Posts Tagged 'läkarblogg'

A Doctor By Any Other Name?

(A reflection for Doctors’ Day)

I am used to being called a “medical provider” instead of a doctor or a physician these days, but it makes me think about the implications of our choices of words. The word “provider” was first used in non-medical contexts over 500 years ago. It is derived from the Latin providere, which means look ahead, prepare, supply.

“Medical provider” is part of the Newspeak of America’s industrialized medical machine. It implies, as Hartzband and Groopman wrote in The New England Journal of Medicine, that:

“…care is fundamentally a prepackaged commodity on a shelf that is “provided” to the “consumer,” rather than something personalized and dynamic, crafted by skilled professionals and tailored to the individual patient”.

The 800-year-old word “doctor” is Latin for Church father, teacher, adviser and scholar. It infers more closely the Hippocratic and Oslerian ideal of what a physician should be like. “Doctor” is used as a title for physicians in many languages, even if other words – like physician – are used to describe the professional role of a medical doctor.

Those other words are often less than flattering in their derivation or usage. Physician, for example, comes from physic, the Latin word for natural science and art of healing, which is noble enough. Less noble is the use of the word physic for a laxative due to the common practice of purging by physicians of the past.

In Medieval times, both physicians and their commonly used blood-sucking worms were called leeches. The Middle English word leche has lived on in many languages’ words for doctors: Läkare (Swedish), læge (Danish) and lääkärit (Finnish). These words are similar to the Indo-European lepagi. It means talk, whisper and incantation and is thought by some to be the true origin of the Scandinavian words for physician.

The Russian word for physician, врач (pronounced vratch), is uncannily similar to врать, which means talk nonsense or lie, and ворчать, mutter. These similarities also harken back to ancient and mysterious rituals of physicians of the past.

The German Arzt is perhaps the most flattering of the words I know for physician; it is derived from the Late Latin word archiater (Chief physician or physician to the Court) and the Greek arch-iatros, where iatros is the familiar word for physician we use in “iatrogenic”.

Personally, if someone asks what I do, I answer “I’m a doctor”, but I never insist on what people should call me.

The language, as it changes, may accurately reflect one very powerful view of what medicine is, but neither the words nor the business model can change what patients need when they are ill or frightened. They need more than generic providers; they each need a human being with knowledge, wisdom and compassion.

Ultimately, whether others call us physicians or medical providers, it is still up to us to define our professionalism and to defend our personal standards. These things are neither generic among providers nor, as some are hinting these days, almost replaceable by technology or treatment protocols.

Star Trek’s fictional United Federation of Planets Starfleet did have a technologic replacement for their flesh-and-blood ships doctors, still nick-named “The Doctor”; installed in most Starfleet ships’ sick-bay was an Emergency Medical Hologram, EMH for short. When its transmitter was activated, it mechanically said: “Please state the nature of the medical emergency”. The EMH eventually evolved into a sort of sentient being, but it is unclear to me how patients really felt about this contraption.

What, then, is a physician? A sixty-year-old answer still says it well:

“The value of the physician is derived far more from what may be called his general qualities than from his special knowledge. A sound knowledge of the aetiology, pathology, and natural history of the commoner diseases is a necessary attribute of any competent clinician. But such qualities as good judgement, the ability to see the patient as a whole, the ability to see all aspects of a problem in the right perspective, and the ability to weigh up evidence are far more important than the detailed knowledge of some rare syndrome, or even the possession of an excellent memory and a profound desire for learning”

Dr John W. Todd, The Lancet, 1951

Physician, Heal Thyself!

Dr. Barbara Brennan practiced Family Medicine in a nearby town for a decade. She was busier than most of her colleagues. Her patients adored her and she had earned a solid reputation as a crackerjack diagnostician. She worked long hours at the clinic and she ran a tight ship at home, managing a large household and even found time to be active in her community. She would be up at five to get everyone in her house on their way, and when she arrived at her office at eight, she always looked beautifully put together and on top of the world.

She never seemed hurried or harried. People wondered how she did it. Her husband, also a physician, admired his wife both as a woman and as a colleague. He had more years behind him as a doctor than she, but he often found himself asking for her medical opinion.

Dr. Brennan had many patients who appreciated her razor sharp diagnostic skills. She diagnosed a pheochromocytoma, a case of fallopian tube cancer, and several other rare medical conditions. She was also well known for her psychiatry skills. In rural America, primary care physicians deliver the majority of psychiatric care. Barbara Brennan moved comfortably between crisis intervention, brief psychotherapy, antidepressants, mood stabilizers and ADHD prescriptions.

There were two kinds of clinical problems she avoided. She didn’t enjoy doing the minor surgical procedures some primary care doctors see as bright spots in their day, and she didn’t enjoy treating fibromyalgia and Chronic Fatigue Syndrome. Suffering from some arthritis herself, she found it draining to work with patients she thought sometimes dwelled too much on their symptoms. It saddened her to see fibromyalgia patients focused on what they couldn’t do, instead of making the most of their physical abilities.

One Friday morning, at the end of an unusually busy week that even Dr. Barbara Brennan thought would never end, she noticed a strange tingling sensation over her right eye. As the day progressed, the tingling turned into a burning pain down most of the right side of her face. She became nauseous and developed a migraine. She had worked in spite of having migraines before and steeled herself to make it through the day. A slight dizziness set in, and she had trouble concentrating.

Finally home, she put dinner on the table, but didn’t eat anything herself. She looked in the mirror for a rash on her face. She asked her husband to double check closely for her. By eight o’clock she went to bed, exhausted and with a throbbing migraine.

Saturday morning her shingles rash was there, subtle at first. Her husband confirmed it and called the pharmacy with a prescription. Her headache was still there and she was still nauseous and lightheaded. She had to move slowly to avoid vertigo and she noticed it took her longer to find words, even to figure things out. As a physician, she knew she must have developed a touch of encephalitis – brain inflammation.

She expected to be out of work for a week, but complications set in. She broke out in hives from the antiviral medication and had to stop taking it after only three days of treatment. Without the medication the shingles flared up again and she became profoundly tired. Over the next few weeks she developed joint pains and muscle aches. She got a sore throat. She felt as if her mind and body moved in slow motion. All she accomplished was to get everybody off in the morning, and by the time she got the dishwasher loaded it was already almost noon. She didn’t take naps, she didn’t even sit down much – it literally took her so much longer to do the simplest things.

She cried in frustration: “What’s wrong with me?”

Her husband looked into her eyes, the right one still framed by the slight scars left by the shingles, embraced her and said what she knew but didn’t want to believe: “You have a post-viral syndrome, maybe early Chronic Fatigue Syndrome”.

Months have passed and Dr. Brennan has not returned to work. She is convinced that she has CFS. She didn’t like it in her patients and she is fighting to beat it in her own case. She now knows first hand how real and devastating this condition can be. She is learning to listen to her body, always doing as much as she can, pushing ahead just a little, so that eventually she can get her stamina and her health back. Sometimes when she pushes herself too hard the sore throat, body aches and tingling over her right eye remind her to slow down again. 

I asked Barbara the other day if she would ever resume her practice. Her answer was: “I can’t afford to ignore my own health. In that job, and at that pace, I did just that.”

Dr. Brennan is living by her own advice – Physician, Heal Thyself!

(Here’s to you, Barbara! With respect and best wishes…)


Osler said “Listen to your patient, he is telling you the diagnosis”. Duvefelt says “Listen to your patient, he is telling you what kind of doctor he needs you to be”.

BOOKS BY HANS DUVEFELT, MD

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