Doctor and Patient

by S. Weir Mitchell

There is a measure of true sympathy which comes of kindness and insight, which has its value, and but one. Does it help you over the hard places? Does it aid you to see clearly and to bear patiently? Does it truly nourish character, and tenderly but, firmly set you where you can gain a larger view of the uses of pain and distress? That is the truest sympathy. Does it leave you feebler with mere pity? Does it accentuate pain and grief by simply dwelling on it with barren words? I leave you to say what that is. We have a certain gentle disrespect among us for the doctor who is described as, oh! so sympathetic,—the man who goes about his work with a pocket-full of banal phrases calculated to soothe and comfort the cravings of the wretched. The sick and feeble take gladly these imitation crumbs cast from the full table of the strong. But sometimes people of firm character revolt at such petty and economical charity. I heard a vigorous old Quaker lady say once, after a consultation, "Thee will do me a kindness not to ask me to see that man again. Thee knows that I don't like my feelings poulticed."

The question of the truthfulness of physicians is one often raised. It troubles the consultant far more than it does the family doctor, and perhaps few who are not of us understand our difficulties in this direction. Every patient has his or her standard of truth, and by it is apt to try the perplexed physician. Some of the cases which arise are curiously interesting, and perhaps nowhere better than in the physician's office or at the bedside do we see sharply developed the peculiarities of character as to this matter of truth in many of its aspects. There is the patient who asks you to tell him the whole truth as to his case. Does he really want to know? Very often he does not. If you tell him, you sentence him. You do not shorten his life, you only add to its misery. Or perhaps his wife has written to you, "On no account tell my husband that he cannot get well. He dwells now on every sign of failing health, and you will make him wretched." You parry his question and try to help him. If he is resolute, he returns on you with a query so positive that you must answer frankly. His wife was right. You have done him an injury. There is the other man who insists at the start that you must on no account tell him if he cannot get well. You inform some relative of his condition. But perhaps he ought to know. He contemplates some work or travel which he should not undertake. You say so, and he replies, "But you have not told me that I am seriously ill." Such is sick human nature.

The people who really want to know if they will die of some given disease are few in number. Those who pretend they want to know are more common. Those who should not know are frequent enough, and among them one is troubled to do what seems right and to say in answer to their questions what is true.

Wise women choose their doctors and trust them. The wisest ask the fewest questions. The terrible patients are nervous women with long memories, who question much where answers are difficult, and who put together one's answers from time to time and torment themselves and the physician with the apparent inconsistencies they detect. Another form of trouble arises with the woman whose standards are of unearthly altitude. This is the woman who thinks herself deceived if she does not know what you are giving her, or who, if without telling her you substitute an innocent drug for a hurtful one which she may have learned to take too largely, thinks that you are untruthful in the use of such a method. And you would indeed be wrong if you were of opinion that to tell her the whole truth, and invite her to break the habit by her own act, were available means. I certainly do not think that you have any right (indeed, I would not even discuss this) to take active means to make her think she is taking, say opium, when you are only giving her something which tastes like it. If she asks, you must answer. But she may not, or does not, and yet when she is well again and learns that the physician preferred to act without her knowledge because he distrusted her power to help, she is very likely, if she chance to be a certain kind of woman, to say that he has been untruthful. Happily, such cases must be rare, and yet I know of some which have been the source of much annoyance to sensitive men. Thorough trust and full understanding is the way to avoid such difficulties. A nervous woman should be made to comprehend at the outset that the physician means to have his way unhampered by the subtle distinctions with which bedridden women are apt to trouble those who most desire to help them.

I omitted above an allusion to the most unpleasant inquirers, those who are either on the verge of insanity or are victims of that singular malady, hypochrondriasis. A patient clearly staggering to and fro on the border line of sanity consults you. Here is a wilful, terrified being, eager to know the truth. "Am I becoming insane? Will I end in an asylum?" How can you answer? You see clearly, are sure the worst is coming. What shall you do with this morbid, scared, obstinate child-man? You put aside his questions, but you have here a person quite or nearly sane to-day, resolute to hear, afraid to learn the truth he dreads. I leave my reader with this patient, and my stated knowledge and my shifted responsibility. "Doctor, if I am going to be insane, I will kill myself." Good reader, pray dispose of this case. Or take the ease of a confirmed hypochondriac. He is miserable, has a hundred ailments, watches the weather, studies the barometer, has queer delusions as to diets, clothes, and his own inability to walk. The least hint of a belief that he is not as well as he was a week ago, or even a too close examination, leaves him with a new malady, and he, too, is a sharp questioner. As a rule, he has no perceptible changes in his tissues. But if he has some real malady,—it may be a grave one on which he has built a larger sense of misery than there was need for, and the case is common enough,—how shall you answer him? It is a less difficult case than the other, and I gladly leave him also to my consultant reader's acquired knowledge and to his personal sense of the value of truth.

Physicians are often blamed for not sooner warning a family of the fact that, in some case he and it are anxiously watching, death is inevitable. As to this the doctor has very mingled feelings. Sometimes he lacks courage, sometimes he is not sure enough to speak. A weak man fears that he will lose his patient and some quack be called in, and thus lessen the little chance yet left. Most of us can recall painful interviews in which a relative insisted on a definite opinion, which we were unable to give. As to cases where there is little or no doubt left, perfect frankness should be, and is, I think, our rule, but no one knows better, or as well as we, how numberless are the chances of escape for cases which seem to be at their worst. Hence a part of the reluctance the physician has to pronounce a verdict of fatal character.

There is another matter of moment as to cases known to be hastening to a fatal conclusion. The responsibility of withholding this knowledge from the patient is usually shifted on to the shoulders of relatives or friends. The medical adviser reports to them his opinion and leaves with them the power to act.

He is often asked if to know that death seems certain makes less the chance of recovery or shortens the lessening number of the days of life yet left. It has often fallen to my sad lot, as to that of many of my medical brothers, to have to tell a patient that he is to die. Some isolated man asks it. Some lonely hospital patient has just reasons for knowing early or late in his disease the truth as the doctor sees it. I have never been able to feel certain that in any case of acute or hopeless illness to know surely what lay before a sick man did distinctly shorten his life. I have seen many people in apparent health made ill by the shock of emotion,—by fear, grief, anger, jealousy. Diseased persons feel less, or show less in a physical way, the results we might expect to see from even the most rudely conveyed intelligence as to their probable future.

It was not my wish to enter into a long discussion of all the qualities which go to make up the ideal physician. I desired chiefly to consider his principal needs, to point out in big defence certain of his embarrassments, and to leave the reader with some sense of help towards knowing whether his adviser was such as he should be in the more important qualities which go to make the true physician. There are other and minor matters which are not without their relative gravity in his life. Some are desirable but not truly essential, and yet help or hurt him much. Whether he is gentle and well-mannered, is socially agreeable, or as to this negative, influences much the choice of the woman on whom, as a rule, comes finally the decision of who her family physician shall be. Too often she is caught by the outside show of manners, and sets aside an abler and plainer man, who has more really the true manners of the heart, yet lacks the power to make himself pleasant. Desirable it is, of course, to be what so many of the best physicians have been, refined and tactful gentlemen, and also charming companions. But a man may be a most competent, clear-headed, honest, scrupulously careful doctor, and yet be plain, ill-dressed, and uninteresting, and all this it is as well to understand. The mass of professional opinion is not so easily pleased as are individual patients. It decides pretty early in any large community, and classifies its members accurately, reversing very often the verdict of the juries of matrons, who do so much to make or mar our early fates. Soon or late it sifts the mass, knows who are the thorough, trustworthy, competent, hard-headed practitioners, who are the timid, who the too daring, who ride hobbies, and who trust too much to drugs. Soon, too, it distinguishes those on whom it can call in emergencies, and the highest class of men who have the great gift of discovery and the genius of observation.

From the public we can look for no such justice, and our professional manners forbid us to speak of our brethren, save among ourselves, with perfect freedom. As a profession, it is my sincere conviction that in our adherence to a high code of moral law, and in the general honesty with which we do our work, no other profession can be compared with ours. Our temptations, small and large, negative and positive, are many and constant, and yet I am quite sure that no like group of men affords as few illustrations of grave moral weaknesses. It is commonplace to say that our lives are one long training in charity, self-abandonment, all forms of self-restraint. The doctor will smile at my thinking it needful to even state the fact. He begins among the poor; all his life, in or out of hospitals, he keeps touch of them always. He sells that which men can neither weigh nor measure, and this sets him over all professions, save one, and far above all forms of mere business. He is bound in honor to profit by no patent, to disclose all he has learned, and to give freely and without reward of his best care to all others of his profession who may be sick. What such a life makes of a man is largely a question of original character, but in no other form of occupation is there such constant food useful to develop all that is best and noblest.