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.

All (Patient) Lives Matter

She is tall, thin, and wears torn jeans like a mannequin. The silky top flows around her, masking the thin torso, the exposed ribs. Her hair is long, fine, and the ends are perfect. Her face is smooth, drawn, a bit careworn, but that is why she is here. She carries herself with an aristocratic bearing that is not learned, but genetically endowed over generations. She is rich, entitled, and she expects to be treated well. She is not sleeping. She does not eat. She is struggling. All the money in the world does not offset true twenty-first century angst. She asks for sleeping pills, as her nightly regimen of cannabis and cocktails is no longer working. Batting her natural lashes, and giving a gentle but directed toss of her corn silk smooth hair, she expects to get them. When asked to settle up at the end of the visit, she pays with cash. 

She is lying on the hard floor of the seclusion room, stark naked, legs akimbo, her belly flopped over onto the floor like a sack of flour. She has been given intramuscular injections of an anxiolytic and an antipsychotic, so she is drooling, sedated and uncoordinated. She cannot stand. Her speech, such as the vitriolic outpouring of expletives and sexual references is, is slurred and marked with staccato streams of spittle. She is actively hallucinating, screaming back at the demons who mock her and tell her to kill herself. She has a college education. She is a beautiful woman, engaging, smart and witty when she is not being torn apart by the illness that has run rampant in her family. When she comes to see me in a few weeks, after she has weathered yet another psychotic storm, she will be mortified that I saw her this way. We will talk it through, and we will do our best to make sure it never happens again. 

She sits quietly in the chair in my office, listening to her mother. Detail after detail of how bad she is, how she constantly acts out at home and at school. How she is not like her mother’s four other kids, how she is a disgrace to her family. How her mother is almost ready to give her up because she can no longer tolerate or handle her. A single tear rolls down her smooth brown face. She asks if she can play with the the toys. She looks at mother. She looks at me. I nod. She gently holds a small doll, stroking her hair. She has been abused since the age of two. She is now six. She never smiles. 

She is short, wiry, with skin tanned like leather. Her clothes are dirty, torn, and mismatched. Her hair is matted, a black-brown tangle of exposure to the sun and nights spent huddled in a cardboard box. Her face shows the telltale pockmarks and acne that help confirm the diagnosis that was already surfacing in my mind five minutes after our visit started. She bravely tries to connect with me via humor, a bad street joke, and when she smiles her teeth are rotting in her head. She tics and jerks and can’t sit still. She looks at the door, then back at me. She has places to go, dealers to meet. How much longer will this take? Would Valium help, maybe? Xanax, then? She knows that she will not get what she came for, and it makes her angry. I am a safe target. She explodes. 

He is older than me by eleven years. He is handsome man, robust and tanned with a perfectly coiffed head of thick, smooth, snow white hair. His face is clean shaven. He wears a lime green Polo, khakis by the same designer, and Italian leather loafers with no socks. He has a simple gold wedding band on his left hand, a college ring on his right. He fidgets, clasping and unclasping his fingers. He sits slumped in the plastic emergency room chair, and I know that this is not his usual posture without even asking. He struggles to lift his head. Eye contact seems painful to him. His voice is a raspy, tired whisper. They were married for forty-nine years. She was sick for the last five. Yes, he has several guns at home. Yes, he has thought about it. Yes, he drinks, every night, four bourbons instead of two. Could he just go home, please? Could he just go home? He is so, so tired. Could he just go home? 
All lives matter. 

People Who Need People

People, people who need people,
Are the luckiest people in the world
We’re children, needing other children
And yet letting a grown-up pride
Hide all the need inside
Acting more like children than children.

People” is a song composed by Jule Styne with lyrics by Bob Merrill for the 1964 Broadway musical Funny Girl starring Barbra Streisand, who introduced the song.

My newly minted son-in-law just started his internship and residency in emergency medicine in Denver, Colorado this summer. I feel for him. The first year is designed to be hell, and it usually is. Once you’re past it, things get better and better in many ways. But first, you have to learn. A lot. You think you absorbed so much in medical school and that you are now a doctor because you have MD after your name. Wrong. You are just starting your journey to being not just a doctor, but a physician.

It starts early, the indoctrination. Living, breathing people who come into your circle of influence, no matter how small it is as an intern, are sick. They’re hurting. They’re wanting something from you. They may be at risk of dying. Your job is to rapidly assess what you see in front of you, make a diagnosis, and fix it. Simple, right?

You learn to run with the numbers, the trends, the evidence base. You know how many symptoms of what severity need to be present to diagnose an acute myocardial infarction or an abdominal ileus or a suicidal depression. You listen, you examine, you rapidly run through a differential, you get labs and studies to augment your thinking, and you decide what to do.

You fix it.

If you’re a psychiatrist, you might do this fifteen times a day. A family doctor might do this fifty times in an afternoon. An ED doc might do it a hundred times in a shift in a busy ED.

The powers that be in medicine these days are trying to turn us all into fast-talking, fast-typing, money-making medical technicians. We evaluate, crunch the numbers and act. Next. Repeat.

Sick people have become patients have become clients have become consumers of medical services have become members have become souls.

We doctors are fast losing touch with what makes us who were are. Healers.

I am learning more about the practice of psychiatry and about myself now than I have ever learned before. I don’t like all of it, but I’m embracing it. As I get older and continue to practice medicine, I learn important things on a more and more regular basis.

One of these is a very simple, back to the basics kind of discovery.

My patients are still people.

In some of my practice settings, I have begun to see the third and even fourth generations of patients from the same family come to me for help. These multiple generations are teaching me about the heritability of depression, bipolar disorder, schizophrenia and substance abuse. They are teaching me about the realities of dysfunctional family dynamics and domestic violence. I hear their stories and I listen. I learn.

I have found that appointments have become visits. Visits have become real conversations. Both patient and doctor look forward to these. This is why I chose psychiatry as my primary specialty all those years ago. I do not want to be the six minute prescription pusher who knows little to nothing about the life of the person he is treating. I can’t practice medicine that way. Never have. Never will.

I look forward to seeing my patients and hearing what they have to say.

I have recently returned to cover a clinic where I have not seen patients for the last seven years. I have changed. Some of my former patients have not. I am seeing many more children than I have ever seen. That may be another post for another day. The return to that clinic, especially following a beloved physician who retired and who practiced similarly but not exactly like I do, has been a lesson in humility, resilience and improvisation.

In the end, the bottom line is that I went into medicine to help people, like many doctors did.

I decided to be a physician because I wanted to get to know people on a level that is almost impossible in any other job or setting. I feel extremely blessed and lucky to be able to do what I do. I am grateful for the chance to reach out, engage, and help.

I’ve told you before that I’m an introvert at the core of it (some of you still don’t believe that), but even introverts need social contact, one-on-one time, relationship.

People who need people are the luckiest people in the world.