There is a subtle reluctance to admit that, at least in the field of medicine, the doctor knows more than the patient and is the expert in the area in which the patient is having trouble.
At a recent medical staff meeting, my colleagues and I had a lively discussion about a new dress code adopted by the agency we work for. In an effort to foster the professional appearance of the employees, several changes to the dress code were announced. Among these was prohibition of jeans, T-shirts, flip-flops, revealing clothing, and the like. One of our colleagues voiced a concern that the new dress code policies went against the spirit of “stigma reduction” in the sense that to make ourselves more approachable to our patients, we should avoid the sort of dress that might make us appear somehow superior to them. Indeed, as part of orientation training at our hospital, we were told that patients felt most at ease with staff members who dressed in the same style as they did. This idea has been implemented so well at our hospital that it is often very difficult to tell staff members from patients, hospital badges on the former and parkinsonism in the latter being at times the only distinguishing characteristics.
That approachability has something to do with familiarity is obvious. Opposites may attract, but people tend to gravitate to those who resemble them most. There is no great leap of logic in assuming that someone dressed in jeans, flip-flops, and a T-shirt may feel more comfortable around those similarly dressed than around a person wearing pressed khakis, oxfords, and a button-down shirt. However, is our “dressing down” therapeutic for our patients? And, to what extent is our dress an accurate and honest reflection of our position?
In psychiatry circles, much has been said over the years about physicians’ paternalism and the stigmatization of mental illness and the mentally ill. From an insider’s point of view, it has been interesting to notice that many practitioners of a specialty that has struggled to be recognized as possessing legitimate medical expertise have also felt very uncomfortable with the authority implied by the possession of such expertise. Somehow there is a subtle reluctance to admit that, at least in the field of medicine, the doctor knows more than the patient and is the expert in the area in which the patient is having trouble. I have wondered whether this phenomenon is not more pronounced in psychiatry than in other medical fields, such as surgery, where the difference between the knife wielding doctor and the unconscious patient is rather harder to ignore. That there are doctors and there are patients implies that somewhere there is a line between health and illness. That those who are ill want to get rid of what is bothering them also implies that what ails them is not a desirable thing to have. Although it seems self-evident that people do not like to be ill, the notion that illness is not desirable and that some illnesses are less desirable than others has come to be known as stigma against those conditions. At the same time, there exists the notion that we ought to spare the feelings of those suffering from undesirable conditions. Since even in an effort at feeling-sparing no one could sensibly argue that such undesirable conditions are actually desirable, it has been argued instead that people with undesirable conditions are just like people without those conditions, or putting it only slightly differently, that the line dividing patients from doctors is illusory. Dressing down, it turns out, is one way of blurring the distinction between patients and those who treat them.
The relationship between the doctor and the patient is inherently unequal. Although in psychiatry this inequality is most pronounced in settings in which the patient undergoes involuntary treatment, it exists in the most voluntary of arrangements. After all, the doctor is assumed to possess some skill or expertise that the patient lacks and is in need of. The doctor is in need of getting paid, but outside private practice settings, the reimbursement comes from a source other than the patient and this reduces the doctor’s need for a particular patient. The patient’s needs, expectations, and hopes are directed toward the physician to a much greater extent and for reasons quite different from those running in the other direction. The relationship is unequal from the start and by its very nature. This fact can hardly be disputed, but there has been no shortage of attempts to minimize it or at least to pretend to do so. Before we deny or minimize the obvious, it would behoove us to ask whom this benefits and whether we can do so while maintaining integrity and honesty toward the very patients whom we are trying to help.
Since the inequality in this type of relationship results from there being a particular kind of expertise on one side and not the other, there are only so many ways of changing the situation. One is to pretend that the patient possesses medical expertise and the other is to pretend that the doctor does not possess it. Neither works very well in practice. The former approach amounts to nonsense because it is always the patient, regardless of how well educated he may be, who comes to and pays the doctor and not the other way around. The latter approach may work in a round-about way when we place the initiative for seeking care and the responsibility for following medical advice on the patient’s shoulders. It is one way of saying that it is the patient who ultimately determines what happens in the treatment. However, this approach does not work in the many involuntary settings in psychiatry in which the patient has little choice in the treatment ordered by the doctor. Since attempts at equalizing expertise do not work, there remains only one approach at leveling the field: to minimize the difference in how things look on the surface of the treatment dyad or, to get back to the original topic of dress codes, for the doctor to dress down.
Assuming that it is not the doctor’s expressed preference to wear jeans to work, whom do we fool when we don them in order to make things appear more equal on the two sides of the treatment relationship? Are we really fooling our patients to whom we give prescriptions and administer injections and whom we lock behind the doors to which we and not they have the keys? Is the jeans-wearing physician really perceived as less authoritarian when he gives testimony that convinces a judge to commit the patient to involuntary treatment? When we try to act as if we do not possess the authority that we in fact possess not only by virtue of expertise but also by law, I am afraid we do so only to soothe ourselves. The patient who may think we are “cool” for dressing as he does will see us for who we really are the moment we use our expertise and authority to contradict him or to insist that he must follow this or that treatment regimen.
Dressing down does nothing for the so-called stigma against mental illness if by that term we mean the notion that it is not desirable to be mentally ill. We can dress as casually as possible and act like pals with our patients, but that will not change the fact that we would not want to trade places with them. And until we feel ready to trade places with our patients we cannot in all honesty deny that an illness, and mental illness particularly, engenders a certain attitude toward those who have it from those who do not. We can pretend by using superficial means that there is no difference between our patients and ourselves, but this pretense will only take us and them so far.
I would argue that ignoring or disavowing the inequality in the relationship with our patients is neither honest nor therapeutic. Our patients, at least those who want the treatment, come to us precisely for the sake of the very thing that lies at the heart of the inequality, that is for the knowledge and expertise that we are supposed to possess. Patients interested in getting better want physicians who are experts in their fields and they accept the authority issuing from a doctor as acting in the interests of their own good. Any idea can be distorted to such extremes that it becomes untenable, and I am not advocating extending one’s authority so as to bully one’s patients or to condescend to them. All doctors sooner or later themselves become patients. Thus, we must never forget that “there, but for the grace of God, go I." This attitude ought to give rise to humility as regards our own fragility and to compassion toward our patients. However, the spirit of this attitude is distorted greatly when we try to pretend to our patients and to ourselves that there is equality in the relationship because we dress alike. This is a false notion that confuses the most superficial aspect of the relationship between the doctor and the patient with what is lying at the very core of the issue. If we act with authority appropriate to our expertise and rooted in compassion and humility, our patients will benefit from the relationship and we will remain honest with them and with ourselves. If we do not, wearing jeans will not help.
Dr Vatel is a Staff Psychiatrist at Evansville State Hospital and Lecturer in the department of psychology at the University of Evansville, in Evansville, Ind.