Professional boundaries

A few days ago, a visitor raised the question of how our doctors know us -- whether as people, or as patients. This is one of the most important ideas in sociology, sometimes labeled with the German words gesselschaft and gemeinschaft (essentially, society and community), because it was discussed early on by the German pioneer Max Weber. In villages, everybody knows everybody else as whole persons; we have our specific relationships with relatives and friends, of course, but we are able to see each other in full context.

In a modern, complex society, most of the people we interact with are not whole persons to us. We just slot together specific role relationships with them: teacher/student, customer/store clerk, speeder/state trooper, boss/subordinate, etc., and of course, doctor/patient. Given time, fortune and personal compatibility, some of these relationships may broaden out and become more "whole," but the vast majority of them never do.

Many people wish that their doctors could be like Marcus Welby: a neighbor and friend. But usually, nowadays, this is not possible. As a basic practical matter, doctors have thousands of patients; they cannot know them all intimately. In defense of their own sanity, doctors cannot be personal friends of their patients because the emotional burden would be unendurable, as would the ethical dilemmas and the conflicts of interest. Learning to compartmentalize, to distance oneself from the burden of suffering and dying patients, is an essential part of becoming a doctor. There just isn't any other way to do the job.

On the other hand, we have needs for reassurance, emotional support and sensitivity from our physicians. And we need for them to understand us, in some ways at least, as people. Our illnesses -- our lived experience of the malfunctioning of our bodies and psyches -- are not the same as our diseases -- the biological processes that doctors are trained to understand and influence. Diagnosing and fixing diseases often goes awry because of failure to understand what they mean as illnesses, and why and how they arise in our lives. Eliott Mishler, in The Discourse of Medicine, Howard Waitzkin in The Second Sickness, Alexandra Dundas Todd in Intimate Adversaries, have all shown, in different ways and from different perspectives, how cure fails when healing is absent.

A great struggle is underway within the medical institution nowadays to understand what kind of relationships between doctor and patient are most effective for diagnosis, cure and healing; what kinds of people make good doctors; and how to train doctors to at least act more like those kinds of people, even if they can't really be them. How should doctors and patients know each other, listen to each other, feel about each other? Where should the boundaries be drawn, and how much of each of us should be brought inside those boundaries?