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Clinical communication can be understood and taught.

Any patient can come in any way.  Any patient should and will present in his own way, at his own time, because each patient is a unique individual who comes into a clinical situation idiosyncratically.  No patient can come in the same way twice because each time he comes is a different time in his life’s history.

Clinicians are trained to expect “textbook” presentations, standard kinds of problems.  If a clinician expected from the beginning to encounter the entire spectrum of pain and fear and disease, that clinician would be overwhelmed by an ocean of suffering.  The clinician limits his perspective so that he can begin to see the total picture, as the one views the snowy plain through a narrow slit, not to be blinded by too much light.

In fact there are commonalities in the ways that patients present themselves for evaluation and treatment.  Because each patient shares the basic condition of being a patient, of being in need of help without having full understanding and mastery of his own situation, he will tend to come seeking help, wishing to be cooperative in explaining, patient in waiting for attention.  We are trained as patients to follow conventions, to wait for attention and help, even to become obsequious in order to avoid making angry demands.

Also, common pathologies tend to present similarly, but unreliably so.  (A patient with an “acute abdomen” will tend to appear pained and doubled-over, but all patients appearing to be pained and doubled-over do not have acute abdomens, and all patients who have acute abdomens do not suffer from the same cause.)

Factors which tend to make patients present in some conventional manner are misleading.  They reinforce our wish to diagnose a disease and to treat it, rather than to meet and understand a human person in a unique life-historical situation, and to help him.  Even when the prominent pathology is clear, the course of the clinical relationship will vary from patient to patient, and will vary in each meeting with the same patient.

The traditional organization of clinical reporting, the “write-up,” positing a chief complaint and a history of the present illness, is structured so that coherence can be discerned by the reader.  The report is formulated after the encounter, by the clinician.  It assumes that the clinician has asked and answered the simple questions, “What seems to be wrong?  How did this come about?”  Sometimes the clinician has clearly in mind this direction of questioning during the interview, but the clinician does not always experience such coherence, even in retrospect.

It would be better to have a clear view prospectively.  Despite the dazzling variety patients manifest, there always will be some area of agreement between clinician and patient early in the first encounter, even if the overall problem and its solutions are not yet clear.

Here are three formats which clinical encounters may follow:

“Ideal” form:  Patient complains of pain; clinician acknowledges and confirms:
Patient:  “Pain here!”
Clinician:  “Pain here?”
Patient:  “Pain believable?”
Clinician:  “Pain believable.”
Patient:  “Pain relievable?”
Clinician:  “Pain relievable.”
Patient:  “Thanks.”
Clinician:  “You’re welcome.”

As a result of the ailment itself, and the patient’s having been conditioned to present symptoms concretely and clearly, the patient identifies a localized pain which is meant to indicate an underlying ailment for the clinician to understand and change.  Because of the clarity of the patient’s presentation based on the patient’s “homework” done in the recent or distant past, the clinician is led to a concrete response.  Both patient and clinician may be pleased with this simple solution, especially if the problem is truly so concrete and superficial.  This fairy-tale reminds me of “Androcles and the Lion” and is equally unrealistic.

Patient:  “You’re the doc?  I’m the patient.”
Clinician:  “How can I help you?”
Patient:  “My leg hurts bad…right here where the jagged bone is sticking out.”
(broken leg)
Ambulance attendant:  “We picked her up on Main Street.  She’s breathing on her own, maintaining her pressure, pulse regular…but she’s not responding.”
Emergency room nurse:  “Thanks; we know what to do.”
(comatose patient)

Common variant:  Patient complains of pain; clinician proceeds with comprehensive assessment(perhaps resulting in referral):
Clinicians often take advantage of any contact with a patient to execute a comprehensive or protocol-template evaluation of the patient’s physical condition and past medical history.  This may be appropriate since real persons have complex and fluctuating life-histories.  A dazzling galaxy of laboratory studies may ensue.  It may be that the clinician is using a “shotgun” technique, putting action before thinking, mechanically going through protocols which have not yet been confirmed valid for this patient at this time.  The clinician is trying to solve the problem the patient complains of, not the problem the patient experiences. The clinician is trying to get rid of the complaint rather than the problem.  The clinician ends by getting rid of the patient, since he cannot get rid of the complaint.

Clinician:  “I’m Doctor Jones, the resident physician.  You’re Ms. Wilson?  What brings you to the clinic?”
Patient:  “My stomach.  It hurts when I cough.  It’s been bad, getting worse for three weeks.”
Clinician:  “When did this start?”
Patient:  “Before my last period…Well, worse before my period, but really worse now.”
Clinician:  “Have you been sick to your stomach?”
Patient:  “I’ve felt sick.  I thought I might be pregnant.”
Clinician:  “Have you vomited?”
Patient:  “Once.”
Clinician:  “Any blood?”
Patient:  “Not much…I think no blood.”
Clinician:  “How is your appetite?”
Patient:  “My mother says it’s my gallbladder.”
Clinician:  “Well, I’ll do some tests and see…”

Patient:  “Hi, Doctor Pollack, I’ve been calling your office for weeks, but I can’t get an appointment to see you.  I know you’re in a hurry, but this will just take a minute.  My arm is hurting worse than last time, and the pills you gave me didn’t help.  Oh, I took them the way you said, but they just aren’t strong enough.  They made me nauseous…”
(I don’t know of what this is an example, but it prompts evasive action on the part of the clinician.)

Common thorny problem:  the patient expresses a vague complaint; the clinician gives various vague responses (generally of the type “I can’t help you, it’s all in your head.”)

It often happens that a patient comes to our attention because of some discomfort which is poorly described by the patient.  A common error is to terminate the processes of communication prematurely, looking too carefully for a concrete and limited complaint.  It is likely to be so that the patient who expresses his complaint vaguely, in a manner difficult to recognize, has a more complex and serious problem than the patient who presents in a more straightforward and concrete manner.  It is likely that when the clinician has made clear his willingness to take seriously the ill-defined condition which has brought the patient to the clinic, the patient will be reassured and become more clear about his real problems.


There are many levels of clinical phenomena.  The three formats above are on a formal, objective conventional macro-level.  They describe the general shape of an individual initial meeting with a patient, which results in a statement of a problem and recommendations toward solving that problem.

There are broader levels which more clearly reflect the nature of the clinical relationship:  When a clinician has had the opportunity to follow a patient closely through various changes, their relationship may be characterized as successful.  (If it were not successful it would likely not have continued.)  The success of a long-term clinical relationship is likely to be described as a special relationship between two persons rather than the statement of a problem and its solution. Clinicians in training rarely get the opportunity to participate in ongoing care of patients.

There are more microscopic levels upon which I ask you to focus.  Small bits of a clinical encounter can reflect the clinical relationship.  Patients are usually oblivious to this microscopic level, being conditioned to seek a formal outcome which will relieve their pain and confusion.  Clinicians should pay careful attention to clinical relationship on the microscopic level, as skill in recognizing these phenomena and purposefully shaping them is the central application of clinical science.  These phenomena are what is known as “process.”

The general shape and outcome of a clinical encounter (which I have characterized as formal, objective, conventional and on a macro-level) are parallel with the summary (or formulation) contained in the report or “write-up.” By contrast, real episodes of process are to be looked a more in terms of content than form, more on a subjective level than on an objective level, look to idiosyncratic details rather than to conventional generalizations, and tend to shift direction repeatedly during the meeting.  These microscopic phenomena reflect the heterogeneity of  “process” rather than the homogeneity of the abstract summary.  Discrimination of the variety of microscopic events in the clinical interview is what leads the patient to believe that the clinician is sympathetic and sensitive.  Perception and integration of the microscopic bits are what allow the clinician to feel that he has comprehended the overall picture of the patient’s experience.

It is not my purpose to burden you with attending to innumerable microscopic bits, but to reassure you that you can perceive, discriminate and reintegrate those bits rapidly to produce coherent clinical conceptions.


Now we can begin to describe clinical work as “diagnosis via discrepancies.”  The discrepancies are those between different bits of clinical interaction.  When those discrepancies are used to bring to the surface underlying conflicts, resolution and decision can take place (synthesis).

There is a standard model of a dialectic triad:  thesis, antithesis, synthesis.  Triads are strung together in a zig-zag fashion, the synthesis of one triad serving as the thesis for another set.  Clinical interchange can be so, the initial thesis being presented by the patient verbally or nonverbally, the antithesis being the clinician’s statement of the discrepancy engendered by the patient’s datum (perhaps by a raised eyebrow, a shrug, a nod or a grunted “I see”) and the synthesis being the tentative acceptance of a resolution for that part of the process.

In this discussion I present initial data given by patients, and a very few of the many valid responses which bring to the surface the discrepancies those initial data imply.  The initial thesis, or datum from the patient, the “chief complaint,” can take any form.  As long as the person who seems the patient is really so (in need of help, incompletely able to comprehend and resolve his own real problem) the initial datum, cloudy as it may seem, will reflect the real problem.  If you do not believe me, test this hypothesis any number of times.

The antithesis, or uncovering of a discrepancy by the clinician, is quite variable, but is likely to take a recognizable form.  It will outline the discrepancy between the patient’s current experience and his past or desired future experience. It may be a discrepancy between the patient’s condition and what is to be expected for most persons (“normals”).

The synthesis, as it comes about in microscopic clinical process, may take the form merely of mutual acknowledgement there is a discrepancy, or even an agreement to pursuing some further action.  The overall synthesis for a particular encounter will be the “plan” which results in relation to the “assessment” which has been mutually reached.

If discrepancies are not perceived and dealt with on the microscopic level by the clinician, they tend to emerge on the macroscopic level, usually in the form of “noncompliance” (that is, the patient’s subsequent behavior will not be in compliance with the clinician’s recommendations).  If discrepancies are scrutinized on the microscopic level they will describe the real processes of clinical relationship, and can be used to reach a real resolution between the persons who are working together.

I propose that we consider a “dialectic” model for diagnosis via discrepancies, and try to illustrate some of the sorts of bits that can lead to resolution in clinical relationship as discrepancies are brought to the surface to be scrutinized by patient and clinician together.

A fairly sophisticated idea is necessary for understanding the several levels upon which phenomena take place in the clinical realm.  Douglas Hofstadter in his book Gödel, Escher, Bach1 gives detailed examples of these conceptual relationships in the realms of mathematics, music, graphic art, number theory, artificial intelligence, and the genetic code.  It is especially helpful to note that the apparent discrepancy between holism and reductionism does not have to be an obstacle to understanding and action.  We do not have to accomplish uniformity of appearance of explanations at different levels of the same phenomena.  It will be satisfactory merely to know that different-sounding descriptions can be compatible.  An example with which we are familiar is that of the genetic code and its translation into phenotype.  There is no easily recognized relation between the sequence of bases in the DNA molecule and the ultimate expression of the genetic code in the individual’s development.  There is a similar apparent discontinuity between the microscopic processes of clinical interchange and the ultimate outcome as formally expressed in the write-up, but that apparent difference is certainly not so severe as the difference we see between genotype and phenotype.

Clinical thinking is an especially important sort of thinking, combining formal logic and social knowledge in the light of a real individual’s life, done in partnership with that very person.  Difficult though it may be to integrate many levels of perception and thought, it must be done for success in clinical endeavors, and it has been done successfully for millennia.  Although we value our Western thought and science and habits, it is clear that this complex task of perception, conception and communication has been done well in distinctly other idioms (Coan, Chinese, Navajo—to name a sprinkling).  I believe the processes are the same; but it is not important here to establish the universality of clinical tasks in the clinical relationship, only to forge a clear enough view of the value of the details of process and their relation to the outcome of diagnosis and treatment—health in the life of the patient (and by extension, health in the community of persons).

There are advantages and disadvantages in being a veterinarian:  It takes much skill to discern problems in a patient who cannot recognize them himself, or at least cannot well communicate his experience of those problems.  Although to lose such a patient is thought to be less drastic than to lose a human patient, pets and valuable stock animals are rarely treated by their owners with mixed feelings (the combination of love and hate most humans hold for each other), so that the loss of such an animal may be an unmixed loss, one without any balancing good, a pure loss.  (Perhaps veterinarians are subject to more profound depression even than physicians who care for humans.)

A doctor of human medicine who treats some uncommunicative patients (perhaps a neonatologist or an anesthesiologist) has standards of development and functioning with which to assess a patient whose spectrum of activities is relatively limited.  Human beings complexly socialized and complexly related to other human beings present a much broader spectrum to the clinician, and cannot easily be assessed in their functioning by a simply objective observer.  Perhaps animals and infants are complex patients to meet, but verbal humans are so complex and each so unique that there can be no thoroughness, validity or justice in merely objective assessment—there must be clinical dialogue, a heavy sharing between patient and clinician—or there can be no truth in evaluation, no productivity in recommendations or actions of a positive sort rather than destructive.

The most dynamic examples are those in which you are a participant.  To discuss models objectively is a weaker experience.  But examples extracted from real experience can be examined here with more fullness than may be available in the rapidly shifting reality we are subject to in the clinic or in the emergency room.

Case I:
Patient:  “Doctor, your pills are no goddamned good..”  (Patient throws bottle at physician.)
Clinician:  “These pills are prescribed by Doctor Smith.  I am Doctor Pollack.”
Patient:  “They’re still no goddamned good!”
Clinician:  “Good.  Now we know the problem.  Come in and sit down, and let’s find out why…”

The real encounter beginning with this interchange happened to result in the formal summary:  “Problem #1:  Prostatic carcinoma, metastasized.  Problem #2:  Depression…”  There are clearly-derivable connections between the real microscopic phenomena reflected in the initial dialogue and the total situation as reflected by the summary statements.  If you can follow such examples as I review them here, and if you can make such connections in your own clinical experiences, you will have available the many levels of clinical phenomena without mystery.

Let me reveal a bit more of the actual case so that you can understand it with me.  The patient was an old and isolated man who, sensing that he was deteriorating, swallowed iodine.  Subsequent to his evaluation and treatment in emergency room and hospital he was found to have prostatic carcinoma.  The pills were to treat his urinary symptoms.  Some major factors of his dissatisfaction became more clear during our interview:  he was dissatisfied because he did not have complete relief from his urinary symptoms, because the treatment had not made him young and strong and happy, because his suicide having been interrupted had not made him more comfortable.

My having integrated those kinds of facts from our initial encounter resulted in our establishing a close clinical relationship.  During the following weeks I made some visits to his home, a small dirty third-floor apartment in the Capitol Hill area.  It was clear he could not care for himself, was threatened with the prospect of dying in isolation, unable to feed himself or to go to the bathroom.  Carefully preserving my respect for him, I developed with him a plan of nursing-home care.  His physical strength rapidly dwindled, and he died within a few days.  He had resolved not only his dissatisfaction with the pills, but (by relinquishing his reluctance to call his brother) even resolved the dissatisfaction of life-long isolation from his family.

His expression of dissatisfaction in the first seconds of our meeting, and the confusion of persons, represented dissatisfactions in human relationships over a period of decades capsulized in a single brief encounter.  Recognition of the meaning of the microscopic expression led to resolution of long-standing alienation from family, suicidal depression, physical debility and degeneration.  To die properly is often a good response to serious disease.

Let us take another simple case or two.

Case II:

A 280 pound man is brought to the state mental hospital by his 90 pound wife.  He protests violently that he doesn’t have any intention of coming into the “loony bin.”  The admitting resident signs him in as a voluntary admission.

There is a discrepancy between what the patient says (that he does not wish to come into the mental hospital as a patient) and his action of allowing his diminutive spouse to transport him across the state in an automobile to come to the admissions office.  Actions speak louder than words.  He clearly desired treatment, allowed himself to be brought for evaluation and admission, which the resident properly did.  (The resident’s proper clinical behavior was in fact a result not of intuition but of experience and instruction.)

Case III

An elderly woman has an appointment to see a doctor whom she met briefly a year earlier.  As he walks with her to the examining room, she makes the casual comment, “What are you doing with grey in your beard?”  She complains of some moderate symptoms of arthritis in small and large joints, but seems to minimize the importance of these symptoms.

The more complete story became clearer to both the clinician and the patient when, after a straightforward examination of the joints and auscultation of the thorax, the clinician paused and observed, “As we were coming into the room, you seemed unduly concerned about the grey in my beard.”  The patient admitted that she was herself surprised to experience such anger at such a small detail.  The clinician, integrating her spontaneous initial comment with what he had come to understand from the brief encounter a year earlier (during which she had characterized herself as active and productive0, and during the examination subsequent to the comment itself (during which he found signs and symptoms of the disability imposed by arthritis), made the interpretation that she was angry at her own aging and degeneration as mirrored in the grey of his beard.  Her acceptance of this interpretation led to a partnership aimed at optimizing her ability to cope with the vicissitudes of age.


These three cases glimpse at initial presentations, each of which shows an idiosyncratic expression of an overall condition important to the patient at that time.  Microscopic processes take place not only at the beginnings of encounters but throughout each encounter.  It is simpler to discuss the initial discrepancies in a clinical encounter because if the clinician has not attached himself to an initial discrepancy and begun the process of dialectic resolution of discrepancies, the nature of the encounter will be superficial and the patient will tend to abandon the relationship soon.

Discrepancies can be noted at many levels.  It doesn’t matter whether any two clinicians will always choose to discern discrepancies in the same order-chain (they could not even if they would), but that in a satisfactory clinical situation any competent clinician will develop a clinical dialogue with a patient so that the significant problems will be recognized by both patient and clinician as the process progresses.

It is the clinician who selects discrepancies on which to focus and who guides the course of the dialogue.  Although there are myriads of discrepancies to be chosen from in any case, and although the same major problem areas can be described and agreed to in many ways, it does make a difference how selection is made.  Here are some practical rules of thumb, a list which is not at all exhaustive.

1.  Select an initial thesis of conscious (“subjective”) importance to the patient.

2.  Select steps to reduce the tension the patient experiences, emphasizing these things can be made sense of, need not seem mysterious.

3.  Do not overlook strengths and health when assessing problems and discrepancies.

4.  You may occasionally wish carefully to increase tension in the patient for the sake of dramatization or emphasis.  (This has a purpose similar to that of symptoms, that is to make the patient aware of problems that are real.)

5.  Summarize major discrepancies and the syntheses which help to resolve them at such important times as the climax of an interview (penultimate), “doldrums” (anticlimax), or before an interruption such as verging on the time to end an appointment, or after an interrupting phone call, or at the resumption of the dialogue at a follow-up appointment (to bridge transitions and distractions).

It is justified for the clinician to maintain control of the flow in the clinical relationship as discrepancies are encountered and resolved.  Remember, the patient is not bound by convention, but the clinician is responsible for the outcome of the process and therefore for the order and structure by which the outcome is reached.  Irrationally and unjustly our culture tries to hold the clinician responsible not only for clinical processes by which diagnosis and decision-making take place, but for the outcome of disease and for the universal condition of mortality both of which are ineluctable, not actionable.

Increasingly criticism is made of paternalism in clinicians, but that criticism usually overlooks the needs of the patient.  The statement, “The patient should be autonomous,” does not mean, “The patient is autonomous.”  There is some lack or need on the patient’s part.  For the clinician to acknowledge that the patient is in need and not ideally autonomous at the outset does not increase the debility of the patient.  When clinicians act “for the patient’s sake” the autonomy of the patient is not abridged thereby.  (See discussion of Robert Veatch’s “consumerist” approach in “In Defense of The Oath.”)

The overall ethical goal of clinical endeavors is to enable the patient to do  as he wishes, in other words to enhance a patient’s autonomy is indeed the goal.  A dialogic model of clinical encounter, one that sees clinical evaluation and decision-making as a two-party process, is more realistic than the traditional model of one-sided assessment, decision and action.  Clinical dialogue is I-Thou rather than I-It2.

We can pretend to be “tin-god” doctors, but we cannot eliminate the patient as a silenced partner.  Since the patient must always be involved as the party of the first part in the dialogue (two-party contract), it is better that the patient be involved as actively as possible throughout all processes.

Unless the clinician wishes permanently to adopt all patients (a patently unproductive proposition), the goal of clinical processes must be the enabling of the patient:
--to understand the meaning of his own history,
--to take responsibility for his own decisions and behavior,
--to responsibly choose his own help as he needs it.

The tension between dependence and independence is always a crucial clinical issue, but should not be seen in one polarized dimension (that is, as dependence versus independence).  Often strength and health can be gotten best through selected dependence (reliance on outside help).  It is not a question of static independence, but of dynamic shifts in patterns of dependency that reflect clinical progress (e.g., methadone detoxification, in-hospital diagnosis and treatment, physical therapy, et cetera).

Important though it may be for the patient to be involved in clinical processes, there is no justification that a person take on being a patient as a career.  The goals and values of that individual may be improved by clinical processes, at least to be treated honestly and fairly.  Sometimes the accumulated demands of a frustrated person cannot be satisfied, and the honest admission it is so may defuse overdetermined complaints.  Unrealistic expectations are ubiquitous.

Each person’s life-history is unique.  The clinician can help the patient in processes of diagnosis and treatment only by knowing something of who this person is and caring some about this person.  Even though the clinician’s knowledge is sketchy, it is from a perspective other than that with which the patient is familiar.  The clinician cannot master the patient’s life or body, but the story the clinician can tell from that interested other angle is different from the one the patient is used to from his own perspective, so the patient will be interested in hearing that story.  If the clinician can communicate the story vividly in the clinical dialogue, not merely in verbal symbols but in action, the patient may be enabled to act more thoroughly in his own life.  To communicate the patient’s own story to him effectively the clinician may use many idioms, even to act it out dramatically.

The idea of emotional catharsis elicited by dramatic presentation is anything but new.  Clichés are overdetermined; they are clichés because they are true to life. We may as well let the story of Oedipus be tried and true for today; it has been told to us by Sophocles, Aristotle and Freud3.  It is a cliché of tragic suffering, and we need such ways to say we suffer each (but each of us must suffer separately, even in the theater).

In Aristotle’s culture it was a public institution to have annual competitions for the writing and production of drama so that each individual in the community could experience emotional catharsis when confronted by a convoluted story and dramatic spectacle.  We have soap operas, but in our individualistic culture it is difficult to stage drama which touches the aggregate of individuals individually.  In the mess of our mass media and fads we run the risk a genuinely poetic expression will instead become commercialized.  Only clinicians and prostitutes have the opportunity to entertain and touch their audiences as individuals (and prostitutes are too commercialized to do it well).  Clinicians can honor real persons by touching their lives intimately without threatening them with exploitation and death.

It is a practical axiom of clinical communication to ask the question, “What is the worst thing that can be happening here, now?” (not aloud, perhaps, but silently in my own head).  The patient has already considered and repressed the worst possible circumstance.  It is neither alarming nor threatening for the clinician to voice it.  Almost always the patient is relieved to hear the clinician say, “Have you considered your chest pain may represent a heart attack?”  The answer in word or gesture always is, “Yes, and thank you for having respected my fears instead of ignoring them.”

But for the clinician to emphasize the most bleak possibilities and to express them is hardly even appropriate to the time of truly dying, and then only for anticipating and confronting previously denied mortality.  While we live, we as patients need the clinician to understand and reflect back to us the reality of our mortality, but also to emphasize that of which we were not fully aware—our extensive health and life.  To be alive means to be able to act, and to be able to do something new in the next moment means the story isn’t yet finished; certainly in the processes of dying we are doing something new.

Clinical theatrics is the most flexible of dramatic improvisations.  It consists in the clinician having understood something of the unique life-history of the patient, having formulated it in his own mind structured not toward hopelessness but toward realistic living, and having communicated back to the patient poetically, with dramatic impact which is as free as possible of moral bias, or truncation of the patient’s autonomy.

The poetic aspect of clinical responsibility is that which is most often abandoned unconsciously by clinicians.  They nor their teachers consider it during training because to act out the story of the patient is to acknowledge that it is the patient whose action really counts.  The clinician’s actions are subordinate to the patient’s.  It is the patient only who can decide and act in the ongoing complex story of his own life.  Only if the patient has come to some understanding (conscious or unconscious) can there be any coherence in processes of diagnosis and treatment.  Given that the method is to help the patient understand the truth, what can the clinician communicate, and how?  The simplest summary of the facts is enough to demand the patient’s attention:  “This is your life…”

Even though each clinical communication can only be coherent in context, there follow a few examples to remind me to use the entire repertory of dramatic and poetic skills, to formulate, stage, direct and perform dramatically for the sake of the patient.

Richard Marshall, hematologist, comes hurriedly late to preside at the clinico-pathologic conference.  With casual haste he asks, “Where is the first patient?”  The several dozen residents, interns and medical students (each of whose coat is whiter than Doctor Marshall’s but not so long) inform him of Mister Jones whose illness has been diagnosed as acute myelogenous leukemia.  “He’s that nice old fellow who farms in Washington County, isn’t he?  His cousin is president of the bank in my home town.  Bring him in!”  The patient in a backless hospital gown is ushered into the room, onto the stage of the amphitheater.  “Oh, Doctor Marshall, it’s so good to see you.  These nice young doctors have spent an awful lot of time saying things I can’t understand.”  “Well, let’s you and me just look into the microscope together.”  Mister Jones’ blood slide is focused in a double-headed microscope and at the same time is projected onto the large screen on the back wall of the stage.  Patient and doctor look into the two sets of eyepieces simultaneously.  “See all them little purple things [the many white blood cells characteristic of his leukemia]?  Why, you’re sicker than a billy-goat!”  “What a relief!  I knew there was something wrong, but no one explained it to me before.”

A man who had been habituated to intravenous opioids for more than ten years has avoided formal treatment for his addiction.  He came for stabilization on methadone only when it became available in the small confidential setting of a private physician’s office.  After more than two years of relatively high-dose medication, during which he has continually delayed beginning “psychotherapy,” he asks for regular appointments.  During one session he remembers an episode of his adolescence when he was upset or uncomfortable, to which his father had responded with rationalizations about how lucky the boy was, how little he had to complain about.  I ask the patient how he felt about that, to which he answers, “I don’t know.”  “Exactly!  You do not know how you feel, just as the defiant adolescent obediently refused to feel or complain of his pain.  You were told not to complain, not to feel.  And you have obediently and repeatedly obeyed ever since.  Do you know how you did this?”  The patient gestures the injection of drug into his vein to obliterate the pain.  We look at each other with relief, laugh together.

A fifty-eight year old man s very frustrated.  He has had the “flu” from Thanksgiving, and now it is nearly Christmas.  He tries to be objective and polite, but it is clear to the attentive clinician his anger is overwhelming. “You have never missed a day of work until now.  Even if what the other doctor said--that you had the flu--might have been reasonable at Thanksgiving, that explanation doesn’t help you now.  It has gone on too long.  This is serious, and I will be glad to help you figure out what’s up and what you can do.”  The grown man cries for the first time in fifty years.  His aggressive lymph cancer eventually kills him, but the clinical rapport (and his wife’s loyalty) sustain him, and allow the patient to avoid psychotic disorientation later in his disease.  Doctor and patient never actually share the drink at the tavern watching the World Series, but never gave up planning that activity which reflected the intact personality of the patient.

A fourteen-year-old woman who had been a thirteen-year-old girl complains of lower back pain after moving household furniture and asks for medicine for relief.  Her mother had begun to be an obedient patient by age six months, has suffered chronic recurrent pain in her abdomen, head and most recently in her lower back.  The mother has been habituated to many medications for many years.  The mother’s mother lives close by, dominates from that distance the other two women.  The youngest woman resents the constant complaining of the oldest woman, who also depends on prescriptions rationed by her physician.  “This is a crucial time in your life.  You can respond to discomfort in the way your grandmother has, in the way your mother has struggled against; or you can accept health, deal with discomfort in some other way.  Life in high school is distressing, and you say it infuriates you that your grandmother will not listen to your complaints because she is so preoccupied with her own, but your mother offers you some friendship despite her own pain.  I will help you any way you wish, but I recommend you avoid back pain by learning to move furniture with the large muscles of your thighs rather than the small muscles of your back.  You will do what you must, but considering your family history, I recommend you avoid break-dancing.”  The atmosphere lightens for a time.

A middle-aged twentieth-century American alcoholic woman avoids re-entering treatment for a number of years, avoids death narrowly through episodes of seizures, but reconsiders treatment only after hallucinations.  She is less afraid of death than madness.

A physician who has avoided being a patient for more than a decade has an episode of chest pain.  He considers the stress of his life and work with irony, “I earned my ulcer, and didn’t get it; I earned my nervous breakdown, and didn’t get it; I earned my heart attack…”  His cardiologist colleague reviews his history, examines him, administers exercise cardiogram and pulmonary function tests.  Contradicting the patient’s pessimistic emphasis on illness, he says, “You are really very healthy, but not well-conditioned.  I would like to see you be well, so…”  The patient begins changes in diet, exercise and schedule.  (But thereafter I had my well-earned inherited heart attacks nonetheless.)

The setting is the sanctity of the consulting-room.  There are no props or costumes.  It is only with verbal symbols, facial gestures (and for flamboyant clinicians, hand gestures as well) that the drama is communicated.  We can say that x-ray films, the squiggles of the cardiograph or impressively columnar computer printouts are props, but they are unnecessary.  It is only you and I, and I tell you not how to live but that you can, for the rest of your life.  Each moment offers opportunity to use the clinical collusion as a lens through which to see the possibilities of this living, you the patient a real-life star, a real hero.  This need not be a tragedy, but emotionally poignant as a tragedy can be.

It is our privilege to see persons closely when we are clinicians.  It is our art to show themselves to them closely, so that they may be more human, with longer or better or wiser lives.


1 Hofstadter, Douglas.  Godel, Escher, Bach, New York:  Basic Books, 1979.

2 Buber, Martin. I and Thou, .  This is not the place for me to explain the importance of Buber’s seminal work, nor the other scholars and philosophers who shed light on these practical applications.  Let me simply say that Sutton’s Law applies.  (When the notorious bank-robber Willy Sutton was asked why he robbed banks, he replied, “That’s where the money is.”  When it comes to human relationship in the most practical and basic applications, of Buber’s work I say, “That’s where the money is.”  Solid gold.)

3 What is common knowledge about Aristotle, Oedipus and catharsis is true.  What is common knowledge about Freud, Oedipus and neurosis is not true. Aristotle explains that a purpose of tragedy is to elicit feelings of pity and fear in the audience, each of whom will identify with the hero; that tragedy is “imitation of an action that is serious and also as having magnitude, complete in itself,” (Poetica 1449:25).  Even though Freud stubbornly clutched the “Oedipus complex” throughout his public life, the results of his hard work are not limited to the narrow bounds of Victorian sexism, but transcended narrow cultural fads to let us each and all look deeper than we had. 

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