Wednesday, October 14, 2015

Staying Put

Elizabeth Berkshire, PhD
During a patient-centered collaborative on pain treatment, a clinician I’ll call “Lear,” blurted out that the patient is the problem. He later apologized, but the burden brought by the patient had been exposed. As part of his apology, Lear said that “they” (patients) needed to get out of their own way. I’m not customarily one for reliance on the notion of a Freudian slip, but this struck me as the kind of truth not easily introduced into speech. It is easy to suffer greatly in the company of a patient in refractory pain, and especially one who lacks the sort of organ-based evidence that can be relied upon to maintain interpersonal (or professional) boundaries. 

Contriving Social Boundaries

Why not welcome unbounded (or collective) suffering? In short, for blogs are meant to be brief, we must contrive social boundaries to stave off the dread that comes from realizing that we actually exist among bodies—not in them. So we’ve adapted ways of thinking about our being.  For example, we can exist in a faulty body. We can also exist in a faulty brain. Take your pick. As Judy Foreman reports in A Nation in Pain (2015), doctors are trained to refer patients on to a “shrink” when the medical model offers no progress (p. 5). Foreman also shares an anecdote from a University of Washington informal survey of graduating medical students who, when asked what would they do when faced with a real pain patient, netted the response: “Run!” (p.9) 

As for the patient, it is easy to suffer alienation in the company of anyone especially trained to keep important parts of you (and themselves) out of the way. We don’t customarily talk about the ways we contrive relations among bodies to keep from spilling the beans about our existence. How could we? We’ve effectively made such talk taboo. Run! How convenient for us all. I say this with compassion.

Beyond Patient Centering

Speaking of convenience, it occurs to me that patient centering (or the pretense that entitlements can be shifted in a long-standing system of institutionally sanctioned power differentials) is counterintuitive to the development of healing communities. It should worry us that the very notion of patient centering, while perhaps born out of advocacy within and outside of institutional systems of care, is not practical. Nor does it substantively alter the status quo. For example, Lear and a select group of his “collaborative” colleagues spoke from behind a podium. Revolutionary dialogue (including the listening part) is easily disregarded if a podium stands only to position folks into roles. 

What to do? We could better lament what the patient and clinician are mutually up against. We’d have to move that pesky podium first. Then we could simultaneously embrace Lear and his insufferable patients. We need not condone professional nearsightedness as we do this. Instead, we might recognize the existential crisis in Lear’s own desperate appeal for care from the patient (please get out of your own way). In fact, Lear’s request bears all the more truth when tethered to a patient who tearfully shared with me that he had failed, time and again, to convey (so as to better heal) his chronic pain. We must stitch them both back into the fabric of life. We must tell them that their alienation from one another is not a mental defect. It is a practical disaster. It is a relational mishap. It is all too familiar. I know this, in part, because I wanted to bolt just seconds after meeting this patient. I had to reach my hands up to his face to stay put. Why? Because I knew exactly what he meant. In that moment we were together (bound) and exposed in ways we have evolved not to trust. We don’t prepare physicians to manage this in the clinic. We also no longer prepare psychologists for this (but that is another blog, for another day).

To Be Another

It is not easy to dismantle the interconnecting and yet disparately empowered statuses (or contrivances) built into how we learn to talk to one another so that we might stay safely tucked in a body. This is why Shakespeare’s Lear implored his daughter Cordelia to “speak again.” He needed her to flatter him back into a titled position (and the safe distance it obliged from all). It is important to know that these rules of speech, and the social taxonomies they maintain, help to keep us all pinched off from the burden of knowing what it is like to be another. In another world, collective suffering might not have been such a burden for a physician, who cannot help but to find herself in terribly close proximity to human frailty. In another world, insufferable pain might not have been such a hazard for a patient to carry. But another world is not what we have.

Elizabeth Berkshire, PhD, is adjunct assistant professor of bioethics at Kansas City University of Medicine and Biosciences.