General MedicineJuly 23, 2014

Doctors are not lifeguards

By James Salwitz, MD

Once upon a time, I was a lifeguard.  This was the natural result of swimming fairly well, Red Cross training, and team competition.  I saw myself as a handsome, tanned guardian at the ready.  Ok, I was prone to self-delusion.  When I became a doctor I carried over that image of high-perched protector on stilt chair, whistle in hand, rescue float close, ready to dive to the assistance of a drowning patient.  I was wrong.

The critical difference between a lifeguard and a doctor is intimacy of involvement.   A lifeguard must able to navigate in the water.  Not many of us would be happy that the bronze babe standing watch could not actually swim.  “Do not worry, I have read all the research on hypothermia, rip tides and CPR,” would not reassure us, if she could not float.  A lifeguard saves by directly applying a skill that at the moment of crisis, the bather lacks; when we cannot, they can.

Not so a doctor.  A physician does not need to be sick, nor have any special skill at keeping themselves healthy.  They can be a robust Adonis of perfect form, or a chain-smoking, obese creature with diabetes, hypertension and an arthritic gimp.  We do not depend on the health of the doctor’s body, nor the emotional stillness of their soul, in order to regain our own vitality.

Strangely, we do desire that our doctor take as good of care of himself as he demands of each of us.  If he is a sedentary 250lbs, we do not take seriously the prescription to diet and exercise.   We will likely ignore a quit-smoking demand from a doc with yellowed fingers. However, is it relevant?  If you are consumed by a complex medical crisis with discomfort, debilitation and radical life change, do you really care if your doctor is eating soy or steak?  There is no comfort in the words, “Well, I have no idea how to treat that cancer, but amazingly I have had it myself.”

Much has been written about how being sick changed a healer’s perspective on disease, suffering and medical practice.  Many times, I have heard, “the best teaching for a doctor is to have an illness themselves.”  I wonder.  While there are valuable lessons learned dealing with rude staff, onerous insurance companies, the struggle to recover and unremitting pain, do those experiences really enhance one’s compassionate radar?  A doctor beaten down by disease may be emotionally and physically frail, and may project their own suffering onto the condition of each patient, even if not relevant.

We want lifeguards to be intimately involved with us in our struggle against consuming waters.  There is no role for objectivity in those frantic moments before we slip under.  For god sake, dive in.  Doctors, not so much.  We depend on physicians in their decisions, teaching and guidance to be objective and analytical, science and data based.  Misery does not wish professional company.  Their skill and wisdom must come from a point well above the waves.  That distance does not mean physicians do not care. Their compassion is based not in their personal health or goals, but in shared humanity, love of life and abhorrence of suffering.  The great art of medicine is that doctors can save without ever needing to swim.

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21 Comments

  • Mike Abrams
    As a patients, I've found some young/fit doctors a little quick to dismiss symptoms and side-effects--- not to mention perplexed that it's much harder to be physically active when we do not feel well. I think it is hard to imagine another's discomfort if one has never been sick a day, even with medical training. That being said, I want my doctor to be highly competent first, and reasonably compassionate second. I hope for his/her sake that he is not 100 pounds overweight, and that he doesn't smoke 4 packs of unfiltered Camels per day. But I would not be quick to accept a doctor just because he's the model of health I used to be 20 years ago.
    Reply
    • meyati
      My current male PCP looks like he's in his 3rd trimester. I much prefer him to the fit hiker/athlete that preceded him. Especially if the patient is an older woman-these young, trim docs don't believe that an older patient is telling the truth, when a patient says that they are active-and that makes for poor care and follow-up. The fit one prescribed me the wrong meds, and ignored my complaint of having strep for 5 months. Today a doctor said that he'd schedule surgery for one of the problems created by strep. I find myself wanting older doctors.
      Reply
      • Bariatric Help
        I am so very sorry to hear of the comments here. I was once a larger lady (dropped 100 pounds) and many in my family are large. I support them when they try to eat healthy and walk or exercise but I rarely ever will make a comment about food or the like otherwise. My Mom is a little different though, I modify it but I dont call her names or anything. I discussed a situation like this with my sister and she said for all the stuff we take and have to suck it up, why don't skinny people have to suck up all the comments. She has a point. I think one can make it easier to help make changes, make it clear you care, but having experienced being large and now small, give each the chance to take responsibility for their own actions. Otherwise, are you treating the other person like an adult?
        Reply
        • meyati
          Your comment should not be to me. I said that my unfit doctor is very competent, he is kind, I didn't say this, but he's also Black. I'm there to talk about my health, not his. The article said -Obese and chain smoking. Perhaps my current PCP is kinder because some people made cruel remarks to him because he is unfit and a minority. Maybe he was raised to be kinder than others. I'm old and Irish. I do know that I don't like the young self-absorbed Adonis type of doctor-male or female. They seem to think that they are the only fit people. While I had my Adonis putting me down, I did a trail that started at 8,000 feet, and went a 1,000 ft in 3 miles. Since it wasn't circular, I returned on the same route.I carried a backpack and had to do easy climbing, pull myself up. I was 68, and this Adonis lectured me about old women telling stories, and he and the HMO said that I had to try the cholesterol meds for prevention, because old women don't exercise. Honestly. I've seen several doctors and my father with this shape-looking like they're in their 3rd trimester. They were retaining fluid because they had stomach cancer. They all died. I went to a KINKOS and a very OBESE woman kept getting in my face. I kept turning back, going to another part of the store, pushing my way through groups to escape. A TV crew was there, but I didn't think anything about that. She'd come right up to me and stare. She never smiled, she never said, "Hi". I'm a woman so small that my nickname is "FLACA" skinny. This woman seemed to be in my way and staring at me. It was so bad, that some young males asked me if I knew her. They surrounded me, and walked me out to my car after we checked out, because she was at the exit. A few nights later this was on the news with my face blurred. She had attitude just like you seem to have attitude. It a news segment on how society, even kindly old ladies, shun obese people. You bet'cha- I'll shun any aggressive person, even those called Flaca-
          Reply
  • Liz
    In some sense until you have been there, done that you don't really "know" what the person is going through. Think of death of a close family member - when you experience it, it is usually a shock just how emotionally painful that is, how debilitating and how long active grief lasts. You intellectually knew it would hurt and last a long time, but you just didn't understand just how overwhelmingly debilitating it can be. Without having experienced death up close and personal an empathetic person can recognize the emotional pain of the person who experienced the death, behave compassionately, "feel" for them. intellectually understand, behave themselves appropriately… but they don't really "know". There are people where empathy is not their "best skill" - they may have learned to "fake it" but usually there are holes in how they "fake it". There are folks who have so insulated themselves from the pain and suffering of others, so they can do their job (and this is how some very empathetic people finally cope with a cop that puts them on empathy overload) and not be emotionally fried themselves that they "forget"… I am sure there are other reasons why people are or become emotionally colder/less responsive/understanding, etc. than they need to be. Some of those folks, when they get a wake up call by going through hell themselves that experience re-awakens or further develops their willingness/ability to understand what their patient needs from them on multiple fronts. Others… well not so much because fundamentally the world is about them, or their emotional intelligence is low, or they can't take that experience and generalize it in a way that is helpful… The process that choses who gets into medical schools does not appear to deliberately choose for people with high levels of compassion, emotional intelligence or empathy. The entrance process focusses on being able to play the grades and testing game. Thus those who have the emotional ability to appropriately handle that aspect of the job of doctor get in to med school for other reasons and so the range of people's "score" on this cluster of personal traits/ability is all over the place.
    Reply
    • pam956
      I agree with your statement about the selection process for medical school. I think that process needs to make empathy an important qualifier, as important as an aptitude for math and science.
      Reply
  • meyati
    Sometimes having doctor that went through what you're going through can make a difference in getting care from other doctors that are humoring you. I developed statin toxicity. and my PCP thought it was all psychosomatic or wanting attention. He couldn't believe that my urine was really black- I peed in front of the nurse--anyway-one of the specialists that he referred me to was also a statin victim. That tipped the scale where I wasn't beating my head against a brick wall. Oh, he thought that CoQ10 was a placebo too. I went in yesterday because I'm the very first person in my family to get any type of diabetes. I don't eat bread, I don't drink sweet drinks or sodas-I have IBS and grease and sugar are triggers for horrible cramps and the scours. I don't hate my old doctor for doing what he was trained to do, but I hate the FDA and the American medical community and ---I can't do what I need to do -and I was walking, hiking, working in the yard until I finally got tired of saying-NO-
    Reply
  • Knot Telling
    Toward the end of my first round of chemo for breast cancer, I was beyond fatigued and asked my oncologist about it. She saw fit to share with me that she had always thought patients were exaggerating the fatigue until she read an article by another oncologist who had breast cancer and was treated with the same protocol. After reading that an oncologist like herself had been wiped out by the treatment, she began to believe her patients. This is a clear failure at empathy, but it also points out another feature of doctor-patient relationships. There is an "us and them" perception that, I believe, in many instances limits the possibility of empathy on the doctor's part. The patient is too "other". Once someone with whom the doctor a priori can identify expresses the feeling or describes the situation, then the empathy can occur and even be transferred to "the other", the regular patients. I don't wish cancer on anybody, and my training has made me wary enough of transference that I wouldn't particularly seek out an oncologist who has had my kind of cancer. (Aside from the obvious limitations of finding a practicing onc with metastatic cancer...) I do think that some sort of training in empathy during late residency and fellowship would not be amiss.
    Reply
  • Bariatric Help
    I can only say that after having myself and others get claims of 'its all in your head' and a lack of discipline, etc to have it turn out there was something really wrong with us, means that there is a problem with doctors. Once doctors get illnesses, etc. life changes a bit, especially if they can't demand because they work at the hospital, etc. The only way to change that is to make reprocussions for doctors who don't listen to patients, who aren't thorough ... and make bad decision calls before they ever sling "mental" darts at people.
    Reply
    • meyati
      Like I said, I was poisoned by statins. I used to be understanding, but now I'm leaving a paper trail. I got lab work back this week and my kidneys are going out. One of my oncologist made a remark that he was sorry that I have such a horrible cancer. I told him that cancer isn't as bad as statin toxicity, because my HMO poisoned me, but the FDA covers this medicine. Statin toxicity is extremely painful on the hips on down. I kept saying -no-
      Reply
  • D Someya Reed
    Two things... Yes, "We (do) depend on physicians in their decisions, teaching and guidance to be objective and analytical, science and data based." But even I remember when doctors didn't want or welcome patients who did their own research, or those who later commented on what they read on WebMD, or even came in with a list of questions. Unfortunately, all of those still exist even today but it is funny that WebMD has become "the darling" of those pushing telemedicine. But no one would want to take medical advice from an overweight, chain-smoking, alcoholic doctor who is on a board enforced program for cleaning up his narcotic/opioid drug addiction (not that this is allowed to be made public information by the AMA or Nursing Board). There are levels of degree but it is not unreasonable to expect a bit more self-care/concern from someone who is telling you how much care & concern you should show yourself. In case it's not apparent, I am agreeing you with and you said pretty much the same. Second, you are correct in your final statement, "The great art of medicine is that doctors can save without ever needing to swim." But we need to know that if we do need the doctor to "swim" he better know how. It has been reported that 40-70% of doctors admit to using Wikipedia as a reference in making their diagnostic decisions. Nothing against Wikipedia but it's not always accurate as much of it can be changed by anyone at any time. Their editors don't catch all the inaccuracies. And, it's also reported that these percentages are believed to be under-reported. Just as we want to know that the lifeguard can actually swim, we want to know that our doctor knows the difference between science and the latest infomercial. I have to throw this in because it seems so relevant as you have questioned the relevant worth of shared experience between doctor and patient. I'm not disagreeing entirely but I could not get out of my head the scene from 'Star Trek III: The Search for Spock' where Dr. McCoy (funny, a doctor) asks Mr. Spock what it was like being dead. Mr. Spock replies that he can't discuss it with him because they lack a common frame of reference. "Bones" then is exasperated over the fact that he can't talk to Spock about death without dying first. However, my second point (having said all the above) is that another "great art of medicine" and laudable skill of the medical practitioner is to know that most any patient knows more about themselves, knows more about their symptoms, knows more about the abilities or mental stability of their loved ones who may ultimately become their caregivers than the medical practitioner could ever hope to know. Some patients (and without a medical degree) can say one thing that may save their own life or the life of another. The medical practitioner (doctor or otherwise) needs to be able to skillfully extract that information, not be so arrogant as to suppress it and inspire trust from each and every patient no matter the perception of his/her own personal, physical condition.
    Reply
    • Bariatric Help
      Excellent response. I found that even bringing things from UpToDate, Clinical Key, Medscape, PubMed, etc. gets a negative response from a number of doctors. Um ... I understand on WebMD, Not those items I just mentioned. If I'm bringing them to you, its because I want you to incorporate those in my care as they sound reasonable and logical. Why is it that doctors who have their own experiences, which could be biased by patient selection, etc. believe it is ok to act on their own beliefs, but if you bring in double or triple blind placebo based articles, that's not good enough for them? Those studies are supposed to be scientific based, and credible. So why do docs think their own experience, one persons', trumps those?
      Reply
      • meyati
        My family doctor in the late 1940s complained about people coming in with proof of their own diagnosis. This isn't a new phenomenon-unique to the electronic age. I live in one of the very few states that allows the public to do research in the universities' medical libraries. one non-medical person diagnosed his wife. His findings were were sent to the news agencies, and now doctors all over consider Lyme disease. Before that only New England doctors recognized Lyme Disease. Because of this husband and an available medical library, doctors now know that Lyme disease is everywhere. I still prefer the medical library to the Internet.
        Reply
        • Bariatric Help
          I used the medical library as I pointed out. Unfortunately I've been right a lot. I'm not dismissing the "art" of medicine, but I think doctors do need to consider that a patient who's pretty much on the money before should be listened to and take that into serious consideration. It should wake a doctor up to exploring 1) why do they feel its an issue and 2) suggest differential dx or whatever for the patient to look up. Seriously, in the days of docs don't have a lot of time, if you have a patient that is credible and can read medical research, use them. They obviously want to help themselves out and could maybe do the doc a favor in return. Not everyone wants a contentious relationship with docs: some of us got them foisted on it.
          Reply
          • meyati
            Look I had strep for 5 months last year. I would have been better off in Mexico. I could have gone to a lab and ordered my own strep test, then walked across the street to a farmacia and got the antibiotic. I could have had a surgeon cut off of a cancer on my face before it became incurable. My doctors almost cry-and say they went over my records-read the Emails to my PCP begging for a strep test. A 4 year-old has more intellectual curiosity than many of today's doctors. I belong to one of the top rated HMOs. The specialists are normally wonderful. I'm being scheduled for surgery to fix a problem caused by the strep. American medicine has greatly failed me, and no telling how many others. I cost the stupid HMO about $10,000 to take care of a a less than $200 problem. $150 for a visit, $10 for the strep, and $10 for the Augmentin.
          • Bariatric Help
            This greatly saddens me, disturbs me, and makes me angry to hear of circumstances like yours. One because they're not isolated and two because of the waste and disrespect to a human being. I'm sorry that this happened to you.
          • meyati
            Thanks-I really mean it. There's a reason that WHO rates America so poorly. The rule of the thumb is the survival rate in obstetrics. Medically, this is a third world country-and not a top rated one either. Spending lots of money does not signify medical care-most of the money goes for administrators and paperwork-and the rules and regs still don't stop scam artists.
          • Bariatric Help
            and on top of that, the good/decent docs get crapped on too.
          • meyati
            I couldn't get pain killer, after part of my nose and a section of my lip was removed, because the DEA was investigating the surgeon. She proved that she only prescribed after surgery-like hand surgery, facial reconstructions for cancer and accident victims, etc. This affected her emotionally too.
          • meyati
            At least in a 3rd world country you can buy pain killer after surgery-my face was covered with sutures, my nose turned sideways, my lips and the inside of my mouth swelled almost shut. All I had was popsicle slivers to give relief. I couldn't even use a straw because a section of that muscle was completely removed.

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