Atul Gawande’s Being Mortal

Sandra Steingard, MD
19
241

Atul Gawande is a physician author whose work has been published in <em>The New Yorker</em>, among other places. Disclosure: I am a fan. What I love and respect most about his writing is that while he is unflinching in his critical view of medical practice, he writes with a deep humility and compassion. Medicine is, despite our aspirations towards technical mastery, practiced by humans. And all of us, even those privileged with years of schooling, are limited in various ways.

In his most recent book, Being Mortal, he explores the complexity of end of life care. He reviews the development of nursing homes in the US and describes some newer alternatives that are becoming available. He also writes about how people approach their final days. He describes with stunning clarity the extremely difficult choices people make as they loose their physical abilities and face their final days.

Why is this a topic I bring to MIA?

As I was reading the book, I was struck by some intriguing similarities between the topic of this book and the one that concerns us here. Gawande describes how forces came together to medicalize aging. At first glance, dying might seem the ultimate of medical conditions but, as he points out, prior to the mid-twentieth century, dying and old age were processes that happened in the home. It was more likely poverty rather than infirmity that brought people into custodial care. As poor houses were shuttered, the old and debilitated were admitted to hospitals whose beds rapidly expanded in the mid-century. But as medicine became more technologically advanced and health costs began to rise, hospitals lobbied for places to send people who no longer required acute care. In 1954, congress funded the development of nursing homes. Gawande’s argument is that nursing homes came in to existence to solve a problem of the hospitals not to improve the quality of life for elders. As he puts it:

“We ended up with institutions that address any number of societal goals..but never the goal that matters to the people who reside in them: how to make life worth living…”

Nursing homes — with their medical focus and high level of regulation – value safety over autonomy. Sound familiar?

Gawande writes about a paper by two medical ethicists (1), that describes different kinds of doctor patient relationships. One is the paternalistic relationship – where the doctor who knows best tells the patient with authority what treatment is needed. The second one is called “informative” where the doctor presents the patient with the facts and asks the patient to make the treatment decisions. But there is a third approach which the authors call “interpretive.”

“Here the doctor’s role is to help patients determine what they want.”

He posits while historically most doctors assumed the paternalistic role, in recent years, they have tended to be trained to take on the more informative one. Gawande worked to shift from a more informative stance to an interpretive one. What did this involve? He learned to ask patients what is most important to them. He learned to listen. It is a stance that treats people – patients – as if they know a lot about their own needs and desires. The physician’s obligation is not to just give the answer or provide information but to help the person understand his owns needs and how he might best achieve them. He describes how difficult this stance can be for doctors. He points out that in their effort to defeat the disease, doctors often make things worse and, more importantly, they lose site of what is most important for the patient.

As I read this book, I thought that this story is relevant to psychiatry in many ways. Hospitals pushed to have people who needed long term care discharged to some other place. Within the existing system of care, regulation pushes in a direction that values safety over personal autonomy. Psychiatrists have also tended, along with their colleagues, to take on a paternalistic or informative stance.

While I am critical of my profession, the truth is that I have spent quite a bit of time with psychiatrists. The notion of the evil psychiatrist -with rare exception – does not comport with my own experience. Although we are people with the vast array of available human flaws, most of us entered the field with good intentions. And while arguments about “psychiatry” have merit, they do not help me to understand the attitude of an individual psychiatrist ( in the sense that while psychiatry may serve a role of social control it does not seem that most people choose psychiatry as a profession with the primary goal to serve that societal function). But we did enter this field through the door of medicine and there is something about medicine – and I think this is embedded in the education, in the expectations of those who seek this training, and in the expectations of society – that pushes us to believe we have to attain and maintain mastery over many things.

While reading <em>Being Mortal,</em> I was also reading Carina Hakansson‘s doctoral thesis, “The Extended Therapy Room.” Her subtitle is apt: “Coming from an authentic place.” It struck me that in many ways, what Gawande was trying to learn was what Hakansson embodies – meeting people as humans who are trying to figure out how to live their lives. Gawande had to forcefully throw off years of learning and training to achieve what seems more natural in the extended therapy room. I also read an article by Borchers and colleagues in which the discourse among psychiatrists who adhered to a needs adapted approach was evaluated. By examining the language used in certain settings, they found that psychiatrists had trouble talking in a humanistic voice.

To be clear, this is not intended as an apology or a strategy to shift blame but as an attempt at understanding.  After reading Being Mortal, I still see a critical role for physicians in helping people who are nearing the end of their lives but they are not necessarily the ones who need to be the leader of the team. There are probably others who by way of training and temperament are better suited to the task. As I have written elsewhere, I have come to this same conclusion when I think about people who are experiencing extreme life distress of the type that sometimes leads them to seek psychiatric consultation. Psychiatrists can sometimes be of some help, but I also think we need to be mostly on the sidelines as people sort our their problems and figure out how to move to wherever it is they want to go in their lives.  At the same time, I think we need to view this as a problem of or challenge for anyone in medicine; if another medical specialty replaces psychiatry in some way,those clinicians may be no less immune to these problems.

* * * * *

Reference:

Emanuel EJ and Emanuel LL, “Four Models of the Physician-Patient Relationship,” Journal of the American Medical Association 267 (1992):221-226.

 

Support MIA

MIA relies on the support of its readers to exist. Please consider a donation to help us provide news, essays, podcasts and continuing education courses that explore alternatives to the current paradigm of psychiatric care. Your tax-deductible donation will help build a community devoted to creating such change.

$
Select Payment Method
Personal Info

Credit Card Info
This is a secure SSL encrypted payment.

Billing Details

Donation Total: $20

19 COMMENTS

    • Well, medicalization of childbirth (and I mean the totality of it, not just certain drugs or procedures) has significantly lowered the risk of women and children dying in labour. That’s a huge achievement that psychiatry cannot even dream to match – in fact tehy seem to be making things worse. That is not to say that there aren’t problems with the way women are treated in these situations (being traumatized and degraded by doctors and nurses) but even in this case significant progress has been made. When I was born it was inconceivable that my mother could have my dad or anyone there to assist or that it would be private or that she would have any decision over the way the labour was conducted – today there are places where women’s rights are being fully respected and where they are not there are organizations actively fighting for them.

  1. Sandra

    To thoroughly evaluate the important themes you are addressing in this blog it is essential that we examine the environment (context, system, zeitgeist etc.) that medicine and psychiatry is practiced within in today’s world.

    I hope you had a chance to read my most recent blog “Dr. Feelgood: Travelling on the “Path of Least Resistance’.” It is extremely difficult to avoid getting caught on this ‘path.’ There are very powerful cultural forces within a profit based – capitalist system that tends to turn everything into a commodity or so-called business relationship. This has had an overwhelming and corrupting impact on both science and medicine on so many different dimensions related to how people interact in the patient/doctor relationship.

    I would argue that we will not be able to get beyond these inherent problems of commodity type relationships unless we address these major systemic issues.

    My own PCP vents with me during each of my visits about “the war on doctors” and how hospitals and hospital groups are controlling his every action, and twisting and distorting his relationships with his patients to meet the narrow economic agenda of those medical entities within a much larger profit based system.

    Certainly the question of how the elderly are treated in our current society is directly related to these much larger systemic issues. Psychiatry is no different except that its’ position in the hierarchy has the added feature of being able to determine what is “normal” or “dangerous” in society and the ultimate power of forced drugging and psychiatric incarceration.

    Richard

  2. I am around a lot of elderly and their underpaid caregivers…families/communities have fractured into small pieces where only the ‘strong’ survive. The care the elders receive is abominable-how can a physician learn of an elder’s beliefs, preference and wishes in a 15 minute appointment? Palliative care seems to only apply to the actively dying; old folks, like children, are not valued in this culture for the reasons stated so well by Richard and others…

    One little quibble: “difficult choices people make as they loose”…did you mean ‘lose’? I see this all the time now; spellcheck or ? Language is culture IMO.

    Good article.

      • B, Sandra, Richard and others. If MIA is a representative sample of those who have a beef with psychiatry, I can conclude that we mostly fall decidedly on the left end of the political spectrum. (I am of course glad that people from a variety of political spectrums chime in here). I bring this up because as a rule, I find that others on the left seem unaware of the issues that we address here. Case in point, the political website Truth Out, has an article dated today about protests conducted by mental health workers at Kaiser. It apparently, involves a significantly large number of therapists and other providers. On the plus side, the article mentions real life triggers, such as the Great Recession, as one of the root causes of societal and individual malaise. But I would have been remiss in my comment to the article, if I didn’t direct readers to MIA for a more critical view of mental health care generally, and the DSM specifically.

  3. Thanks for another very insightful essay…I agree with all of your points…my hope is that we can keep the human in human services…instead of focusing on the ‘product.’ I have heard this word many times a day lately in my work in the mental health field (industry)…not sure where to start to be a part of something much different…but I so appreciate your article Sandra and all of my friends in the MIA community.