When To Screen For Things Medical That Could Kill


One of the themes that keeps coming up in those little “newslets” for 15 minutes of Continuing Medical Education each is that systematic screening for several serious diseases, like cancers, is simply not as efficient as one wishes it were. At the very least, in terms of cost, it rarely pays. Sometimes people try to identify a subset of people who should be screened; but all too often, even that is a daunting task.

Some stalwart and doubtless realistic physicians sometimes suggest–screen patients who ask for it. This seems strikingly similar to the young doctor in Amiens who told me, that if he wanted to build a practice and feed his family, he had to give everyone antibiotics. It is that ancient trend of anti-intellectualism, patients who second-guess the doctor, people who are worried about their health– And yet, these people could argue that (they have paid their health insurance and earned what they think is good care), and they are individuals and not statistics.

The need of patients to be treated like humans is so primordial, so basic, that it is a source of constant complaint, among the wildly intelligent as well as among the intellectually challenged.  We want people to know what they are doing, of course.  But people are accepted as authorities on the flimsiest of pretenses.  Age? Experience?   Knowledge? With psychiatry, the establishment of authority is the most fragile of all. And with psychologists. When I was a resident in psychiatry, I felt there was a tremendous amount of clinical knowledge that I had to assimilate.  I did not just want to be an “also ran,” but rather to be the best.  Among the best, at least.  I mean, I had taken my training in faraway places but good places, solid places. It became very clear, very early on, that the clinical interaction, the interaction between doctor and patient, was something mystical and fragile. There was surely a sense of “calling,” of something sacred and wonderful.

I must have been very young indeed when my rabbi, Rabbi Rodwogin, the one who officiated at the synagogue where my father of blessed memory played the organ, told me that a girl could not be a rabbi, but a girl could be a doctor.  And taking care of the body was as sacred as taking care of the spirit and mind. I thought of that early conversation years later as a resident, when I was on one of my library binges at the University of Kansas. In the American Psychologist, a journal published in the fifties, I read a very elegant series of studies that convinced me that, in a psychotherapeutic relationship, the only real predictors of whether or not a patient would get well were how badly they wanted to get well, and how much they believed that the therapist could make them well. It was obvious.  If anyone was going to get better from me, I would have to instill confidence.

My verbal abilities have always been a strong suit.  The other residents, mostly male, were fairly jealous. I was happy when my supervising psychiatrist said in a residency meeting, “Estelle is proof that someone who is really different can be a really good psychiatrist.” Me, in Kansas in the 80’s, I looked out the clinic at a grain elevator and wondered what I had to do to make people believe I had been born in the shadow of one. People somehow believe that they are going to do better with a doctor who looks and sounds and maybe even believes what they do.

When I was in training, I actually heard reflections (from patients) about my Boston accent.  I was asked a lot about being female.  I had no dating life, but got looks of amazement from people (generally women) when I told them my main worry in life right then was getting through psychiatric training, and that I had not thought terribly much about dating or marriage. That was usually enough to get them back on track enough to discuss the subject at hand which was (after all) them. Later, when I was supervising residents–all of whom had at least a decent knowledge base, I saw what they brought to the trade, what they were becoming, and what they had to become. We women, although we were few, were empathic.  We felt sorry for the suffering humans who came to us to ease their pain.  My supervisor always liked my term for it, “sloshing empathy.”

Many of the women went through a period early in training (as I did, but initially had trouble admitting) of going home and crying over how horrible their patients’ lives are. We get over that period.  Experience hardens, at least a little.  What is harder to see is that this is a good thing, for the brain really does seem to work better when you can hold the emotions at bay.  I became clearer-thinking about how to deal with a woman whose husband beat her and whose son was in jail and who was losing the family farm, all at once. During this time, I formulated my plan of “how to locate and marry your lifetime love” for the most pessimistic reasons imaginable. To me, it was preventive medicine. I thought I was too emotionally fragile to continue to work if I ever had to go through a divorce. I wanted to marry “correctly,” the right person the first time. I did. And one of the most pleasant things I get to do in life is teach other people how to do it. (I’m currently updating this book and will announce its release soon).

The “externals,” the way you look physically, is an undisputable part of the first impression.  For a brief moment, I thought this would be easy, compared to all of the cerebral processes required to become a psychiatrist. “Transferrence” and “countertransferrence” are ancient and powerful concepts.  They date back to Sigmund Freud, father of us all. When two people sit alone in a room, there is a lot more going on than just two people sitting in a room. This is no less true of a doctor and a patient, no matter what the doctor’s specialty is. In “transferrence,” the patient brings to the doctor not just the memory, but also the feelings of all the similar relationships this person has had before. The same thing happens to a doctor, who gets in a room with a patient.

For me, I have a fairly easy and informal style with patients that sometimes surprise them. I really believe that this is because pretty much all of my family whom I have met and known in my lifetime either was a psychiatric patient or should have been.  I tend to treat folks like family, and they seem to like it, for I am generally pretty popular. I learned while I was back in Kansas that all I had to do was wear, for example (and most frequently) a pastel-colored suit, I did fine.  Sometimes people would actually tell me that I reminded them of their mother. When I got thinner, curiously enough, I seemed to remind them more of wives, sisters, or girlfriends, people whose authority they were far less likely to accept.

I struggled for authority a bit, before I figured out I could play up my (advancing, like everybody else’s) age, and get some authority out of that, becoming an even more powerful and authoritative mother for them. When the doctor has feelings toward patients, that is “countertransferrence.”  Me, deep down I feel you’ve got to give them that motherly “love” tempered with responsibility, as you just can’t count on anyone else to do it. There is more to it than that, of course.

After WWII, doctors sometimes went to “Balint” groups, to understand how their own personal prejudices affected their (superficially seeming) “objective” diagnoses and treatments. A society running that kind of groups still exists.  I know precious few doctors who have been through them. But the paradigm gives me a platform to reason from the most frequent complaint I hear about other doctors is that they seem distant and impersonal. They may be insecure, and not able to establish their authority in no other way than presenting themselves as purveyors of absolute truth. The medical research is a constantly changing fund of knowledge. At its best, if and when it is possible to scrape away at least a few of the layers of bias that surround what I still believe is an asymptotic approach to absolute truth. Part of the truth is that I cannot think of any field that necessitates, more than medicine, making decisions without any kind of clear-cut data to guide you most of the time.

Back to the original question, if a patient should get screening for an illness they request, just because they ask for it. Me, my answer is, not without the patient knowing whatever data is available, and participating in a cost-benefit analysis. Is the test difficult or painful?  Does the relevant illness have a marker?  How good is such marker?  How easy is it to find? How much does the test cost?  Will the patient’s insurance pay for it? The patient has to come first, so these factors must be seen and weighed. I am a lot less likely to ask what I think is the major question others ask. The question is, “Will I raise other folks, costs of insurance by ordering the test?”



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