Saturday, March 26, 2005

On Doctors

I've been meaning to post about this for a couple of days, but I've been distracted by work and my pathetic attempts at a social life and by my annual hamantaschen-making extravaganza. (It is, apparently, possible to bake with vertigo, although I'm still finding little bits of prune filling in various nooks and crannies in my kitchen. I can bake while the room is spinning, but it's not particularly tidy.) But the cookies are done and I'm taking the morning off of work, so I'm going to post about it now.

In the course of the Terri Schiavo discussion, I have seen several guys on lefty blogs express shock and outrage that medicine is being politicized and that they wil now need to find out the political beliefs of their doctors. No offense, but on what planet do these men reside? How sheltered could they possibly be? Is there honestly anyone out there who doesn't realize that the practice of medicine is totally political and that the doctor/ patient relationship is frought with power?

I've had a lot of experience with doctors over the past year. I have seen three rheumatologists, two ophthamologists, a dermatologist, an otolaryngologist, a neurologist, an endocrinologist, and an internist, not to mention scads of fellows, residents, nurses, and techs of various kinds. And it's become pretty clear to me that there are two kinds of doctors: the ones who see me as a body and the ones who see me as a person. To doctors who see me as a body, I am an object, not a subject of medical care. They take care of me, and my role in the process is to present myself for inspection and then comply with the treatment they prescribe for me. If I don't like that treatment, don't think it's working, don't think the side effects are worth the supposed benefit, etc., I should keep those opinions to myself. My opinions have no bearing on the process, because the doctors are the experts. My only role is to be acted upon.

The doctors who see me as a person, on the other hand, recognize that I am a partner in my treatment. They are willing to admit that they don't have all the answers, something that is nice considering that they don't really have any answers. (My condition is so rare, and my particular presentation so staggeringly rare, that nobody really knows what treatment works best. And my diagnosis is still provisional, so they don't even know if I actually have the thing they're treating me for.) They recognize that any treatment is a calculated risk: we're weighing the possibility of a favorable outcome against the the possibility of debilitating side effects. They realize that as the medical experts, they are best able to determine how likely something is to work and how likely it is to harm my body, but that ultimately I have to be the one to decide whether the risk is worth taking. It's my body, and I'm the one who has to live with the outcome.

This is a political issue, if you accept that the exercise of power is always political. Doctors are people with power: the power to dispense or withhold drugs, for instance. They also have extraordinary social power. It's very difficult to defy a doctor; it goes against a whole lot of social conditioning. I've had enough doctors dismiss me as silly and irrational to know that my first instinct is to feel stupid and ashamed, rather than furious at the asshole for thinking he or she has more right to control my body than I do. And it's an issue that intersects with all sorts of other power relations. Doctors are much more likely to see some people as able to make rational decisions than others. It matters a lot, for instance, that I am young and female. I don't think my otolaryngologist, who is old enough to be my grandfather, is capable of seeing any woman my age as a rational creature in charge of her own destiny. It also matters a lot, I suspect, that I am highly-educated and white. I have realized that my doctors are much more likely to treat me like a person rather than a body if I present myself in an adult, professional manner. I make an effort to dress up for doctors' appointments. I wear makeup. I am careful to speak in complete sentences and to modulate my voice so that I don't sound too young or overly-emotional. I treat my doctors' appointments like a job interview.

I think that for a lot of healthy people, and especially healthy straight white guys, the Terri Schiavo case has been something of a wake-up call: it's made them realize that on some level, medical care is about power. In this case, it's about the power to decide when to end someone's life and who, if anyone, ought to be able to exercise that power. But for sick people and for people who can't take for granted that their doctors or the larger society will respect their judgement and autonomy, the power relations in medicine have always been evident. We've never had the luxury of thinking that medicine is apolitical.

This is very true in the field I work in -- obstetrics. Women view the birth of their babies as a sacred life passage and one of the most significant days in their lives. The wrong kind of birth attendant will see the birth as a medical procedure to be managed.

A "good patient" will accept whatever treatments the doctors suggests, even though the majority of births would go just fine with no treatment at all. As long as she comes out of it with a live baby, she shouldn't have any reason to complain.
I got in a huge argument about this with a medical student on the comments section of another blog. There was a link to a story about a woman who had refused to have a c-section, and he implied that it was probably because she was vain and didn't want a scar. I pointed out that there were all sorts of non-frivilous reasons not to want a c-section: maybe she didn't want to spend the first weeks of her child's life recovering from major surgery. But his first impulse was to think that any woman who defied a doctor must be stupid or evil.

I think that maybe some doctors' need to develop an infallibility complex, though. It might be too hard to make life-and-death decisions if you admitted that you sometimes screwed up.
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