Doctors, Politics and Animals

Tekst av Afonso Fernandes
Universidade do Minho, Portugal

Ask any medical student about their Psychiatry clerkship, and you're likely to get an earful about the countless hours spent observing interviews and listening to conversations. While other fields of medicine are much more dependent on laboratory results, imaging, and invasive procedures, the outpatient psychiatry experience relies mainly on the art of communication equipped with a logical armature. Thus, psychiatrists are highly skilled communicators, and I was eager to learn from them during my time as a medical student.

I asked my clinical tutor to spend the afternoon at the psychiatric outpatient clinic. Since I was not familiar with the patients' medical history, she was kind enough to guide me through the idiosyncrasies of each patient before receiving them. After my first couple of hours in this setting, the doctor told me that we would receive two patients: father and son, both living with schizophrenia.

As the interview progressed, I got to know that the father had been living with the disease for over a decade and that his son fell victim to the inevitability of the genome at an early age. The treatment plan was being complied with, the positive symptoms had ceased, and the negative symptoms had improved since the last visit. However, the feeling of uneasiness that arose when the doctor asserted that "everything was excellent" was too obvious not to be noticed. The doctor's reaction was not immediate; more questions were asked about the symptoms and the medication and, when the interview was approaching its end, the doctor addressed the avoided issue by asking: "What is worrying you the most?".

This question was the permission the patient needed to address the issues that – although not directly related to his mental illness – brought him great suffering. Apart from the positive and negative dimensions, patients with schizophrenia experience impaired attention and working memory dysfunction, hindering their ability to find a job. The father explained how fragile the economic situation of the family was; he told us that it was becoming increasingly difficult to buy the medication required to control the disease and that the difficulties that he and his son faced when trying to find and keep a job did not bring much hope.

Is the economic situation of the patient a doctor's problem? When nonadherence is a direct consequence of poverty, it becomes difficult to answer negatively to this question. Moreover, since nonadherence is responsible for higher hospitalization rates, absenteeism, and lower social participation of people with severe mental illness, it is not only a doctor's problem but a problem for all of us.

“Is the economic situation of the patient a doctor’s problem? When nonadherence is a direct consequence of poverty, it becomes difficult to answer negatively to this question.”

After exploring the kind of help that the patient was seeking, the doctor picked up the phone and made an appointment with the social worker, who promptly took over the case. In certain contexts, the best treatment comes in the form of sheltered jobs and social security benefits.

This is not a plea for making the doctor's office the place where all the problems are magically solved, but rather for making it the place where all the problems can be addressed —a plea to offer help when help is sought. In a fragmented system with lack of information, support, accessibility, and countless bureaucratic hurdles, when confronted with the patient's concerns, the doctor should act as a facilitator by providing solutions and by showing the options available to address the problem at hand. This is the political task of the doctor: to fight for policies that are capable of solving people's problems and bring these policies into people's lives. When Aristotle said that "the human being is the political animal," he included us too.

“This is not a plea for making the doctor’s office the place where all the problems are magically solved, but rather for making it the place where all the problems can be addressed—a plea to offer help when help is sought”