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Paul U Unschuld
DISSECTING ROOM
LIFELINE Paul U Unschuld Paul U Unschuld began his academic career at Johns Hopkins before moving to Munich University. His research focuses on the history of Chinese medicine, policy issues associated with alternative health care, and crosscultural bioethics. He is currently completeing a 10-year project of an annotated translation and analysis of the Yellow Emperor’s Classic: Basic Questions, a 2000-year old Chinese medical corpus. What would be your advice to a newly qualified doctor? Now that you have fulfilled the requirements defined by your peers, examine the expectations of your patients. What alternative therapies have you tried? Did they work? On a very bumpy flight, when my neighbour was about to soil my dark suit, I remembered a Chinese technique to mitigate his nausea; my suit was saved. What is your favourite film? Only Angels Have Wings (John Ford, 1939) with Rita Hayworth and Cary Grant. Suspense, technology of the time, and a broad range of feelings without recourse to excessive violence and obscenities. What are you currently reading? Karl Jaspers, The Physician in the Age of Technology. A delightful reencounter with this defender of rationality in medicine. What do you think is the greatest political danger to the medical profession? An increasing dependence on knowledge, technology, and values generated by others than the medical profession itself. If you had not entered your current profession, what would you have liked to do? Originally, I had studied Russian and Chinese to be a Foreign Service specialist on sino-soviet relations. Have you ever broken one of the ten commandments? I was quite young when I realised that my family-name (which means innocence) is a label inadequately describing the labelled. What part of your work gives you the most pleasure? The moment when accumulating data on a specific issue is followed by an understanding of their meaning.
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Caring for the sick he trouble with you doctors”, said the crystal healer, “is that you’re not taught to protect yourself. Working in hospitals with all those spirits, all that disease, you take on negative energies, and they take your energy. No wonder so many of you are losing the plot . . .” Not the sort of language that I am used to, but she was right. Psychologists call it transference, and in his screenplay for Bringing out the Dead (see Lancet 2000; 355: 1293), Paul Schrader invokes ghosts as a concept to explain those hidden elements of clinical encounters that stick to, and can haunt, medical professionals. Whatever the lexicon, the phenomenon is the same. And although the full syndrome has not yet been delineated, many aspects are recognised: a burning wish that work would give you a respite; a standoffish, cynical, or irritable response to difficulties of patients or colleagues; and the classic symptoms of “heart sink” or “gut wrench”. The affected professional is seen leaving work with head bowed, still preoccupied with re-run conversations as he or she reaches for an evening drink (“just to unwind, you know, the first two or three are good for you”). And these days, the pressure isn’t easy to escape outside work. “Does that make you sick”, announced one UK magazine recently. Where, though, do they tell you that the public can make you sick? The media are doing an admirable job of highlighting health professionals’ failings, yet much of this exposure also hurts the vast majority who are trying to do their best in an unhealthy environment. This also adds to the misery of patients, who bring further mistrust and anger to their consultations. The trick of “psychic protection” is not overtly taught in our training programmes, leaving many to suffer the consequences of stress and disrupted
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work and home lives. This can ultimately lead to sickness in staff, whole departments, and even institutions. One common coping strategy is to hide behind the “them-and-us” barriers of professionalism, an outmoded modus operandi that hinders more than helps. But although I would love to cast the first stone at medicine’s separationist philosophy, I know I am not without sin. And that in itself is the key to improvement. For in realising that I need more protection from unwanted influences, I realise that I have needs as a professional. In admitting that I sometimes hide behind professional barriers to protect myself, I am admitting that I am fallible. And in recognising that my patients’ needs and failings can have an unwanted influence on me, I must surely recognise that my needs and failings can be an unwanted influence on others—whether this is an irritation with a patient I cannot “cure”, a cynical stance with a referring colleague, or an overenthusiastic prescription for the latest therapy which the patient did not want. Many current difficulties would be resolved if we, and society, accepted that health professionals are only human, that we cannot be all things to all patients. It is not always an easy path. I have horrified some patients by admitting that I (and “medical science”) don’t know the best course of action for them or that I don’t have the resources to solve their problems. “What do you mean?”, they ask. “I thought a doctor would be able to help.” Such dialogue provides an excellent opportunity for education, not only on the limitations of medical science, but also about the human beings behind the profession. And the opportunity for learning isn’t restricted to one side of the clinical encounter. Kelly Morris
THE LANCET • Vol 356 • July 15, 2000
For personal use only. Not to be reproduced without permission of The Lancet.
LIFELINE Paul U Unschuld Paul U Unschuld began his academic career at Johns Hopkins before moving to Munich University. His research focuses on the history of Chinese medicine, policy issues associated with alternative health care, and crosscultural bioethics. He is currently completeing a 10-year project of an annotated translation and analysis of the Yellow Emperor’s Classic: Basic Questions, a 2000-year old Chinese medical corpus. What would be your advice to a newly qualified doctor? Now that you have fulfilled the requirements defined by your peers, examine the expectations of your patients. What alternative therapies have you tried? Did they work? On a very bumpy flight, when my neighbour was about to soil my dark suit, I remembered a Chinese technique to mitigate his nausea; my suit was saved. What is your favourite film? Only Angels Have Wings (John Ford, 1939) with Rita Hayworth and Cary Grant. Suspense, technology of the time, and a broad range of feelings without recourse to excessive violence and obscenities. What are you currently reading? Karl Jaspers, The Physician in the Age of Technology. A delightful reencounter with this defender of rationality in medicine. What do you think is the greatest political danger to the medical profession? An increasing dependence on knowledge, technology, and values generated by others than the medical profession itself. If you had not entered your current profession, what would you have liked to do? Originally, I had studied Russian and Chinese to be a Foreign Service specialist on sino-soviet relations. Have you ever broken one of the ten commandments? I was quite young when I realised that my family-name (which means innocence) is a label inadequately describing the labelled. What part of your work gives you the most pleasure? The moment when accumulating data on a specific issue is followed by an understanding of their meaning.
264
Caring for the sick he trouble with you doctors”, said the crystal healer, “is that you’re not taught to protect yourself. Working in hospitals with all those spirits, all that disease, you take on negative energies, and they take your energy. No wonder so many of you are losing the plot . . .” Not the sort of language that I am used to, but she was right. Psychologists call it transference, and in his screenplay for Bringing out the Dead (see Lancet 2000; 355: 1293), Paul Schrader invokes ghosts as a concept to explain those hidden elements of clinical encounters that stick to, and can haunt, medical professionals. Whatever the lexicon, the phenomenon is the same. And although the full syndrome has not yet been delineated, many aspects are recognised: a burning wish that work would give you a respite; a standoffish, cynical, or irritable response to difficulties of patients or colleagues; and the classic symptoms of “heart sink” or “gut wrench”. The affected professional is seen leaving work with head bowed, still preoccupied with re-run conversations as he or she reaches for an evening drink (“just to unwind, you know, the first two or three are good for you”). And these days, the pressure isn’t easy to escape outside work. “Does that make you sick”, announced one UK magazine recently. Where, though, do they tell you that the public can make you sick? The media are doing an admirable job of highlighting health professionals’ failings, yet much of this exposure also hurts the vast majority who are trying to do their best in an unhealthy environment. This also adds to the misery of patients, who bring further mistrust and anger to their consultations. The trick of “psychic protection” is not overtly taught in our training programmes, leaving many to suffer the consequences of stress and disrupted
T
“
work and home lives. This can ultimately lead to sickness in staff, whole departments, and even institutions. One common coping strategy is to hide behind the “them-and-us” barriers of professionalism, an outmoded modus operandi that hinders more than helps. But although I would love to cast the first stone at medicine’s separationist philosophy, I know I am not without sin. And that in itself is the key to improvement. For in realising that I need more protection from unwanted influences, I realise that I have needs as a professional. In admitting that I sometimes hide behind professional barriers to protect myself, I am admitting that I am fallible. And in recognising that my patients’ needs and failings can have an unwanted influence on me, I must surely recognise that my needs and failings can be an unwanted influence on others—whether this is an irritation with a patient I cannot “cure”, a cynical stance with a referring colleague, or an overenthusiastic prescription for the latest therapy which the patient did not want. Many current difficulties would be resolved if we, and society, accepted that health professionals are only human, that we cannot be all things to all patients. It is not always an easy path. I have horrified some patients by admitting that I (and “medical science”) don’t know the best course of action for them or that I don’t have the resources to solve their problems. “What do you mean?”, they ask. “I thought a doctor would be able to help.” Such dialogue provides an excellent opportunity for education, not only on the limitations of medical science, but also about the human beings behind the profession. And the opportunity for learning isn’t restricted to one side of the clinical encounter. Kelly Morris
THE LANCET • Vol 356 • July 15, 2000
For personal use only. Not to be reproduced without permission of The Lancet.