‘‘The Medical Self’’ 83
Ill physicians interacted with their doctors differently than did other
patients. Self-doctoring muddled boundaries and roles. Sick physicians
tended to expect and/or receive VIP treatment. As a result, roles at times
clashed, and decisions emerged on whether openly to disagree, confront,
or challenge their physician-of-record. Some chose close colleagues as
physicians, further confusing or colluding roles, and avoiding confronta-
tion with one’s disease. Through these choices, denial assumed multiple
forms.
These narratives raise key questions of how therapeutic styles function
more generally in lay patients’ preferences and experiences concerning
treatment referrals. Therapeutic nihilism has been mentioned, usually as a
strategy to be avoided. Professionals often face countervailing pressures to
help severely ill patients as much as possible now, rather than waiting for
the completion of definitive studies at some point in the future (8, 9). But
I have not found any studies of therapeutic nihilism as an approach or
principle in clinical decision-making: when and how commonly it shapes
physicians’ decisions in referring patients or prescribing treatments. Are
colleagues’ perceptions of therapeutic nihilists correct? How consistent
are physicians in their styles? Lay patients as well no doubt perceive such
differences among physicians in therapeutic tastes, styles, and nihilism,
but patients’ observations, preferences, and responses concerning these
categories remain unknown. The role of subjective factors in clinical re-
ferrals more generally has also been neglected.
Similarly, these doctors reveal that physician reputation influences
referral patterns in ways that might impede patient care. Yet little research
has been done on the composition and accuracy of physicians’ judgments
of colleagues’ reputations, which thus need to be explored.
To some degree, physicians here chose their patients. But it is not clear
how this phenomenon operates more broadly, and how commonly, and
whether lay patients experience or observe this process. Research on pa-
tient satisfaction has focused on whether patients feel they have a choice
or not, rather than examining other key components of satisfaction,
such as aspects of the compatibility or ‘‘match’’ between doctors and pa-
tients, and the ways lay patients balance trade-offs between empathy and
skill, and resolve disagreements with their providers.
Prior research has viewed patterns of self-doctoring dichotomously, as
either present or absent. But questions emerge here of how doctors de-
cide where to be on this spectrum, and how they support, maintain, or