Choosing My Own Doctor
Ann Starr
Starr is a
visual artist with an MA in English. Her art
focuses on the role medicine plays in the cultural
understanding of illness and health, body and mind. Her paper is adapted from a talk she gave at
the Program for Humanities in Medicine at Yale
Medical School on March 1, 2001.
I have it as good as it
gets. Not only am I a healthy woman in a healthy family, but
my husband’s employer makes a large monthly contribution to the
HMO that provides excellent care to our family and has for twenty
years. They have covered the births of our children, too many
orthopedic surgeries, the pastel mountains of medications we have
consumed over the years. They have provided, moreover, continuity of
care. Maybe not continuity in the strictest sense, but, at least, as
doctors have come and gone over the years, we have always been
served, nay, invited to choose our new ones.
I have in fact had the same internist for over ten years now, and I
think him a paragon of informed and compassionate practice. I
have life-long friends whose intuitions about me are much less acute
than my doctor’s. It’s good, too, to go to a doctor whose
conversation is always a pleasure, no matter how feeble or worried I
am feeling. We are a great match, my doctor and I.
But do I enjoy this good fortune because I chose him? Yes and
no.
First the Yes. At the time we linked up, there were only two
PCP practices (of around twelve) open at my health plan. I
interviewed the one doctor about whom I had heard good things from a
friend. Her husband and the doctor had known each other as
undergrads at Harvard in the ‘60’s. I guess that’s “a
good thing?” Of the other I had heard nothing. Definitely a
bad thing.
My friend’s tenuous association with the one doctor supplemented
the consumer information provided by the management on all doctors,
viz.: undergraduate and graduate degrees, names of medical school
and residencies. Doctors’ photographs were also provided,
photos executed, I am convinced, by the same concern that does
annual photos for public school children: all the subjects similarly
posed, all smiling, tidy, and genial. I gazed at the pictures
of two white men and studied their credentials.
I speak as a middle-class mother who never studied medicine, bore
two babies, has had her share of infirmities physical and mental,
and was dismayed by the defection of yet my fourth internist within
three years. I am always lost to understand what of possible
importance to me is encoded in the HMO brochures displaying the
smiles, the well-knotted ties, modest earrings and University Red
vs. University Blue degrees. I had certainly experienced some
extremely uncongenial doctors with brilliant smiles. I have
never had a doctor with other than “great credentials:” it’s
the only kind there is in suburban Boston. So the issue was
finding any assurance that the next doctor would not leave the
practice within a few months, wouldn’t walk in while I undressed,
or would inquire before pronouncing to this owner of a ten-year-old
Toyota that driving a Mercedes wouldn’t be good for my neck.
So I chose to interview the first doctor because I had heard his
name in a sentence lacking a negative. It made all the sense
to me. I think he found it peculiar for me to interview him at
all. Clearly I seemed to misunderstand something fundamental
about both the concept of choice and the process of choosing.
Well, I didn’t like him very much either.
So that’s how I chose my doctor. He was the one who was
left. He was too new and young, no name-recognition (even with
the nurses) to recommend him to the likes of me--or to anyone else
who had neither names nor anecdotes to upgrade the essential process
of drawing straws.
HMO’s market doctors as products. Most of us on this side
are cast in these transactions not as the sufferer to the healer,
but as consumer of health care services who is expected to select
the nicest- (or blandest-) looking delivery system, the one with the
specifications that seem best to the fussy ignorant. We choose
doctors only in the thinnest sense, as our choices are guided by a
very little information, and that with content that is largely
uninterpretable by non-physicians. Basically, most lay
people (patients, that is) will choose a Yale M.D. over one from
Northwestern or Alabama, no matter what the content of the degree or
its relevance to the medical issues in the patient’s lifelet alone
the characteristics of the individual degree-holder.
Since only the most minor essential distinctions between doctors are
in fact advertised, doctors are rendered essentially anonymous,
ironically by the very corporate strivings for the personal touch.
Interchangeable doctors are presented for study in Web pages and
printed materials by potential patients--who are, of course, equally
interchangeable.
We patient-purchasers for doctor-products are, in a literal sense,
non-entities because we, like doctors themselves, are wholly
replaceable. Through advertising’s eye, each practicing
physician is introduced to an idealized composite patientand that
is, of course, one who does not exist. The Marketing
Department reduces the parameters for choosing a practitioner by
radically simplifying both the presentation of the doctors and the
implied interests of the consumer/patient. May the patient
expect the doctor to give emotional support in grave situations?
Aggressive assistance getting tests or referrals? Ability to
help weigh diagnostic uncertainty? Smiling class photos and
summarized credentials have little content to begin with, but are
entirely blank on many things the marketing department cannot promise, like all these individual distinctions in practice and
character. So the apparent benefit of choosing a doctor is in
fact lost in a taciturn process one can characterize generously as
ineffective, less generously as cynical.
Upon what more independent basis can patients learn about doctors,
short of having a medical emergency be the occasion for assessing
“fit”? There are always stories, if you keep your ear to
the ground. But my experience is that for every horror story
about Dr. Blank, you’ll find another in which she figures as the
heroine. And this is, of course, because these are intimate,
individual relationships. Reactions to doctors are vivid and
fervent, as they should be. Even a best friend’s beloved doctor
(let alone one’s friend’s husband’s old college pal) may
reduce you to a jelly of anxieties.
My own, experiential advice for patients wishing to gather
information independently is simply to look around the doctor’s
office and decide whether you want to come back. The
doctor’s office as a space is rarely cited as the profound and
subtle source of primary information it is. In fact, it took
“choosing” my current doctor for my eyes to open to the
sourcebook four walls can be. Patients can read the doctor’s
strategy (conscious or not) in the visual details of the
surroundings. Moreover, we usually have at least ten draped
and chilly minutes to look around, if only we will put down People and do the research.
I take there to be three common modes of office decoration that seem
to be predictors of the way patients can expect to be received by
the practitioner. First, there is the consulting room filled
with didactic anatomical charts. These remind us, gratefully,
of our ignorance of the slippery body we are presenting, and make us
relieved that the doctor is not so grossed out that he cannot attend
it. Where there is one of these posters, there will usually be
several, demonstrating in graduated degrees of detail the pink-gray,
slick and opalescent tissues it is loathsome to admit might resemble
anything having to do with one’s self.
When the anatomical chart is evidently derived from a medical supply
business, I wonder if the doctor considers it merely something to
cover the blank walls--a cheap decoration of a particularly
disagreeable type. I prefer ones that appear to have been
ordered by the practice. (This is, undoubtedly, a matter of my
own snobbery, but I mention it as the sort of thing that is there to
be considered.) I have yet to have a doctor explain anything
to me by reference to one of these charts. They function in my
case only to have a sinister and depressing effect while I await the
doctor, wondering what the hell is wrong with me, fantasies growing
more urgent in the face of these quasi-articulate and alarming
images. There is, moreover, the guilt of the educated. I should know what I’m seeing, shouldn’t I? Need I
reveal that I haven’t known the pancreas from the spleen since
those five days in seventh grade when it was important to do so?
That is one kind of consulting room. Another features the
crisp reassurance of handsomely framed diplomas, citations, and
certificates of membership in professional organizations. In
this category (which demonstrates luxury simultaneously, with the
expensive excesses of the framer’s art) come the diplomas from
college through medical school, certifications into levels of
practice or professional organizations, memberships in colleges or
honorary societies of specialists. If you look closely, you
might find the occasional letter from a Girl Scout troop mixed in as
a minor form of this expression of auctoritas. In my
experience one does not too often encounter citations from charities
or thanks for gratis services performed. (Just my
observation.) But if you are the type that wants the doctor to
be authoritative above all, look for this sort of evidence, measure
the square-footage of the credentials, and weigh it against your
level of need for acquiescence.
Finally, there are the offices filled with family presence.
Movies from mid-century once showed the images of loved ones on the
doctor’s desk, handsome frames backed up to the patient, faces
smiling to the family man on the other side. These days, the
family smiles from plastic box frames benignly hung above the
examination table where you sit falling out of your paper drapery.
“Here is my photogenic family clustered about me. They are
with me even as I inspect your hernia.”
The family gathering sends messages the more problematic for the
patient when the photos are, as they much too often are, of the
wholesome group on what some of us might consider luxury travel.
These snapshots of togetherness on the veldt, in the rainforest, or
at Cançun appear to be just the sort advertised in the journals
that lie about some waiting rooms, discarded by doctors who have
already booked to exotic destinations and no longer need to consult
the itineraries proposed by Physicians’ Leisure. Pain
beneath the photographs of straightened teeth on a catamaran is
keener than it needs to be.
These family images are often accompanied, moreover, by de luxe
calendars received as perks from environmental charities. The
patient’s care is delivered in a context no patient can compete
in. It is at once global, (“I am protecting these
magnificent elephants from extinction”) and yet exclusionary for
being set in an intimate context, in the family room where the
patient is a naked stranger.
Let me return to my doctor’s office and the discovery that the
mode of decoration can reveal something about the practitioner.
His wall is dominated by a very large reproduction of Canaletto’s
“Entrance to the Grand Canal from the Molo, Venice.” It is a
museum print from the National Gallery of Art in Washington.
In the finest brushwork, the architectural marvels are laid forth
across silvery water, against a pearly early morning sky. The
few good citizens of the city who visit the quay’s fishmongers or
who take the air are clearly painted in on top of the cityscape,
afterthoughts to a self-contained and perfectly tranquil scene.
This picture made a walloping impression on me when I first visited
his office, over ten years ago. Where it is not true to say
that I had never seen an art image in a doctor’s office before, it
has been a rare enough occurrence. I had never seen any but
the most conventionally consolatory: floral still lives or details
from Monet landscapesimages so ubiquitous as to carry simplified
interpretations on their surfaces. While I waited in the
consulting room to meet this doctor, I was disconcerted to gaze upon
this beautiful image of the unhurried 18th-century city.
How could I interpret this? It was something to think about, a
statement that wasn’t pandering to a pat notion of a generic
patient’s needs or assumptions.
At a basic level, this doctor’s choice of office ornament
subverted my (alas, too practiced) expectation of where the clinical
encounter would begin. I awaited him in a space where the
personal--taste, inclination, experience--was to be tolerated, even
while medical authority was put to work. There was an initial
therapeutic aspect for me in the simple fact that he set the scene
in an unanticipated way. By withholding conventional icons of
medical authority he called attention to himself.
What can be made of a doctor’s thus calling attention to himself?
Isn’t the value put these days on “patient focus?”
I’ll suggest that by subverting the visual cues that highlight
medical authority, this doctor identifies where the real authority
lies: in his medical knowledge, training, experience, and clinical
skills, certainly. But it also lies in his relationship
with the patient that allows for those medical qualifications to
be put to effective use. That is, the authority is not only
medical (learned), but it also lies in the doctor’s
vision of why he chooses to practice, what he, personally, brings to
the patient. My preconception of what I “should want” or
“can expect” from a practitioner was less than he was
prepared to offer. So, I was emphatically not a
consumer in his office: I was not being asked to swallow anything.
Rather, I was asked to look up and see the doctor’s own process of
observation and judgment with respect to myself--a patient and an individual with a complex identity. Perhaps he saw even
more of this patient than I could allow myself to see, especially in
health as reduced as mine was. Thus, while the doctor worked
on my stated health problem, he also reflected my illness as one
aspect only of a larger, surrounding personal identity.
I have made these observations in the context of talks to medical
groups, and both times I have clearly created anxiety I did not
expect. What do I think constitutes correct or helpful
office decoration? The decorators (“Decorators?!” I
thought) say one thing; the individual doctors say another.
For that matter, is the space decorated for the patient or
practitioner? If for patient, which patient? There are
so many kinds of taste, so many ways, it is implied, of being wrong.
I have come to think that the best a doctor can do in creating a
visual environment for meeting patients is to display images that
are both personally engaging to the doctor and yet open enough to
create and absorb a variety of unagitated responses. I like to
see something that can provoke a simple question to create a
conversation. Even if it is a conversation only in the
patient’s imagination, it will block a unilateral response of
fear, flight, or defeat. Whatever image is used, I think it
needs to be unapologetic: it should be large, dominating. I am
personally sick of Monet’s waterlilies. But if they are
offered up decisivelynot a dutiful little patient-pleaser between
the calorie chart and diploma they can make me think that the doctor
is an individual with a preference in something besides patient
behavior. Then he or she is not someone whose objective is to
second-guess what generic patients want, nor to pacify clients, but
to work in a relationship with them, offering something of himself
as the gambit.
Published: October 28, 2001
© Ann Starr, 2001
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