|
This month's Chronicles are offered up as a meditation on how two particular roles in our society are defined and interpreted according to the themes of what Marxist sociologists and anthropologists refer
to as the "dominant" culture. We refer to the roles of doctor and patient. Who is a "doctor" and who is a "patient" in American culture? This question is the same as "Who is the person
in any culture? Depending on how it is answered, the question can be extremely simple-minded or extremely complex. Why is it important? We believe because the more we
understand about the cultural knowledge we rely upon to give us our bearings in the world, the more we realize that neither behavior nor beliefs are "natural" or "universal", that two
people can look at the same action or event and come to very different conclusions about "what's happening". If one is a tourist in a strange land gawking at the natives throwing
buckets of colored water at each other during a religious festival, this can be a harmless and quite diverting spectacle. It also makes good copy to send to the folks back home. If, on
the other hand, one is told and believes that refusal to participate in this ritual will result in one's child contracting small pox, the same activity assumes an altogether different significance.
At the most obvious level, the "doctor" is the one in the white lab coat, usually with a stethoscope around his neck. The
"patient" is the one sitting meekly in the waiting room, sneezing, coughing or otherwise looking miserable while waiting to be shown to an exam room. The one thing we can all agree
upon about the practice here at 201 East 65th Street is, that for each segment of the day, almost every day of the work week, we get the most varied and interesting polyglot of
cultures represented in our waiting area, people who have been brought together for a brief moment in time by one common thread—they are all "patients" who want to see the "doctor".
What do these "patients" look like? The beautiful young model sitting off to one corner reading incredibly enough, Proust's Remembrance of Things Past. The endearing elderly couple
who hold hands and go nowhere without each other, certainly not to the doctor, even if only one of them has the appointment. The restless thirty-ish stockbroker pacing
incessantly and interrupting the conversation on his cell-phone to ask the girls at the reception desk "How much longer?" every ten seconds. The professional writer, always with his
yellow legal pad and leather satchel of notes, scribbling furiously, but, compared to the stockbroker, blissfully oblivious of time. The handsome, gay stage designer, here for a test
result, who smiles to break your heart on the way out. In an endlessly fascinating stream they come through the doors each day and leave impressions of identities that have taken a
lifetime to construct and that just as surely say who they are as the more obvious markings of their gender or ethnicity. So we see on the one hand a "patient" who has come in
because s/he cannot sleep at night or has lost hair or cannot seem to lose weight no matter how hard s/he tries. Some patients might be there for relatively simple reasons—a cold or
temporary stomach upset from eating the wrong food. Others might have come in reluctantly to check out a lump in the breast or swelling in the groin after several months of ignoring
it, hoping it will go away. Some people are content with messages left on their voice mail following a visit, saying, "Everything was fine on your lab tests". Others insist on being
sent copies of every single test, even the normal ones, for their private records. Those are the "symptoms" or explicit behavior that we see from our side. On the other hand, it is now for the doctor or physician
assistant figuring out how best to help or treat the patient, to take into account not just the physical manifestation of illness, but the individual psychosocial and cultural stage on which
each patient acts out his/her daily life and which inevitably constrains his/her attitude towards the doctor, his/her belief in the efficacy of the medical advice or treatment plan handed
out, and finally, his/her understanding of what is needed to get well. To take one example: the New York Times' recent series of articles on the state of race relations in America today
demonstrates how deeply people are affected by their own perceptions of how others perceive them. In one of the articles in the series, a Black Internet entrepreneur did not blame his
former White partner for his business failures when they decided to go their separate ways. However, he did see race as a factor in the reason he felt investors placed less
confidence in him, why he therefore believed he had to work twice as hard and lay more stress on his marriage and family, and possibly his health. (What do his homocysteine levels look
like we wonder!) Do men ask for Viagra because of physical problems with erectile dysfunction or because "the culture" defines masculinity by "how long you can make it last"? Will the
orthodox Jewish or Muslim woman talk about pain or other symptoms in a "private" or "female" area of the body to a male doctor or assistant? How do people of different cultural
backgrounds discriminate between ailments or diseases labeling them "shameful" (AIDS), "ridiculous" (sleep apnea that results in snoring), or "dirty" (herpes)? Why do many people view
"depression" as the mere self-indulgence of a wealthy society with too much time on its hands, or dismiss "obesity" as simply the result of a lack of self-control? And what about patients
like the woman who once proclaimed indignantly to one of our secretaries who asked why she needed a refill so soon on her prescription for Xanax: "What are you talking about? Everyone
I know takes Xanax or Valium to stay sane in this society!" Just as patients are "whole" people, sometimes capricious and unpredictable, sometimes cooperative and vigilant about taking
active responsibility for their own health, so too are doctors and their staffs. What do patients "see" about a doctor or medical assistant besides their competence? Do they feel
nervous if they perceive the doctor as too "young", too "brusque" too "familiar", too formal"? Are patients necessarily more comfortable with physicians or physician assistants of
their own sex, ethnic or social background? In the upper and upper middle class enclaves of New York City, are people more pugnacious in terms of questioning their treatments or
physician's competence, more ready to threaten litigation or malpractice because they have the means at their disposal to do so? Or do they still cling to the approach of "You tell me doc. I'm just the patient"?
The great sociologist Erving Goffman spent his entire professional life investigating what he called the "presentation of the self in everyday life"(also the title of one of his most
influential books). Goffman's theory was that human behavior cannot be predicted by stereotyping people according to labels such as "female", "Chinese", "gay", "liberal" "lower class" etc.
People learn the rules of social language in the course of their interactions and experiences with others. The problem for the anthropologist of medical practice or any
other profession, is that in the America of the twenty-first century, it has become difficult, if not impossible, to see individuals as representatives of small, self-contained worlds
with well-defined boundaries. Just as anthropologists of the forties were already acknowledging the blurring of lines between "urban" and "rural"," peasant" and "townsman", so
too for us today, as anthropologists of everyday life, we have to constantly remind ourselves that a patient is more than a patient, a physician is more than a physician, a P.A. is more
than a P.A., a receptionist, secretary, billing clerk or filing person is more than a receptionist, secretary…….. We all have our unique stories behind the characters we outwardly play,
just as we each possess our own bio-chemical makeup that predisposes us to act within a certain range of behaviors. In The Man Who Mistook His Wife for a Hat, Oliver Sacks writes:
If we wish to know a man, we ask "what is his story, his real, inmost story? ," for each of us is a singular narrative, which is constructed continually and
unconsciously by, through, and in us—through our perceptions, our feelings, our thoughts, our actions; and, not least, through our discourse, our spoken narrations.
Biologically, physiologically, we are not so different from each other; historically, as narratives, we are each of us unique.
You might find your attention wandering at this point as you say "O.K. O.K. , we get the point. Now what? What does this have to do with me choosing a doctor to take care of me and
my family?" Oddly enough, everything. Once we accept the multi-faceted nature of human interaction, we can begin to answer questions such as: Why do people go to see
physicians? Why does my Aunt Sadie, still doing all her own housework at the age of 83, climbing up and down three flights of stairs every day, still insist that she has a rare and
mysterious disease that no doctor in the world has been able to diagnose properly and consequently she suffers, oh how she suffers…. What happens during the encounters of patients and
physicians? Why does John Brown feel perfectly satisfied with his visit even if it was interrupted by five phone calls and Mary Smith feel she is never able to express all her concerns during
an office visit? How is information exchanged? What else is exchanged? When Jenny L. is told she does not need antibiotics, why does she insist she "knows" her own body and
Zithromax is the only thing that "helps me"? How do exchanges differ in different settings and among patients and physicians with distinctive characteristics? Why is apiece of medical
advice accepted by a patient from one physician and the same piece of advice rejected when it's given by another? What are the effects of these exchanges on subsequent patient
attitudes and behavior? What cultural rules govern the encounter of patient and physician? Despite the attention given today to environmental/biological explanations of human social life (which includes patterns of
sickness and healing) by sociobiologists like Edward O. Wilson, we believe it is narrow and, in the long run not particularly useful, to reduce human nature to biology and to minimize the
significance of varying cultural forms as "accidental details". Human beings are more than the sum of their physical parts or bodily functions. What do you think? |
