"I saw the Whale in clinic this week. Her incision looks great!"
Thus spoke a surgeon to a wide-eyed medical student here at Harvard who related the comment to her peers (and me) in a group discussion about professional development. The Whale's condition was morbid obesity, and her incision was from weight-loss surgery.
The student was appalled at her mentor's seeming callousness, and so were others, who eagerly shared similar experiences. They allowed that this kind of battlefield humor (out of patients' earshot, of course) was a way of dealing with stress. But they were astonished at the pervasiveness of such language and the apparent relish with which even senior physicians participated.
One student demurred: he noticed that these same patients felt they were getting excellent care. What difference did it make how doctors talked about them in private?
It reminded me of a moment in my own training, when a patrician psychiatrist of the old school — much beloved by his patients — was told by a nurse that an elderly hospitalized patient wanted to speak with him. "What does that old cow want now?" he replied. We laughed nervously, a bit shocked but reassured that at least the old cow loved her doctor, who gave her excellent care.
But there is a slippery slope here. If we can make backstage fun of obese and elderly patients, should we feel free to do the same about those whose behavior — as opposed to appearance — is unsettling or off-putting?
Volatile, melodramatic, angry, manipulative, unpredictable, untruthful — such patients strike dread into their caregivers, who hope for their earliest possible discharge. They are sand in the gears of the clinical machine, and psychiatrists like me are often called to prevent (or, worse, mop up) the havoc they can create in the hospital.
Out of their hearing, these difficult patients are typically called borderlines, narcissists or sociopaths, whether or not such descriptions are really accurate. There seems little or nothing to like about them. While a "whale" can still elicit sympathy at the bedside, the borderline or sociopath elicits anger, anxiety and fear.
There is no doubt that such patients present a huge challenge. But surely we are not making it any easier for ourselves by referring to them as "raging borderlines" or "malignant narcissists." I submit that when we do, they become the "other"; their humanity is obscured by their psychopathology.
Consider an emotionally volatile patient whom the doctors pigeonhole as borderline. Curiosity about her behavior vanishes, replaced by a pseudo-certainty about "how to handle" her. Clinicians assume that all borderlines cut themselves and "split" others (that is, pit one caregiver against another), that they violate established boundaries and need firm limits.
But this is more a composite caricature than a real person, a patient who obediently lives up to the very low expectations held by her caregivers. The defiant or untrustworthy patient — the alleged sociopath — suffers a similar fate. Everyone "knows" that sociopaths are liars and manipulators, cannot be trusted and need to be treated with an iron fist. The fact that lying and manipulating exist on a continuum of severity and can at least have semiproductive uses (Congress, are you listening?) is obscured by moral outrage.
And so the doctor's determination not to lose a contest of wills undermines the opportunity to have successful discussions about treatment. The patient instantly senses that the doctor distrusts and dislikes him, and this, coupled with the patient's lack of respect toward authority figures, leads to a rapidly deteriorating situation, often ending in a discharge against medical advice — much to the team's relief.
Of course it is possible to chuckle about "whales" and "cows" in private and still be respectful at the bedside. But in stereotyping obese or elderly patients, we may be diminishing them in the same way we diminish (or dismiss) the alleged borderlines and sociopaths.
