Book Review
Straddling Kingdoms
Author Robert Klitzman shows how doctors struggle when they journey from doctorhood into patienthood.
A review by Charles R. Meyer, M.D.
In the world of medicine lie two kingdoms, patienthood and doctorhood. Each has its own culture, language, and customs. Ideally, doctors should straddle both kingdoms. They should understand the culture of patients and explain the culture of medicine. They should be bilingual and able to translate the perplexing patois of their scientific trade for their patients. They should ease the passage from life to death. Yet these kingdoms sometimes seem miles apart and their subjects irretrievably alienated, sometimes talking past each other, sometimes warring.
When doctors cross over to patienthood, temporarily or permanently, a war between cultures occurs within the doctor-patient. It is this war that Robert Klitzman, M.D., explores in his book When Doctors Become Patients. An associate professor of clinical psychiatry at Columbia College of Physicians and Surgeons, Klitzman interviewed 70 physicians about their experience of having serious illnesses including HIV, cancer, heart attack, and psychiatric disorders.
Klitzman’s doctor-patients were privileged patients, informed by their training and able to navigate the shoals of the medical system with an insider’s aplomb. Yet, accustomed to “calling the shots,” they struggled with the loss of control that comes with illness. “It’s the great failing of most physicians: they are controlling people. But to be a good patient, and get the best care, you have to say, ‘I’m the doormat. You can do what you want,’ and not second-guess,” Klitzman writes. As workaholics, they agonized over time away from work and struggled “to find renewed purpose and sustenance. As their work threatened to slip away, many strove to clutch on to, or replace it.” And they frequently felt caught between their role as a patient and as a doctor, some believing that “to adopt a new role, as a patient, would necessitate giving up the other, as a doctor—as if individuals had a zero-sum identity.”
Yet, in many respects, these doctor-patients were typical patients. They feared disease and death. They sought multiple opinions or tried “alternative” therapies when confronted with bad news and dead ends. And, unfortunately, like many patients, they encountered a flawed medical system with botched orders, interminable waits, and insensitive, sometimes cruel physicians.
Surprisingly, Klitzman’s physician-patients had a terrible time with their own physicians. They stumbled when trying to find one, not knowing whether to pick a friend or an anonymous doctor and they were unsure how to gauge the quality of whom they picked, “You don’t know how good a doctor is—whether from hearsay or reputation. You have to be their patient to find out—in terms of caring, empathy, and understanding. None of these qualities are described by the conventional measures of excellence: faculty position, number of referrals, size of practice.” Their doctors frequently didn’t know how much to explain, nor did they know how much to ask. And when the physician-patients did ask, they sometimes received cavalier brush-offs. Indeed, Klitzman’s stories of blunt, uncaring doctors could fill many episodes of House.
Although Klitzman’s chapters are organized thematically, his technique results in a somewhat rambling sequence of anecdotes. Inevitably, different doctor-patients have disparate opinions, and his take-home message at times gets garbled.
So how does a savvy visitor to the land of patienthood act the part of the perfect doctor-patient? It’s a tough assignment since being human keeps getting in the way. MM
Charles Meyer practices internal medicine and is editor in chief of Minnesota Medicine.