BMJ  2005;330:1394 (11 June), doi:10.1136/bmj.330.7504.1394

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Book

The Doctor in Literature: Satisfaction or Resentment?

Most of us would rather dispense with the services of doctors, dentists, lawyers, and grave diggers and prefer to meet them only in plays, movies, and books. Solomon Posen of Sydney University provides one such opportunity with The Doctor in Literature. In his reading he has roamed widely, from Plato and Pliny to Osler and Proust and even to authors published as late as 2004. He has screened the vast literature at his disposal and found heroes, crooks, and criminals. Many of his selections are culled from the days when full time salaries were few and doctors had to collect their fees directly from their patients. Some of these descriptions should disabuse doctors discontented with present day arrangements of the notion that the past was an unalloyed golden era for the practice of medicine.

Solomon Posen Radcliffe, £29.95, pp 304 ISBN 1 85775 609 6 Rating:

Throughout the book Posen illustrates the persistence of an irrational dislike of doctors, dating from classical times and based largely on "a deep resentment of powerful experts with their semi-secret knowledge, who promise results but fail to deliver." Although much has changed in 2500 years, much has remained the same. Patients always resented doctors' fees, especially when they felt that the treatment did not help and that they did not get their money's worth. In plays and books and even nursery rhymes, doctors are often represented as money hungry, greedy for gold, and suffering from "congestion of the purse."

Not surprisingly, some doctors were also embarrassed by their dependence on fees, especially when these "constituted an irritant to the patients" or when the patients had no money. Trollope's Doctor Thorne advised the doctor to take his fee unobtrusively, "without letting the left hand know what the right is doing," as if he were "hardly aware that the last friendly grasp of the hand has been made more precious by the touch of gold." But fees have also been viewed as having a positive aspect. Some doctors always charged large fees, especially to wealthy patients, reinforcing in the process the value of their ministrations. For even to this day a lingering perception remains that a poor doctor cannot be any good.

There are many other causes of patients' displeasure. They do no like to be kept waiting for the doctor in the office, in the hospital, or for the results of tests. They may be angry at being ill, especially when their disease is incurable, and they may resent their doctor's contrasting good health, his hobbies, his Wednesday afternoon golf, the theatre visits, the opulence of his lodgings. His bedside manner may seem inappropriate, affected, too dismissive, too insensitive. Some patients resent being seen by the doctor's assistant rather than by the principal himself. The conscientious doctor may be surprised to learn that many patients are irritated by his thorough history taking, by repetitive questioning (especially by a series of different doctors), and by a complete physical examination that seems humiliating, intrusive, or, at best, irrelevant. Even hand washing has been viewed as an act or sign of abandonment; and the traditional ward round, with the professor followed by retinue, may also be perceived as insulting and humiliating.

Trollope: advice on doctors' fees Credit: TOPFOTO.CO.UK

The excessive use of medical jargon and technical terms is another source of annoyance, as is doctors' frequent failure to provide understandable, non-patronising explanations. "It's a funny thing how hard it is to get a straight answer from a doctor," says one patient; while another compares her doctor to a veterinarian who never tells her anything and treats her like an animal. Still others, with Matthew Arnold, would rather do without "a doctor full of phrase and fame / to shake his sapient head and give the ill he cannot cure a name."

Elsewhere we read about doctors who are incompetent, ignorant ("has forgotten all he learnt in medical school and has not opened a book since he graduated"), arrogant, or downright cruel. Some are despots, some are lunatics. Others have weird therapeutic notions, such as Charlotte Gilman's doctor, who confines his wife in a room for total bed rest in The Yellow Wallpaper ( 1899). A few doctors have a one track mind, a single operation (excision of the nuciform sac), a single remedy (milk diet, castor oil, stimulating the phagocytes, or "a bottle of physic that tastes and smells like the devil"), or a single diagnosis ("this year everything was ameba, another year it was endometritis"). Some doctors are described as resisting all scientific advances, such as the surgeon whose favorite joke was "close the door or the germs will get in," or the physician to whom the stethoscope was a newfangled French toy. Many are clearly conscious of their patients' social status, reacting accordingly by being meek and subservient or arrogant and bullying. They are often ineffective as witnesses in court, especially as the leaders of the profession prefer not to be involved, and many "experts" are third raters and even drunkards or alcoholics. When sued themselves, doctors generally have the cards stacked against them, regardless of the merits of their case.

So we have here an excellent book—learned and amusing, but also one that doctors might think about as they make their daily rounds. It may be read right through or used as a source of reference on some particular subject. Conscientious readers will find it slow going unless they overcome the constant temptation to turn to the references section.

Stroger Hospital of Cook County, Chicago, Illinois, United States gdu222{at}yahoo.com

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