Books

'Doctor' and the Business End of Things

Andrew Bomback explores ways in which "the healing art" and the connection between doctor and patient is understood in contemporary western culture.

Doctor (Object Lessons)
Andrew Bomback

Bloomsbury Academic

Sep 2018

Other

Everything most of us civilians probably think about healing or the general act of solving medical problems is likely to exist only in the context of dire circumstances. We understand doctors and the act of doctoring when there is no other option. We tell symptoms to our phones and get immediate results but they mean nothing if they're not the result of human connection. We impose superhuman qualities to those who diagnose the need for tonsillectomies or schedule open heart surgery. We settle for lollipops to dry our tears and words of comfort to guide us through life without loved ones suddenly lost on the operating table. Doctor is a decisive verb and an omnipotent noun yet somehow still a mythical figure that's hard to understand if we can't get beyond the fear of familiarity with such a being.

Early in his sweetly composed contribution to Bloomsbury Academic's Object Lessons series, which is as much a tribute to the legacy of his pediatrician father as it is an examination of the healing arts, Andrew Bomback's Doctor surrenders to the artistry of his profession, the teaching element. The doctor is an artist and also -- as from the Latin docere -- a teacher:

"A doctor is expected to teach… my job is primarily to talk… to patients… families… other doctors… nurses and secretaries…Sometime I write…"

Bomback notes that the ideal of modern medicine seems to be failing the ideal that the job should be more of a "communicator than a healer". Of course, what we know about healing and how we assess it here is purely from a Western medicine perspective. The brief format of the Object Lessons series restricts examining universal perspectives of medicine, and that limited perspective makes this a purely "American"-themed book. Nevertheless, Bomback works well within a relatively brief structure. Doctor is about father as much as it's about doctoring, and the image of his father is striking:

"…my father's obituary will mention his doctoring in the first sentence… The obituary won't mention his stutter…"

Bomback contrasts the struggle his father has always had verbally connecting to patients with the smooth presentation skills of TV doctors George Clooney of E.R. and Patrick Dempsey of Gray's Anatomy never had to stumble through a consonant block while speaking with patients. He notes: "The modern doctor 'talks' with computer notes. We don't have time for thirty-minute discussions." The older generation of doctors don't adjust, or won't adjust, and time marches on.

How are we as patients evaluated by doctors? Bomback notes:

"There's a major disconnect between what patients expect of their doctors and what doctors are actually able to do."

He relates the brutal January 2015 story of a Boston doctor (Michael Davidson) who as murdered by a man frustrated with the American Health Care system. Bomback didn't seek out these stories but rather absorbed the stories on Facebook. Bomback names Davidson's murderer (Stephen Pasceri) and rather than somehow relate an understanding of the frustration (not condoning the murder) he realizes that after seeing the surveillance photos he will "…hate the entitled look on his face. It's a look of someone who thinks he knows more about medicine than the doctor he murdered."

Bomback best emphasizes his point by relating his experiences as the father of a patient. All patients might not be doctors, but all doctors are patients. Bomback and his wife Xenia are forced to deliver their child Mateo in the triage area since all 15 labor and delivery beds are filled. Bomback concludes that Doctor Peralta, who makes this decision, does so because she knows he and his wife are both doctors. It's a family of doctors from a family of doctors. Bomback waxes poetic about how he and his wife would perceive the miraculous role this doctor played in their lives:

"Later, we'd talk about Dr. Peralta as if she were a superhero, about how she swooped in at the last moment, took care of everything, and vanished…"

It's a human reaction he has to the accomplishments of a fellow doctor, one based on emotions rather than pragmatism. He sees Dr. Peralta a few weeks later, overhears her trivial discussion about an awful first date, and suddenly he's disappointed:

"I didn't want to hear this conversation. I was being unfair to her… I wanted her to be a superhero, and she just wanted to be another person in the elevator."

Humor plays a role in the life and function of a doctor. Most of us know the common comic tropes where the doctor tells a patient of good news and bad news, or the patient receives a diagnosis and then asks for a second opinion. Bomback offers that the portrayal of doctors in popular culture had always seemed uncomfortable. In such programs as Seinfeld and Curb Your Enthusiasm, their "…misanthropy somehow stood out among all other misanthropy on display." Doctors are easy targets of humor and sometimes derision. They tell jokes about their patients, communicate in code with acronyms like "GOMER" (Get out of my emergency room), but patients keep doctors on pedestals. "Patients laugh uncomfortably at these jokes," Bomback writes. "Their health isn't funny."

One of the more interesting keys to Doctor surfaces in the chapter on slogans, which Bomback notes are the opposite of doctor jokes. Slogans are the advertising taglines, plastered on billboards or in magazine advertisements, messages intended to support and comfort and reassure even in the cold light of reality. They're less euphemistic so much as trite at their worst ("We're trying our best") and necessarily numbing at their best ("I know it's hard"). The absolute worst phrases, like "exceptional care, exceptional people" or "exceptional technology, extraordinary care", put the emphasis on sales rather than healing.

Much of the flow Bomback creates in Doctor relates to the way he communicates with his family and his patients. He notes that where once he was tired of hearing about the legacy of his father's life as a pediatrician, now he feels nothing but pride. That pride in family tradition comes with complications, however. Deeper, though, is the fact that there will always be a necessary barrier between professional relationships and emotional intimacy between doctor and patient:

"Sometimes we're lucky enough to have something resembling intimacy with our patients… private world… Sometimes I have to force the intimacy…"

He notes that using the lower register of his voice is necessary when he wants his patients to understand the gravity of his information. He most appreciates the young patients with positive outlooks. With them, the reader imagines, there's no distance that needs shortening, no gaps that need filling. No matter how smoothly those relationships go, Bomback properly concludes that the distance between patient and doctor will never go away.

The idea of concierge medicine, in which the extent of the patient's bank account can dictate their ability to keep a doctor on personal retainer, available on an as-needed basis, reminds Bomback of his father. The family doctor from an era half a century ago, usually based in a rural or small-town environment, was an all-purpose paternal (or maternal) figure. The greatest pediatrician was a concierge doctor before that term came into common lexicon for those with disposable income.

"Doctors can talk themselves into or out of pretty much anything," Bomback notes in the middle of this book. He sees his father as the "…Willie Mays of pediatrics…" That said, the question surfaces as to when a doctor should retire. Of the older doctors from his father's generation, still in service when the business has been greatly given over to syndicates and corporations and much younger practitioners, Bomback sees it clearly: "I think they are working because they are afraid of a time when they won't be doctors."

Is medicine the healing art? Are doctors practitioners capable of seemingly magical acts that many millennia ago would have had them hanged as witches? Doctor wisely doesn't cover such notions. Instead, Bomback makes it clear that medicine is a business. It's that simple. He had romanticized the idea and role of the country doctor, but the field in which he and his fellow practitioners operate (notice that they will never stop being practitioners) is one that depends on billable hours. Deeper texts have been written about the understandable conflict between the practical need to make money and the idealized desire to heal. Bomback knows this, so the stronger passages in Doctor exist within his discussion of words.

"Patients hang on their doctor's words. A patient asked me if she was cured…' Everything you say,' another patient said, 'is important to me…'"

It's a heavy burden for any profession to carry. More so than most religious leaders, whose promise to their followers is based on blind faith and allegiance to moral precepts, words from a doctor are expected to be heavy and absolute. Bomback holds words to high standards while also understanding that doctors will also provide placebos. He discusses "harp lies". The idea here is that if you tell somebody you are a great pianist or singer, it can be easy for me to make you prove it. If you tell me you are a great harp player, it might be be more difficult to prove. Doctors provide verbal placebos. They will "kiss a boo-boo", if you will, to make it better. They will pat a head and rub a tummy and speak in a soothing tone that gives the appearance of security but underneath still contains a grim prognosis that needs to be addressed. Consider this passage from a chapter dealing with "History and the physical"

"The patients will tell you what's wrong with them if you just pay attention to the stories they are telling."

This seems to be the key to Doctor, and the basic truth that the medical field understands but doesn't always apply. Here, as in most of the other small chapters, it would have been nice to get deeper elaboration, more case studies. Doctors hear their patients speak, but are they listening? Sometimes true understanding of a patient's oral history has to come through literal tools of the trade. Bomback notes that stethescopes are often perceived as magical tools through which truth is absorbed. Claudia Rankine might have written "a truce with the patience of a stethoscope" in Citizen: An American Lyric, but the key image comes from Bomback's daughter Juno, whom he sees as a patient doctor wielding her toy stethoscope:

"'I can hear it,' she says with a smile, her hand cupping our neighbor's chest. 'I can hear your heart,' she whispers to her friend, as if they've both shared a magical experience."

Bomback covers a lot of territory in this small volume, and it can be frustrating to reads this and hope for a consistent through line. There's the presence of his father, the connection with his doctor wife, and the precarious existence doctors sometimes find themselves in while they are patients. Again, the volume would have been enriched had Bomback provided a brief discussion of different cultural perceptions of doctor (noun) and doctor (verb.) While Doctor doesn't resonate or linger in the mind like most of the usually wonderful additions to the Object Lessons series, and Bomback's prose is not as emotionally powerful and poetic as other Doctor-writers (Sherwin Nuland, Oliver Sacks, Robert Coles, among many others), it's a quick and understandable read that offers doorways to many other avenues worthy of deeper exploration.

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