As part of the crowding-out of humanity from human culture, I’m shocked to consider how the humanity of medicine has been squeezed out of our culture.
For some odd reason, I took to reading the writings of Sigmund Freud during college. I was a science major, and had no earthly academic goals for doing so. I’m glad that I did – I learned a tremendous amount about humanity and psychiatry, of their good and bad aspects.
Freud was for a time idolized, and then denigrated. He really deserved neither. He was an intelligent man, a doctor, who asked questions and put them to practice in his medical work.
Freud was no Freudian. He regularly came up with concepts, formalized and elaborated on them, only to discard them several years later and reformulate concepts.
He developed a group of fans, the Freudians. One of the warning signs about any movement is when they name themselves after a person or thought – Marxism, Leninism, Freudianism. It is a sign that the founder has left behind enough novel ideas so as to paradoxically enable the dull-witted to plug in the concepts without any intelligence whatsoever. When one sees something labeled “Marxist” or “Maoist” or “Freudian,” one is guaranteed that no genuine thought will follow; merely an assembly of parts according to a set plan – intellectuals Legos. Perhaps one should call it “Legoism.”
One of the most useful concepts in Freudian thought is that a provider, or physician, should meditate upon the interaction of the patient, consider the dynamics and the hidden exchange between them. Freud’s theory was described, amusingly, as “Keep taking the history until the patient is all better.”
The Lost Dialectic
He focused on the immediacy of the human dyad between provider and patient – something I’ve called dialectic, to rescue the poor term from meaningless obscurity. A dialectic is that which involves a discourse for the purpose of seeking the truth. Seeing a patient is often little more than a medically-focused dialectic.
Nobody gets it anymore.
I do, of course, have faith in receptors and neurotransmitters and GABA agonists and NMDA competitive inhibitors, of course. As to the brain anatomy – the paths of the various connections between the ventral anterior cingulate gyrus here and yon – most neuroanatomists would be surprised to rediscover that Freud started out as a neuroanatomist, and peeled off as a psychiatric empiricist from the laboratory studies. He knew his tracts and nuclei better than many research neuroanatomists today.
Another surprise would have it that Freud’s “theory” did not spring intact from his mind, but rather empirically from his findings from his patient care. He got scads of it wrong, of course – we all do, when we are empirically observing patients. We make generalities – and have them crash into impossibility. We learn absolute medical maxims, that fall to shreds on the care of the patient.
Freud’s mentor, Jean Martin Charcot, said something like this:
Theory is marvelous. Theory is wonderful. But no theory has been constructed that is powerful enough to cause facts to disappear.
THAT is a humble scientist.
The Patient Encounter
The terms “transference” and “countertransference” have fallen into disuse, which is really a shame. Freud postulated that the energy of change by a patient is driven by the feelings exchanged in the dynamic, and the fantasies – assumptions and generalities which are colored by previous experience – that the patient brings into the relationship, as does the physician.
Freud used to scrape down his proposed fantasies in the therapeutic dyad to the raw primitive origins, so many of his theories read like odd primitive litanies of childish sexuality. But the intermediate levels are just as valid as the most primitive imaginings of the patient’s mental processing.
These elements are everywhere in the humane medical encounter. Freud discovered that much of the substance of cure and healing comes from the medium of therapeutic encounter. Medium, yes, in the manner that McLuhan became famous for discussing.
It seems a strange echo of the Victorian days to see the discomfort with modern medicine’s postulates of physicians and patients having feelings for each other. Human feelings. It is not clearly stated, but physicians are not supposed to have hostile or uncompassionate feelings for patients, and for them to have intimate or warm feelings for the patient is unsavory, and likely actionable.
The patient, at least in America, enters with the tough veneer of the customer. There are discrete products that they wish – and the sales clerk will either comply or resist. The medical exchange has turned into a shop vendor’s counter, between strangers no less.
We live with the postulate that all patients are identical; the entirety of the future of American medicine is bet on the premise that the medical exchange is an algorithmic process, subject to refinement by quality loop elements. This fantasy – it is no more real that Freud’s postulated Oedipus fantasy – will doom medicine for many years.
The pretense goes beyond the idea that patients can be dissected into non-interacting compartments, to postulate that there is nothing to the nominal aggregate called “the patient.” There is nothing real beyond the complexity of neurobiochemistry.
This is simply false, when the subject is humans. It is foolish to try, and monstrous to gamble a society’s whole medical system on the postulate.
I have feelings for all my patients. Sometimes there is a bitter struggle that evolves into a working relationship; sometimes a soft and gentle milieu, only to be followed by the next patient, having a harsh and comical interaction; and others, mistrust and suspicion. The affective elements of the exchange are entirely worthy and commendable, in fact – they are part of the doctor’s “radar.” I have found them to be telling diagnostic elements far more sensitive than the numerical test. All that is necessary is that the feelings are based upon the patient’s transference, not driven by the doctor’s countertransference.
All sorts of rubbish is heaved about, complaining about the doctor’s complicity in narcotic prescribing to the addicted patient. Little attention is paid onto the patient’s expectations, and intolerance of primitive frustration when the physicians set guidelines. The patients often “bulldog” – a social interaction unknown in the clinic, but familiar to the prison. If a person holds the power to get you something, you dog them down until they deliver. Many physicians who prescribe narcotics have patients who bulldog and frighten them into obedience. And yet society prefers to blame the physician when intimidated. It is cowering before sociopaths – and that is never wise.
Blaming the doctor in this instance is no different than blaming the hanging victim for being lynched, or the woman for being raped. Yet, we turn towards the sociopath, and beat the victim. Why?
All you need is love…
Yes, that’s a pleasant song. But the question in medicine is, why does our society prefer to have medical encounters be impersonal, mistrustful and furtive, rather than stable, committed and pleasant? How does that mirror our culture?
Sadly, quite precisely. We have internet porn – but no couples’ support. We advertise that we are “pro life” – we are nothing of the sort. Many elements of healing are process, not products – but we ignore that, because products profit.
It is us that tolerates the collapse of the American medical system. Why?