Us versus Them: A False Dichotomy?

My friend Jordan Grumet MD wrote a piece in his blog on January 20, 2017 entitled “Us and Them”. In it, he described how a coworker had been diagnosed with a deadly brain tumor, a glioblastoma multiforme, which is normally thought to be a  “uniformly fatal brain cancer”. When he and other residents learned of her diagnosis, “that day in the ER, she ceased being one of us, and became one of them. The sick people.”

Although Jordan and I usually see eye-to-eye on most things, in his case I must disagree.

Doctors are a pretty tight group. We stick together most of the time, no matter the issues, and we have each other’s back. We never really expect to get sick, much less contract a potentially fatal illness ourselves, but of course being human just like our patients, we do. I believe that when a doctor gets sick, he or she is still very much one of us, just ill and in need of help.

Much like when a doctor gets addicted to pain killers or drinks too much and becomes impaired, he is still a doctor, still one of us, although a demonstrably flawed member of our group who may face sanctions due to his ongoing behavior. He does not suddenly become an alcoholic or an addict only, but is simply a doctor with an addiction problem.

I think that using the false dichotomy of Us and Them, or Us versus Them in the current politicalspeak, is not helpful or accurate.

We should not, as professionals, distance ourselves from trouble or heartache by putting patients in the “them/sick people” box. It insulates us from the pain, that is indeed true. It also takes away our ability to be more real, present and human with our patients. Even if, especially if, the patient is one of us.

If I am sick, I still want to be treated as a person who also happens to be a doctor. I am well-trained in some aspects of medicine, but my training may be all together inadequate to face my own illness without the help of my doctors, who also may happen to be my peer group and perhaps even my friends.

I would never want to be involuntarily removed from my peer group due to circumstances beyond my control.

A Defining Moment

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A commenter on the blog yesterday prompted today’s post. (See, if you pay attention to what is going on around you, ideas just fall into your lap)

Why do some people feel the need to define themselves by their illness?

Why would they not, like most of the rest of us I guess, define themselves by their talents, their wealth, their ability to be perfect parents, or their skill at foosball? 

Let me offer a few random things that I think might play into this. As my time to write is limited this morning I trust that all of you , my very smart and not-so-shy readers, will fill in the gaps for me and add more as you see fit in the comments today. 

I have seen a lot of people over the years in a clinic setting who have applied for and achieved disability status. That is, they have amassed a truckload of paper work, gone to be evaluated by a separate (non-treating) mental health professional, had all of this information presented to a court system or administrative law judge, and then been granted the privilege of receiving what is in fact a very small amount of money to live on each month.

They are re-evaluated periodically, usually every few years, to insure that they still meet disability requirements. These re-evals are the source of intense anxiety for some of my patients, as they figure if they have not been presenting as “sick enough” or that my paperwork reflects any amount of improvement that they will no longer receive “their check” each month. 

I have also seen this happen in other systems such as the VA, where maintenance of livelihood (that is, staying sick enough to keep getting paid for it, in essence) is predicated on continuing to have a fixed number of documented symptoms or diagnoses that make you  “service connected” at a percentage that translates into a fixed amount of monetary compensation. 

Yes, these kinds of systems encourage you not to work hard to get better, but to put a lot of effort into documenting that you are still sick enough to keep getting paid for it. 

There are those who have conditions such as hypochondriasis. They are absolutely sure that they have something wrong with them that the doctors have just not been able to find yet. They go from place to place, doctor to doctor, clinic to clinic, trying to find that one elusive diagnosis that will tie it all together. They in a sense define their lives not by a particular illness, but by the search for an illness that may or may not exist in reality.

Malingerers, on the other hand, have something that drives them to fake illnesses, manufacture them, embellish them and work then for all they’re worth. Secondary gain plays a large part in this, of course, in that illness gets one out of jury duty, court appearances, military service and long periods of idle time in jail. These folks define themselves by very specific illnesses and symptoms, carefully crafted and maintained for very specific reasons and purposes. 

Keeping oneself in the sick role can serve many purposes. 

It sanctions your disability, at least for a certain time and to a certain degree. If you’re sick, you’re not a functional member of society, and that’s okay for now. You’re expected to get better and return to being that member, of course, and that’s where it breaks down for those with hypochondriasis and those who malinger. 

It gives you the added benefits of physical, emotional, and financial help when you really need it. Again, this is good to a point. The problem is, over the years people have learned to work the system and milk it for all they can, and that’s not the way things were designed to work. 

You know how people who are abused will stay in an abusive relationship, despite horrendous emotional, physical and mental anguish and pain? Well…

When you’re sick, you learn to be sick. You get used to it, for better or for worse. You learn what that means. You learn that to get well, while considered by most of us the the desired goal, may mean giving up interactions, attention and financial security. You’re not so sure you want to, or even can, go back to working and being “normal” like everyone else you see around you.

Sometimes, the devil you know is better than the devil you don’t. 

Comments, oh wise readers of mine?