On the Nature of the Patient-Physician Relationship: A Case Study

Of the three fields, medicine, law, and divinity, the practitioner most widely esteemed and valued by society is the physician. In small towns across rural America it is not surprising to find an eminent physician virtually running local politics and affairs associated with his vocation. Though many times unwarranted, it is human nature to have such an innate respect for the leech. This sprit of admiration was much the case in the fictional New England town of Mount Ephraim, New York in February of 1976, when one physician was called, in the midst of a crisis, to do his duty, according to the novel, We Were the Mulvaneys, by Joyce Carol Oates. A female, age seventeen, attended the high school prom and afterwards attended two post- prom parties, during the course of which she had become intoxicated. A male, approximately one to two years older than the female, raped her after the second party (Oates 135). Medical attention for the victim was not pursued for several days following the assault (136). Proceeding such a traumatic event the most appropriate treatment, which, given that no irrevocable physical harm had been inflicted (135-6), should have centered on professional counseling for both the female and her family, was not achieved. The situation, once placed in the hands of the family physician, was terribly mishandled. As a complete result of not knowing how to handle the situation the family is ultimately unraveled. They are the type that put up a nice facade, but behind it they are weak and miserable. Much of what should have occurred in the physician’s office did not occur and what did occur was woefully inadequate, thus ineffective, in securing the goals to restore and repair what had been damaged. First, it is apparent that the physician was capable of attending to the girl’s current mental state. His reaction was initially compassionate, yet very characteristic of the ideal physician. “[…] [The doctor] urged her to sit, offered her a tissue, and spoke comfortingly to her, ” (134). He also demonstrated that he could be firm with the mother.

[The doctor]’s nurse escorted [her] into an examining room, and [the mother] would have followed them, but [he] suggested that it might be better is she waited [in the consulting room] […]. (135)

Second, from the girl’s reaction to being in the consultation room one can infer that she neither needed her mother, nor felt uncomfortable being in the presence of the physician. “In [The doctor]'s consulting room, […] [the girl] grew calmer. It was a familiar place,” (134). He should have promptly excused the mother, but possibly not to the waiting room as the mother, too, was emotionally unstable. Rather he should have let the mother remain in the consulting room with the nurse to tend her needs, and the physician should have taken the girl into an examining room where they would have been able to talk unhindered by the presence of two extra people, the nurse and the girl’s mother. Although, the physician eventually removes the mother from the equation when, at the girl’s suggestion (135), they go into an examining room finally, but the nurse accompanies them. Neither do they leave the consulting room and the mother with the intention of talking about the situation, but simply to give the physician an opportunity to determine what physical harm has been done. This assessment is not contradicting the notion that a nurse should have been present when the physical examination was preformed; rather, it is to emphasize the fact that in interviewing and counseling the girl the physician should have sought accomplish this in a more confidential manner. Third, he unfortunately further compounded the situation when he physically, thus psychologically, distanced himself from the girl and her mother and used his desk as a barricade.

“She could not bring herself to look at [the doctor] behind his desk, nor at [her mother]. […] [The mother] hugged her, herself in tears, as [the doctor] looked on, and [The mother] wept, wept as if her heart had bro­ken. And [the girl] sat stiff yet unresisting, allowing her mother to embrace her but not returning the embrace. (134)

The description alludes not only to the notion that the mother’s presence not only impeded the openness of the dialogue, and had a detrimental affect on the girl’s state, but that the physician has not done enough, and in fact has created more barriers than just the natural notion of being a medical doctor, to tare apart his image as the old unapproachable stoic clinical physician. From observation, the impression of feeling inferior to a clinical man is quite commonly manifested in children, adolescents, and adults alike as an automatic reaction, and this behavior does not need to be qualified by the presence of an uncompromisingly cold clinician to be exhibited. Therefore, it is the primary obligation of the physician to rectify the situation whenever and wherever it exists in order to establish an open; meaningful; and, ultimately, a successful patient-physician relationship, where success is measured by how much good can be done to aid the patient. This sacred alliance is explained in the American Medical Association’s “Fundamental Elements of the Patient-Physician Relationship” of the Medical Ethics Code number E-10.01.

From ancient times, physicians have recognized that the health and well-being of patients depends upon a collaborative effort between physician and patient. Patients share with physicians the responsibility for their own health care. The patient-physician relationship is of greatest benefit to patients when they bring medical problems to the attention of their physicians in a timely fashion, provide information about their medical condition to the best of their ability, and work with their physicians in a mutually respectful alliance.

Fourthly, the physician’s demeanor is contrary to what it should have been. Instead of confidently, yet compassionately and understandingly, addressing the matter he becomes visibly flustered. He allows it to be known how uncomfortable he is in handling the matter, thus, sacrificing the confidence of the family, chiefly the mother, as is inferred in the following passage:

He held a sheet of paper in his tremulous hands and frowned at it, as if his own handwriting perplexed him. […] “It's been several days since the assault and so there wouldn't be—I'm sure-“ and here [the doctor], the most gentlemanly of elder men, faltered, “-any traces of semen remaining.” […] [The doctor] was shaking his head, visibly nervous, frowning at the report in his fingers. He was a man whose courtly, warmly gra­cious manner could sometimes shade into awkwardness. (135-6)

The girl does not open up and permit herself to ventilate to the doctor partly because of his disposition and partly because of the mother’s presence, but instead sees him only as one concerned with physical injuries and not emotional ones. That is the picture that he paints by inquiring only about what physical harm has been committed, who has committed it, and where it was committed.

“Hurt [Jane]?” [The doctor] asked. […] “And where did this happen, Marianne?” […] “Who was the boy, [Jane]?" [The doctor] asked quietly. “What did he do to you?” […] [The doctor] said, frowning, “But something was done to you. [Jane]? You've been---hurt?” […] (134)

[…] [Jane] said calmly, looking now at [the doctor], “I am ready to be examined now, Dr. [Doe], I guess.” (135)

The physician demonstrates clearly that he is of the old Austrian (Central-European) school; that is to say his personality is condescending and autocratic in nature. The notion that a patient, or in this case her mother, would question him, the physician, is completely out of the realm of all possibility. As the physician, he welded absolute autonomy regarding the treatment of his patients according to this manner of thinking. (Chamberlain)

"It appears that your daughter has been sexually abused."

[The mother] was on her feet, anguished. “Oh God. Oh Jesus. She's been raped?” (135) […]

“There is evidence of 'forcible penile penetration,' yes. The hymen has been ruptured and there are bruises and lacerations in the vaginal and pelvic area and bruises elsewhere—thighs, abdomen, breasts.” […] (135-6)

“Raped? Marianne?”

“[Ma’am], she doesn't say-that. She hasn't said that, dear, you see.”

“But of course that's what it is, Dr. [Doe]! Rape.”

He said, carefully, “I've prescribed painkillers for your daughter, and something to help her sleep. She's a brave young woman, and it may be that you and [John] need to listen to her, and not,” again he paused, with a fastidious licking of his lips, “do anything rash.” (136)

Their "old" family physician foresaw the future for them, and, though he was in a position powerful enough to circumvent most, if not all of the coming tragedy, he did not. Much what he did was fine; although his manner was awkward, feeble, and, in a few instances, dictatorial in nature. It is rather what he did not do that permitted the emotional imbalance to exist. Works Cited: American Medical Association. “Fundamental Elements of the Patient-Physician Relationship” E-10.01. . 1990. Chamberlain, Dr. Robert. Lecture/Personal Interview. medical ethics and ethnic tendencies in medicine. Monday, February 2, 2004. Oates, Joyce Carol. We Were the Mulvaneys. New York: NY. Plume, Dutton Signet, Penguin Putnam. 1997.