Young Judgmental Bastard Me

Occasionally, a post works its way through Cyberworld purportedly written by a doctor, exhausted not just by work but by the allegedly irresponsible character of the patients he sees. Usually, those patients are sporting apparently lavish outfits, expensive accessories both sartorial and electronic, and creative gold-plated dental work. A recent one noted the fact that one such patient was on Medicaid and bemoaned “a culture in which it is perfectly acceptable to spend money on luxuries and vices while refusing to take care of one’s self or, heaven forbid, purchase health insurance.” I am often asked my response to these sorts of posts. For the record, here is mine. Let me begin, as I often do, with a story. About me.

When I was in medical school and considering what specialty I could pursue that would sustain me in the decades to come, I realized that the ability to have a long-standing relationship with my patients, to be part of their lives over much of their lifespan, was a major value for me. I also discerned that being able to see a wide variety of patients in a community was just as important. This pointed me towards the Primary Care specialties of Family Practice, Internal Medicine, and Pediatrics. After I graduated, I still had not made up my mind which of the three I would choose so I did a Rotating Internship, a year of a little bit of this, a little bit of that, to help me decide. It was during this year that I encountered a number of adult patients whom I really found to be, quite frankly, intensely annoying. There would be the smoker who was not going to quit, the alcoholic who saw no problem in his half a bottle of vodka each evening, the obese person who said she really didn’t like salads and would rather take the elevator than the stairs. Whenever I would point out how important it was to make changes in decades-old patterns of behavior, their shared mantra seemed to be, “Can’t you just give me a pill for that?” Then there were the pro-active drug-seekers, the ones who would say, “Doc, I got this bad pain in my back, and the only thing that helps is Percocet.” If I would ask about the source of the pain, try to get a history of possible injuries, inquire about whether an X-ray or anything else had been done to work this up in the past, the standard response was, “I don’t care about all that! Are you gonna give me the damn Percocet, or do I gotta go somewhere else?!”

With kids, on the other hand, it was quite easy for me to create a narrative that anything that was going on with them was because of things that happened to them, rather than because of what they had done to themselves. Of course, I would have to deal with parents, but for the most part, kids were innocents, blameless for their conditions, and as I settled on my professional course, this place of being able to treat those unaffected by age and greed and life seemed the most appropriate and pleasing to me. And so I became a pediatrician.

Of course, over the ensuing three decades, my view has become more nuanced, my judgment less harsh. As I have gotten to know not just my patients, those thousand upon thousands of kids, but their families and the communities in which they live, I have come to a profound realization about my younger self:

I was a real judgmental bastard.

In my thirty-plus years of working mostly in impoverished communities, I can tell you that the view promoted in some of these posts by stressed physicians that there is some vast community of closet millionaires living the high life on Medicaid is a not merely a fiction, but a damaging and divisive fiction at that. It plays into a narrative about “deserving poor,” mostly rural and white, versus “undeserving poor,” mostly urban and African-American. The objections of these physicians in their posts are really the same general objections that that Young Judgmental Bastard Me had about all adult patients: People do a lot of thoughtless, short-sighted, selfish things with their health and with their money.

I would invite these physicians to look at their own spending and judge whether it is always wise and prudent. For myself: Is that trip to New York to see Broadway shows really necessary? Shouldn’t I be putting more money into my 403B? Do I really need that pint of Häagen-Dazs Vanilla Swiss Almond ice cream? Well, No, Yes, and Ah, c’mon! Each one of us can find thousands of things in others to judge and to find irresponsible. But how often do we turn the mirror on ourselves to coolly judge our own shortcomings and improprieties? To assure you all that my eight years of Jesuit education were not wasted, I now offer two learned and pertinent quotes:

- Robert Burns (Scottish national poet, 1759–1796): “O would some power the giftie gie us to see ourselves as others see us.”

- Jesus Christ (Jewish prophet 0–33): “Judge not, that ye be not judged.” (Matthew 7:1, King James version)

An inescapable facet of the human condition is the tendency, even necessity, to judge other people. We do it all the time, starting at about 6 months of age when babies with secure attachments to parents start manifesting Stranger Anxiety, i.e., when an new person enters the room, the baby looks at the parent as if to ask, “Is this okay? I don’t know them. What do you think?” It is a crucial survival adaptation for a vulnerable infant.

As we get older, though, it is incumbent upon us to recognize where these judgments come from and that, at a certain point, they are no longer useful and can effectively block our other natural human tendency towards empathy. Empathy is a much higher-level response to our encounter with those whose lives are vastly different from ours. Empathy calls us to imagine walking a mile in another person’s shoes, to consider what forces in the community and experiences of others bring them to a place that may seem, at first glance, alien and perhaps even repugnant. Yet when imagination, mindfulness, and empathy are engaged, we may come to the sober realization that, not only could we see ourselves acting the same way given the same situation, but perhaps we might not do as well as they have.

To be clear, whatever other doctors post about irresponsible patients is their own business. What we feel is what we feel, after all, and we have no control over that. My concern is that how they may act on these feelings seems to show no insight about why they feel this way, and in acting as they do, they make sweeping judgments about, not just the patients they mention, but about a whole class of human beings.

This is a problem. I assume that any licensed physician is well-trained and fully versed in the pertinent facts of anatomy, physiology, pharmacology, and all the other cognitive disciplines a physician needs to be considered professionally competent. And to be clear, I also completely understand the obvious frustration and even the ostensible weariness such physicians express at seeing the same scenario played out over and over in their practice. However, when I see these sorts of posts, I have real doubts about diagnostic skills, not so much in the realm of physical ailments but in the domain of the social, spiritual, human dimension of the healing arts. If the default response to human suffering and perceived imprudent use of meager resources is, “Why can’t they be more like me?” the job of creating an environment for health in the broadest sense is made ever more difficult.

Every day I see patients and families who are living in communities where it is unsafe to walk the streets, where schools are crumbling, where the very fabric of the social contract that I take for granted simply does not exist. As I listen to stories of parents working three minimum-wage jobs and getting by on four hours of sleep a night just to keep a roof over their children’s heads, I am humbled. Yes, there are days when I go home from my work bone tired. But I go to a nice house. I know that I will be able to pay the mortgage and the light bill. And I also seriously doubt that I could survive the life that so many of my patients and families endure day after day after day. When you have nothing, $200 spent on a pair of shoes may have meaning for that person, as a symbol of hope, of aspiration, that I will never be able to comprehend. I am humbled daily by families who manage to get by in what for me would be unlivable conditions. The surprise, the miracle, is not that kids and families sometimes do badly in such a milieu, but that so many actually do okay.

When we doctors takes our infantile Stranger Anxiety reaction and act on it unfiltered and unaffected by mature and generous empathy and compassion, we can never truly evolve from mere physician to true healer.