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Essay: A Young Doctor's Hardest Lesson: Keep Your Mouth Shut

December 28, 2004
 By KENT SEPKOWITZ, M.D. 



 

An unspoken but ever-present issue in the life of any
doctor is an immodest, completely nonmedical concern: are
doctors boring people? 

Sober and serious, surely. Respectable and educated, one
hopes. A bit stuffy at times, perhaps. But dreary? 

As a profession, I think we do tend to run on the dry side,
though till recently the reason had eluded me. Then, last
month, my wife and I bumped into an acquaintance of hers
while walking along the street. The person, unbeknownst to
my wife, is a patient of mine, someone whom I treat for a
chronic infection. After the patient and I shared a moment
of mutual panic, we three chatted amicably and moved on. 

Except, that evening, my wife kept asking me why I was
being so quiet and, well, boring. And I suddenly saw the
problem: doctors are waterlogged with secrets, hundreds of
them, thousands of them. 

Each day brings a new batch: patients' admissions about
drug use or sexual indiscretion, a hidden family, a
long-held dream, an ancient heartache, undisclosed H.I.V.
infection. 

Over the years, this begins to add up, the bulge expands,
the joints get stiff. Yet the secret - the consequences of
our ever-expanding repository of others' secrets - remains,
well, secretive. The situation simply is not addressed, not
at the start, middle, or the end of a career. 

The most difficult aspect of a training doctor's life is
not suddenly bearing witness to someone else's pain and
death; it is not adjusting to arduous work hours; it is not
the imposing amount to be learned and synthesized. These
surely are intense, life-transforming endeavors but are
still related to other experiences. 

No, the biggest shock along the road to becoming a doctor
is the startling revelation that you can ask and the
patient will tell anything. Young doctors, when they first
meet patients, don't know quite how to react. After all,
most people are raised to be careful in their interactions,
discreet in their inquiries, fair-minded in the way they
might pursue personal information. 

Now, suddenly, everything goes. As doctors, we can and must
ask a battery of questions about last weekend's big night
out, about how that rash may have occurred, about why you
have been sniffling for so many months. And sure enough,
right on schedule, most patients answer with little or no
discomfort. 

But with this intoxicating power comes an equally strong
interdiction: shut your trap. You can ask what you want but
you'd better keep quiet about it. 

A person's trust in you, in medicine, in society's ability
to assure someone's safe passage through illness requires
learning quickly how to keep secrets. 

This sober business of maintaining confidences is the
closest we come to the priesthood. Forget healing, forget
laying on of hands: it is the importance we place on
silence that is our most important spiritual activity. 

Yet the world offers few hints (or incentives) on how to
button your lips across the decades. Indeed, we celebrate
the most unbuttoned among us: movie stars and gossip
columnists, Barbara Walters and blabby neighbors. 

How much juice can they squeeze out of someone? 

Other
professions that traffic in secrets typically maintain
silence for a fixed period: lawyers and spies, accountants
and politicians, mobsters and four-star generals. Power or
leverage is at stake, but once things settle, the gabfest
can resume. 

But for us, the silence is forever. The consequence of this
tight-lipped life is readily evident anywhere young doctors
have congregated. Exploiting the single loophole in the
code of silence - chatting up one another - they busily
swap stories about patients. Near-maniacal peals of
laughter are heard as the latest "I once saw this woman in
the E.R. who" tale is recounted. 

The hilarity, the need to yelp, surely derives from
something other than the quality of the story at hand. I
know this because, um, I have transgressed a few times, to
try out a story on someone not medical. And rather than
hearing the appreciative party guy hoot of laughter, I
receive only a confused squint. 

So we learn to keep quiet about the whole thing, trusted
advisers in the persistent palace intrigue. But conducting
business this way is confusing. What is off limits, and
what remains in play? Can I say this or that? 

Pretty quickly, it becomes clear that the easiest and
safest - though the quietest and dullest - approach is
simply to shut up concerning just about everything. 

It makes for some admittedly dim evenings, perhaps, but at
least this way everybody's odds and ends stay locked up and
out of reach. 

http://www.nytimes.com/2004/12/28/health/28essa.html?ex=1105281815&ei=1&en=2a256d5b9e1744d1


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