Richard Smith: Does it take a “bad” patient to make a good doctor?

richard_smith_2014Trying to define a good doctor is as elusive a task as trying to define a good life or a good death. Like good lives and deaths, good doctors will come in many forms, and I search for them constantly as I read. Most doctors in novels are “bad”—fools, crooks, sadists, and cold fish. But doctors shouldn’t feel badly about that because bad characters vastly outnumber good ones in novels because, as Somerset Maugham writes, “vice can be painted in colours that glow, whereas virtue seems to bear a hue that is somewhat dun.” But I have found a good doctor, an outstanding one, and it is a “bad” patient who has made him a good doctor.
I’ve found the good doctor, whose name is Andy, in A Little Life by Hanya Yanagihara. It’s a powerful novel that at times has a Dostoevskian intensity. It’s the story of four friends who met in college in Boston and moved to New York together. A novel about friendship and love, the story narrows to be about two friends, one of whom, Jude, was severely abused as a child. The “little life” is his, but the title is ironic. He has awful physical and psychological problems, so he needs a good doctor. And understandably he has terrible difficulties trusting anybody, so how can he trust a doctor?

Jude met Andy at college, and he is the only doctor he can trust. (Another doctor was the man who abused him more than any other.) Andy is not a general practitioner but an orthopaedic surgeon, which is fortunate in that many of Jude’s problems are with his arms and legs, but unfortunate in that his deepest problems are psychological. Andy, a good doctor, recognises his limitations and constantly urges Jude to see a shrink. It takes years for that to happen and leads nowhere when it does. (Yanagihara has a deep understanding of psychological problems but no confidence in the ability of shrinks to fix them.)
Jude needs constant care, and he sees Andy almost every week, and at times more often, for 30 years. He is the most difficult of patients, refusing to tell all that has happened to him, lying, and regularly ignoring Andy’s advice. Jude will never go to an emergency room or to another doctor, and he often calls on Andy in the middle of the night in a terrible mess, needing surgery. Sometimes Andy has to go to him. The nights are often a terrible time for Jude, and Andy gets him through by ringing him in the middle of the night, night after night.

Andy and his wife become close friends with Jude and his partner, and they celebrate 30 years together with a dinner. At the dinner Jude toasts Andy and thanks him. Andy responds:

“Thirty years of being disobeyed. Thirty years of dispensing priceless medical advice gleaned from years of experience and training at top institutions, only to have it ignored by a corporate litigator, who’s decided his understanding of human biology is superior to my own.” All those at the dinner laugh.
Corporate litigator is in italics because it’s what Jude is and it’s a bad thing to be in that Jude is hugely gifted at maths and music but has sold his soul by successfully defending villainous corporations. Jude loves the work, and it’s only when immersed in work that he can forget his pain completely. That Jude is a corporate lawyer is perhaps important too in that money becomes no object, so Andy can be well paid. But when he first saw Jude as a patient Jude had no money, and Andy saw him for free.

Andy is truly patient centred in that he accepts that Jude ignores his advice, will not tell him for a long time how he came by his injuries, and will not accept psychological treatment. He might be what has been perjoratively called a “heartsink patient.” Andy is not gentle with him. He berates Jude, swears at him, and at times forces him to follow his treatment or rings him every night to ensure he is taking the treatment.

Immediately after Andy has spoken at the dinner his wife speaks:

“But you know, Andy, if it weren’t for Jude I never would have married you.” [She turns to Jude]: “In medical school, I always thought Andy was sort of a self-absorbed douche bag, Jude; he was so arrogant, so borderline callow…that I assumed he was going to become one of those typical surgeons—you know ‘not always right, but always certain.’ But then I heard him talk about you, how much he loved and respected you, and I thought there might be something more to him, and I was right.”

So Jude, the “bad” patient (no patients are bad, just as no customers are wrong) has turned Andy into a good doctor and brought him a good wife. (I wasn’t sure what callow meant, and so looked it up. It means: “immature, inexperienced, naive, green, as green as grass, born yesterday, raw, unseasoned, untrained, untried.” So Andy, then a medical student, would like all medical students have been callow, not just “borderline callow,” whatever that means. Is this sloppy writing or has Yanagihara deliberately had Andy’s wife use language poorly?)

But the crucial words are love and respect.

Perhaps to be a truly good doctor you must love and respect your patients, even the “bad” ones; and in return they will help you become an even better doctor.

Richard Smith was the editor of The BMJ until 2004.