User:Mepeeler/Doctor-patient role reversal

Jan Steen - Doctor's Visit

Definition

Doctor-patient role reversal is a theme seen in many medical works of literature, medical television shows, films, and art, as well as in real medical practices. It involves the physical and especially psychological process of the doctor figure transitioning, through events or circumstances, to a patient status, while the patient is simultaneously placed in the physician’s role. One or both of these transitions may take place in a single work, but they often occur simultaneously.

Once the “magic white coat” is gone, certain attributes taken for granted in the medical profession are stripped away, such as control, authority, and distance from death and illness.

Often in literature, or television and film, this role reversal leads to some sort of realization or cathartic experience for the doctor. Having experienced “both sides of the stethoscope,” they develop a double lens that allows them to better treat and understand their patients (Madison).

History

The historical origins of the roles of doctor and patient, although they range drastically around the world, share the similar pattern of the “sick” in need of a “carer.”

Doctor uses a stethoscope to examine a young patient

Small, isolated civilizations such as the Kalahari bush people had little need for specialized medical experts, and each member of society had the potential to be both a doctor and a patient. As human populations have grown and cross-cultural connections have increased, transmissible diseases from malaria and the Bubonic plague to AIDS and swine flu have followed. And as disease became more pressing, so did the need for a healer (Porter 30).

To fulfill the role of caretaker, a class of medicine-men has arisen in almost all human societies. Though they have incredibly different methodologies, belief systems, and practices, healers from traditional shamans to modern doctors serve their patients in order to facilitate healing (33). Modern doctors are separated from their patients by a wall of information. They use their knowledge of their patient’s symptoms and presentation as well as of human body in general in order to form a diagnosis and treatment. Their role is to cure and to care.

According to Roy Porter, the two major roles of the sick are either as the outcast who is isolated from society in order to protect its other members, or as the patient who is cared for like a child (31). Patient’s are, of course, independent beings and “any patient's response to illness depends upon nature, character, and “premorbid” personality, upon age and accomplishment,” meaning that each will present a unique case for his doctor (Spiro). In modern society, however, the vast majority of the sick have settled comfortably into the latter role, allowing the doctor to care for them.

A blurring of these well-defined roles occurs when doctors themselves become sick. When two medical doctors, Howard Spiro and Harvey Mandell, reflected on this ill-defined territory, they came to the conclusion that “When a doctor is sick, especially in a hospital, he or she undergoes a role reversal. Strangely, the doctor is the patient, and the familiar aspects of the hospital are unrecognizable from a stretcher. Loss of control is hardest of all for sick doctors, so used are they to the obedience of others;…Sick doctors are lonely patients, isolated but on watch, vigilant against error…It is not easy to be a doctor and a patient all at once.” These doctors are caught in between their two conflicting roles, unsure of which to occupy at any given moment (Spiro).

A major obstacle for physicians in the patient role often has to do with trusting their caretaker, a crucial part of all healthy physician-patient relationships. They often also fear vulnerability, and must wrestle with the additional complexity that is introduced to a relationship when colleagues treat colleagues (Beecher).

Generally, doctors have difficulty accepting the patient role for themselves and fail to follow recommendations and guidelines for care they would normally advocate for their own patients. This leads to safety risks for the physicians, especially the development of cognitive disorders such as feelings of isolation, depression, or guilt (Spiro).

Examples in Literature, Television, and Film

Regeneration

IIn Booker Prize Winner Pat Barker’s novel Regeneration, Dr. W.H.R. Rivers is the practicing psychiatrist at Craiglockhart War Hospital. Although he is endlessly caring and devoted to his patients, stress from causing them to painfully relive their war experiences in order to heal begins to take a physical toll on Rivers: “He pulled down his right lid to reveal a dingy and blood-shot white. What am I supposed to do with this gob-stopper? He released the lid. No need to think about that. If he went on feeling like this, he’d have to see Bryce and arrange to take some leave” (Barker 106). Here we see the first sign of physical sickness and fatigue: his blood-shot eye. But instead taking immediate action to treat it, as we would do to a patient, he dismisses it ignores it telling himself, “No need to think about that.” Denial and lower standards of care typical of doctors treating or diagnosing themselves when ill is apparent in the way Rivers disregards his clear physical symptoms of illness.

After one particularly busy day, Rivers awakes with chest pain. “At first he tried to convince himself it was indigestion, but the leaping and pounding of his heart soon suggested other, more worrying possibilities . . . He was getting all the familiar symptoms. Sweating, a constant need to urinate, breathlessness, the sense of blood not flowing but squeezing through veins. The slightest movement caused his heart to pound” (139).

In the morning, Dr. Bryce, Rivers’ colleague at Craiglockhart, arrives to examine Rivers. The following passage shows the complex exchange caused by Rivers doctor-patient role reversal, as colleague treats colleague:

[Bryce] produced a stethoscope, and told Rivers to take his pyjamas jacket off. The stethoscope moved across his chest. He sat up, leant forward and felt the same procession of cold rings across his back.
     ‘What do you think’s wrong?’ Byrce asked, putting the stethoscope away.
‘War neurosis,’ Rivers said promptly. ‘I already stammer and I’m starting to twitch.’
     Bryce waited for Rivers to settle back against the pillows. ‘I suppose we’ve all got one of those. Your heartbeat’s irregular.
‘Psychosomatic.’
     ‘And, as we keep telling the patients, psychosomatic symptoms are REAL. I think you should take some leave.’
Rivers shook his head. ‘No, I –‘
     ‘That wasn’t a suggestion.”

Rivers plays both the patient in being examined and the doctor in diagnosing himself. Yet he tries to refuse the recommendations necessary debilitating symptoms, certainly out of fear of neglecting his patients, but perhaps out of fear of vulnerability as well.

"Perspective Shift"

In his short essay “Perspective Shift” Daniel Shapiro’s narrator provides a first person description of a young man in obvious distress because of the cancerous chest scans displayed in front of the two of them. The man paces, frustrated by the uncertainty of the journey to come. Shapiro’s unnamed narrator regards him calmly, noticing his almost frantic helplessness and remarking, “I have seen this clinical presentation a thousand times.”

The reader follows the seemingly short and simplistic story easily until the final lines. What had seemed to be a scene of a doctor witnessing a young patient’s unraveling in the face of a potentially terminal diagnosis is completely turned on its head. The narrator clarifies the situation in his last thought, “He is my young doctor and that is my tumor taunting us from the scan.” The roles which had seemed so clear through the story were reversed. The calm, levelheaded, and in-control narrator whom the reader had assumed to be the doctor was in fact the patient. And more strikingly, the nervous and stressed young man whom the narrator almost seems to pity in his naiveté is in fact his doctor, reduced from a caretaking role to one in which his own patient seeks to comfort him. This shocking truth of the scene, revealed to the reader at the end, epitomizes the way doctor-patient role reversal occurs not only in great works of literature as a carefully planned theme, but in real life, in real medical practices.

Frankenstein

Frankenstein engraved

In Mary Wollstonecraft Shelley’s Gothic classic Frankenstein, Dr. Victor Frankenstein undergoes this same shift. He starts out the novel as a brilliant, young student of science at the University of Ingolstadt, fervently seeking the secret of life. When he finally gains this knowledge, he begins work on his “creation” with even more zeal. After months of tedious work, the creature comes to life. But instead of success and gratification, Victor feels only horror and shame at what he has made. Although the monster disappears, Victor’s distress causes him to fall into a feverish illness. This marks the beginning of his transformation from a confident scientist to the ill patient role: he loses control over his “patient,” and the anguish from the feeling of powerlessness to reverse his deed causes him physical illness.

Later, when the monster kills Victor’s closest friend Clerval, this transformation is drastically seen. Upon the sight of Clerval’s dead body, Victor narrates, “The human frame could no longer support the agonies that I endured, and I was carried out of the room in strong convulsions. Fever succeeded to this. I lay for two months on the point of death; my ravings, as I afterwards heard, were frightful” (Shelley 121). No longer able to maintain the godlike control he had once had over his surroundings, Victor is broken. He cannot successfully manage the role of patient.

House, M.D.

Dr. Gregory House is at once both a doctor (a brilliant diagnostician at Princeton-Plainsboro Teaching Hospital) and a patient who suffers from chronic pain in his leg due to a muscle infarction. House makes his living by treating seemingly incurable patients, but it is often mentioned on the show that his is the only case, which he is completely unable to solve. House is addicted to pain medicines, most notably Vicodin, and over the course of the series, goes in and out of rehab centers and even a psychiatric hospital. The show investigates the dynamic of doctor as patient frequently, but arguably best in the penultimate episode of Season 4.

In the Emmy Award winning episode of House, M.D. titled “House’s Head,” the titular Gregory House suffers serious head trauma and amnesia in a bus crash. Over the course of the episode, which aired on May 12, 2008, House works with his team to regain his memory and piece together the events preceding the accident, including who his fellow passengers had been. The brilliant doctor spends much of the episode in the unfamiliar role of patient as his colleagues try unsuccessfully to treat his injuries with rest. He is taken into the Emergency room of the Princeton-Plainsboro hospital where he works. While his fellow doctors diagnose him with “edema and localized swelling in the section of the temporal lobe that controls short-term memory,” House rejects their medical advice in favor of his own, more radical treatment options.

Throughout the episode, House his plagued by an unshakeable feeling that he saw a symptom in one of his fellow passengers, which signaled a fatal disease. He agonizes that “someone is dying because I can’t remember.” Even as his greatest medical asset—his brain—is crippled by amnesia, House refuses to leave his position of diagnostician. When his role is forcibly changed to that of patient, House cannot accept his own body’s weakness. In search of his memory, he pushes himself past his limit, taking Alzheimer’s drugs until he can reenact the accident but almost at the cost of his life. His fellow doctors resuscitate him when he goes into cardiac arrest. House proves time and time again in the episode that he is willing to risk anything, including his life, in order to gain a diagnosis. While becoming a patient, he refuses to stop being a doctor and the conflict between his two roles almost breaks him.

External Links

"When Doctors Get Sick"

"Role Reversal" Minnesota Physician-Patient Alliance

"Role Reversal: When Doctors Become Patients" Edelstein

"'Doctoring' Doctors"

---

References

Barker, Pat. Regeneration. New York: Penguin Books USA, Inc., 1993.

Beecher MD, Lee. “Role Reversal: When the doctor becomes a patient.” Minnesota Physician-Patient Alliance. 2001. Minnesota Physician-Patient Alliance, Inc. 9 Dec 2011. http://physician-patient.org/pages/role-reversal-when-the-doctor-becomes-a-patient/

Egan, Doris. "House's Head." House, M.D. FOX. 12 May 2008. Television. House Pills - House M.D. Photo. Photograph. Fanpop. Web. 6 Dec. 2011. http://www.fanpop.com/spots/house-md/images/522056/title/house-pills-photo.

Madison, Cathy. “Role Reversal.” Minnesota Medicine. April 2009. Minnesota Medical Association. 9 Dec 2011. http://www.minnesotamedicine.com/PastIssues/PastIssues2009/April2009/CoverStoryApril2009.aspx

Porter, Roy. "The Roots of Medicine." The Greatest Benefit to Mankind. New York: W.W. Norton, 1997. 14-43. Print.

Shapiro, Daniel. "Perspective Shift." The Social Medicine Reader. Ed. Nancy M. P. King. 2nd ed. Vol. 1. Durham: Duke UP, 2005. 143-44. Print.

Shelley, Mary Wollstonecraft. Frankenstein. Rockville: Phoenix Pick, 2009.

Spiro, Howard M., and Harvey N. Mandell. "When Doctors Get Sick." Annals of Internal Medicine. American College of Physicians, 2004. Web. 9 Dec. 2011.

---