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