The Gaze

Preface: this post is not meant to answers any questions, only to pose them. One of the benefits of the Asheville program is the "extra" curriculum outside of the hospital and the clinic. This includes monthly meetings to discuss ethics. Here, we can draw on experiences and talk about some of the dilemmas we've wrestled with within ourselves, or issues we've seen our patients face. This is a safe environment where we can feel at ease and discuss these quandaries without faculty (only our ethics sensei joins our group of eight). We also meet with faculty and course directors each month at the Chocolate Lounge to indulge in a glass of wine or coffee and discuss some of the finer aspects of medicine. We can talk frankly with established physicians, and discover their perspectives on the parts of our science that are not so black and white.

Our last conversation evolved into how we, as physicians, talk about our patients. Not about how a doctor should talk to a patient, but about how a doctor talks about a patient when the patient isn't listening. Where are the boundaries? The bottom line is, "is it right that a physician's behavior changes when a patient or medical student is not in earshot?" Physicians are asked to perform a highly stressful job for incredibly long hours. Stress can be brought on by dealing with matters of life and death every single day. The seriousness of these situations necessitates coping mechanisms. So, is it okay to get on the phone and vent with one of your colleagues about a difficult patient in a perhaps less than cordial way? Or, to make light of a frustrating situation, so you can go back to work the next day and envelop yourself in the gravity of the day to day? If you are a model of patient care and integrity when you are aware of the "gaze" of society (http://en.wikipedia.org/wiki/Gaze), does it matter what you say behind a patient's back in the security of rounds, or in your own car/home/place of business? Is there a place for this type of coping in the hospital itself?

For a budding third year, filled with altruism and excitement, I haven't yet felt the strong need to "cope." I haven't had to deal with years of frustrating patients (and don't forget the wonderful ones, too!), so I can't comment with any real expertise. What will be my answers to these questions 15 years from now? Will I be jaded by long hours and deep frustrations? Or, will I be able to answer honestly from a view outside the box? I can see both sides of the coin though. How does one deal with a patient who is obese, diabetic, has cardiovascular disease, hypertension, etc. and will not take care of himself or herself even though the patient has the time and money? How does one cope with an 18 year old on her fourth child who refuses birth control? In the clinic, the answer is easy: you are professional, you are at your best, you do what is best for the patient. But when your patients leave the clinic and you realize they haven't left your psyche, what then?

I've seen it in EMS, and again here in the hospital. After a 600 pound patient requires an "Orca Lift" and needs eight firefighters to be extracted from a house and put on a stretcher, the race is on for jokes post call. Or, a man in the hospital is so overweight that the trocars cannot penetrate the abdomen because of so much excess tissue. Comments will be made, but when and where? And by whom? Weight isn't the only example, but it certainly seems to be a common topic for jest. Ask anyone who knows me; I try to employ a large amount of humor in everything that I do. There are few situations in life of which I don't make light. But, these situations beg the question: as long as your patient care is done in a professional manner, does the rest matter? Where are the boundaries?

Aren't the eyes and ears of the patient the most important? An interesting comment was made during our discussion about how often the attendings and residents tone down their comments when a medical student is present. Aware of our gaze, they don't want us to lose our sense of idealism. I ask myself the obvious question: if the language changes because of the presence of a patient or med student, is that language appropriate at all? My first instinct is to say "no," but that is certainly hypocritical. There are plenty of jokes that my inner circle of friends find humorous, but which I would never make to a stranger. Knowing my best friend's true beliefs allows for leniency for our more crude jokes. Since these aren't about patients are they okay? The same being equal, I would think not. Or, is it that the business of medicine is just too serious to joke about? I continue to struggle with this gray area.

As stated earlier, I don't have any answers at this point. I can only be aware of my own gaze. I am not so naive to think I will never participate in the comfort of patient banter, but hopefully I will continue to be aware of my words and their context. Just something to think about.


As you can see, each question begets more questions. My questions started with our ethics discussion, and I looked at the Ring of Gyges as a thought experiment: http://en.wikipedia.org/wiki/Ring_of_Gyges.