become a patient?  Will the patient deny fear?  Will her orderly accounts of experiences (symptoms) be allied with plausible explanations of their nature, and likely be followed closely by practical remedies the patient has already chosen?

No one who truly has understanding and solutions for her own potent problems ever becomes a patient.  In fact, when a previously comfortable and secure person suffers changes that stimulate fear and confusion that person avoids becoming a patient even more strongly, for a time.

What if a secure and comfortable person becomes a patient merely as a formality, prompted by external circumstances?  What of the person who is a patient merely to record a physical examination to fulfill documentary requirements to attend college, for instance?

He experiences fear of the discovery of unknown disease.  He imagines the clinician may discover leukemia—or worse, venereal disease.  She fears exposing her breasts, or wishes to be assured she will not become pregnant (but will not mention it).  He fears his penis is shorter than those of other college applicants, but will not allow the consideration to stay in his mind.  She wants to ask about the effects of drugs, but imagines the clinician is not willing to keep her secrets, or would morally or legally punish her for bringing up the subject.

If you insist I have been unfair to take the example of a normal adolescent (who has been said to be just a bit unstable in any case),  let us  take the more mature healthy person, the subject of the "executive physical examination" or the routine annual Papanicolaou test.  Must I mention what that person may fear or imagine?  Must I give examples of mis-hearings  and  misinterpretations that person will execute when you say everything  seems  normal?   Never  tell  a patient,  "There is nothing wrong with you."   If there were nothing wrong he would not have come to be a patient.

What of the patient who may be unwell?  What is likely to be that person's experience? How does one become a patient?  Let us take a simple likely example  in  which  something  happens clearly:  A person vomits blood.  (Don't ask me  how much,  what  color,  whether there was associated pain, its location and character, et cetera.  We consider persons, not pathologies.)

What would you do  if  you vomited blood?  You would be alarmed. Then you would imagine horrid causes.  Not being able to easily imagine sure remedies for horrid causes, you would imagine innocent  causes.   Not  being  sure  of  the cause you would be tempted to wait for the next episode not to occur.  You will have denied as much as possible.  (It is hard to  imagine nothing--this  is  the problem gay men have imagining not developing AIDS.)  Perhaps you would go through such  ruminations  in  seconds,  or would drag them out for weeks or months.  But something of convincing significance has occurred, and in a moment you feel you cannot deny it (or your mother or spouse or your pain will not allow you to deny it) you become a patient.

You have expectations of the clinician--nice ones like, “She will help me solve this, make it nothing," or,  "He will be kind, help me tolerate my pain."  Whatever  your  expectations, they  are expectations of large magnitude and significance.

Your expectations are also negative.  That quack may turn your merely frightening condition into surgery (butchery).  Rather than blaming the quack for your expected death you may blame your spouse or mother, your disease, or luck or God.

Enough gory details of your own emotional experiences  (which  in  reality would be more gory and detailed).  How can you speak or act toward the clinician?

Whether well or ill,  prompted by sudden changes which are clear, or nagged by questionable changes which are chronic, a person becomes a patient through fear of death or its concomitants, and with great expectations of the  clinician, positive and negative.  The patient's behavior, mode of expression, verbal or nonverbal idiom can be most anything, especially in the beginning.  What is more complicating, in reality, is that most patients have previous experience with clinicians and out of a cruel kindness try to present a technical idiom by jumping to diagnostic and therapeutic  conclusions  in  technical lingo, universally misleading.

The resolution begins with the real meeting.  Negative expectations and extreme fears can be narrowed.  I have outlined elsewhere how the clinician can learn to meet the patient well (see “Dialogue, Dialectic, Drama”).  For now, describing the patient's experience, let us observe that the patient can be well met, negative experiences minimized, positive experiences maximized by whatever calm and rational means.  Or the meeting may be so disastrous that the patient flees, better off without the clinician.  Or there may be some compromise,  an acceptance of mediocrity, the main advantage of which is that it keeps the relationship going so that future improvement is possible.

To you as a clinician the patient may approach from any direction in any fashion, but once the two of you have made some contact with each other, you, the calmer and more rational (and less threatened and less pained), can work systematically toward narrowing negatives and nurturing positives for the patient's sake; and with her increasing calm and reason, increasing competence and independence, finally she will have paid you off financially or emotionally  You will be satisfied to let go, to let the patient go her own way in relative health (knowing how to return when it seems right).

When the patient somehow pays you off or finds some resolution of his battle with disease or death, the patient is more or less liberated.  Treating patients well calls for similar discipline as does teaching, or raising children; the goal is to enable the patient to become more autonomous.  For the patient to find equilibrium with disease or death (sometimes by dying) and to settle accounts with you the clinician, are approximately contemporaneous.  All along, the clinician has been the agent of death as well as the agent of life.  (I am shocked to hear  that,  thinking myself a sincere altruist, a fighter for health and life, that I had resided only among the living, a mere mortal myself.  But I am in a position of neutrality in a sense, promoting life but accepting death.)

There is a meaning to clichés.  That medical practice is treated universally by patients as mysterious and powerful is amply documented by common language.  Sobriquets for clinicians are often derogatory in a witty way, reflecting directly the patient’s fear.  They are a little bit funny only when used by someone not subject to the clinician as agent of death, either malicious or incompetent.  To make use of such humor as one way of defusing the fear it is I  the clinician who occasionally call myself or my trusted colleague "quack", "pill-pusher”, "charlatan", "saw-bones", "head-shrinker," et cetera.  (The wise and  witty  physician-priest Rabelais would give us an extensive list of insulting names for clinicians.)  But it is not my purpose now to derogate clinicians (who are truly derogated only by their own misbehavior).  I wish merely to show that patients have fearful expectations of clinicians that color the clinical relationship.  These also I insist are constant and universal, whether or not manifest.

I have said the patient's fear and unrealistic expectations  (positive and negative) must be present initially, and can be narrowed and minimized by real meeting with a calm and competent clinician (one not also overwhelmed with fear and unreason).  Although the initial meeting is crucial, all subsequent events are subject to distortion by superstition as well, which it is the clinician's responsibility to deal with effectively.  It is not the person of the patient which is to be rejected,  but sometimes his fixed ideas which, arising from fear and unreason, are to be acknowledged, respected and set aside.

A concept against which I wish to mount a crusade is "patient noncompliance".  What is meant by noncompliance is that there is something contrary in the patient that prompts him to disobey the authoritative instructions of the clinician.  Literally this is true.  The implications, however, are true only to a power relationship, not to the more desirable and effective clinical relationship we seek to understand and use.

It is most practical to assume that a patient's behavior within the clinical relationship and in reaction to his conditions makes sense, for if we say we can make no sense of a person's behavior we have no way to deal with that person.  It is just such a rejection we execute when we label a patient's behavior "noncompliant".  We terminate processes of ongoing diagnosis and treatment by rejecting the patient outright, or perhaps by suspending our expenditures of energy on that case until the patient "comes  around" to cooperating  better, forced by the progress of disease, as if the disease were the clinician's ally in a struggle against the patient, rather than the clinician the patient's ally against the feared disease.

When a patient is not following our recommendations it is not practical to assume the cause of the discrepancy to be some undefined contrariness in the patient.  The many conditions which may lead to a discrepancy between the clinician's recommendation and the patient's subsequent behavior include almost everything except the patient's undefined contrariness.

The patient has become a patient through fear of death, which has rendered him essentially irrational.  In his irrational fear the patient associates the clinician with death, tending  to counter mistrust with overwhelming trust (a “counter-phobic” defense), unrealistic expectations and passivity.  If the patient's behavior is not in accord with the clinician’s recommendations it may be that:  (1)  fear and irrationality have not yet been acknowledged and outlined clearly enough (which task is the clinician's); (2)  the clinician's real trustworthiness has not yet been well established in that she has not manifest real care for the patient; or (3)  the clinician has not yet proven the plausibility (rationality) of his diagnostic interpretations or therapeutic recommendations, nor that the clinician will be loyal and continue caring enough to struggle alongside the patient.

These are examples of the kinds of questions which the patient may experience and likely repress from consciousness:  Is there really something wrong with me, that I have to subject myself to this?  Could I get away with ignoring it?  Does the doctor really give a damn?  Does  he  even know my name?  Does she really know what is wrong with me, or is she guessing?  Will his recommendations hurt me more than help me?  Does he want me to undergo this test just to run up my bill?  Will she care as much, or even continue to follow my case when she finds out I can't pay cash?  If I don't get well will he give up on my case or refer me to someone else?  If I do get well, or if my disease isn't exotic, or if it's "just in my head", will he lose interest?  After all I have gone through to trust her will she abandon me?  What will I do if I am ever really sick, or more sick?

Let us keep  in mind these  simple observations about ourselves as patients and as clinicians so that we can be less confused and more effective in our serious clinical tasks.


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