CURRENT BOOKS

Doctors as Patients

By Allan Bernstein, MD

When Doctors Become Patients,
by Robert Klitzman, 344 pages,
Oxford University Press, $35.

Do doctors make the worst patients? In his book When Doctors Become Patients, Dr. Robert Klitzman begins by describing the depression he experienced after a traumatic death in his family. He was totally unable to recognize the classic symptoms. After all, he was a psychiatrist; he couldn’t have a mental illness.

Klitzman goes on to interview, in depth, 70 physicians and medical students who had illnesses that ranged from HIV/AIDS and metastatic cancer to myocardial infarctions, chronic infections, leukemias and lymphomas. His subjects describe the transition from their vision of themselves as God-like beings to the uncomfortable and often degrading experiences they endured in hospitals and emergency rooms, even in their own institutions.

Two categories of illness appear early on: “medical student’s disease” and “post-residency disease.” The former is a syndrome of trainees, who fear they have the symptoms of the conditions they are studying. The latter is a denial of illness, no matter how glaring the signs and symptoms. Post-resident physicians seem to practice selective denial in regard to their own health. Their workaholic personalities and sense of invulnerability often preclude objective assessments of their own health. Magical thinking is rampant: “If I don’t have a biopsy, I don’t have cancer.”

After Klitzman’s subjects acknowledged their illness, a common dilemma was whether to continue being the doctor, in control at all times, or to become a patient and cede that control. Many of the subjects ordered their own tests and imaging studies and prescribed their own medications. Others elected to let their physician run the show.

For those who ceded control, certain topics were difficult to discuss with their physicians. The subjects could admit to poor eating habits, failure to exercise appropriately and inconsistent medication compliance—but depression, substance abuse and unsafe sex seemed off limits. Many subjects would prescribe their own antidepressants and fill them at pharmacies where they were unknown. They would not submit these bills to their medical insurance for fear of others finding out. They knew that confidentiality, even in this age of HIPAA, is rarely observed. After all, if you’re in the hospital, your chart is at the nurses’ station, and your colleagues are making rounds and writing notes at the same site. Conversations are overheard, or charts are looked at “just to see how you’re doing.” Word gets out.

All the subjects became acutely aware of the problems in our medical system. Even as “insiders” with scheduled admissions, they still had to wait in the ER for 6-8 hours until a bed became available. The lack of privacy and the absurdity of the open-back hospital gowns made an impression. Most refused to wear gowns, insisting on their own clothing. They were woken up to get sleeping pills. They were given medications with predictable side effects, such as diarrhea, at night, further impairing their ability to get adequate sleep. The convenience of the nursing staff took precedence over the appropriate timing of treatments.

Side effects of treatment were rarely discussed, or were simply glossed over. Mild nausea and vomiting are not mild when they affect you. Abdominal cramps, slow thinking, weight gain or blurry vision are rarely “mild” for anyone, no matter what the pharmaceutical brochures say. Hair loss—transient with chemotherapy and permanent with brain radiation—was not discussed. “You’re a doctor, you know this stuff” was the common explanation, even to a psychiatrist or an anesthesiologist who would never treat certain conditions.

Communication was often poor. When the subjects phoned their doctors to request test results, the callbacks often took days. As one subject observed, “If I called just doctor to doctor to discuss a case, he’d come right to the phone. If you’re just a patient, he won’t.” The treating physicians would often make hospital rounds at 7 a.m., waking up the patients. If the patient nodded a sleepy “I’m OK,” the doctor was out the door. Covering physicians often had a marked lack of information about the medical details. All the subjects reported extreme appreciation when their physician would sit down in the room when making rounds. Sitting down may have added two minutes to the encounter, but the sense of personal care became palpable. The subjects came to recognize how important face-to-face time is when treating severe illness.

What happened when these “wounded warriors” returned to work? Their colleagues resented them for not taking call during their acute illness and taking less call now. Colleagues were also hesitant to make referrals to physicians who might be impaired by illness or medications. HIV/AIDS was especially damaging to further practice in terms of referrals. Expected promotions did not happen. Partnership offers were put on hold. Many colleagues distanced themselves from the returning physicians, who in turn were uncomfortable about discussing their illness or bringing up the issue in conversation.

On a more positive note, the returning physicians changed their practices significantly. They clearly understood side effects of treatments and would discuss them in detail with their patients. They allowed more time for patients and were more conscientious about returning phone calls, lab reports and imaging studies. They reduced their practices (and their incomes) to provide a more compassionate level of care. They understood some of the absurdities of hospital rules and the added stress those rules inflicted on patients.

Does a doctor need to get sick in order to learn empathy? Should medical students spend a week as a “patient” in the hospital to learn what real patients are going through? I would hope the answer to both questions is no; yet the experiences described in Klitzman’s book raise serious questions about how we educate physicians and how inconsistent we are in our dealings with patients. If we, as “insider” physicians, have problems with a medical system we supposedly know, how does the rest of the population get the care they need and deserve?

When Doctors Become Patients, demonstrates Klitzman’s ability to listen and to distill what were clearly lengthy interviews, some done over a long period of time. Some of the subjects died during the process or immediately after. Others retired from medicine or took less demanding jobs in the medical field. One went back to school and became a lawyer, but continued to describe himself as a retired physician: “Once a doctor, always a doctor.” Klitzman was able to approach the uncomfortable topics and elicit responses from people who typically don’t talk about themselves.

After reading When Doctors Become Patients, I could identify areas that needed improvement in my practice—as I suspect each of us could. My one brief hospital stay many years ago was appropriately noisy, busy and lacking privacy. The first drug I received made me hallucinate for six hours, a fact that was not recognized by the staff. After reading Klitzman’s book, I realize I got off easy.

E-mail: bernsteinallan@gmail.com

Dr. Bernstein, a neurologist, serves on the SCMA Editorial Board.