Passages from the Masters: Leo Tolstoy’s “The Death of Ivan Ilyich” (part 2)

The next passage from Leo Tolstoy’s The Death of Ivan Ilyich more directly addresses the patient’s experience with the medical examination and the dissatisfaction that may come from the patient-doctor interaction:

… The whole procedure was just what he expected, just what one always encounters. There was the waiting, the doctor’s exaggerated air of importance (so familiar to him since it was the very air he assumed in court), the tapping, the listening, the questions requiring answers that were clearly superfluous since they were foregone conclusions, and the significant look that implied: “Just put yourself in our hands and we’ll take care of everything; we know exactly what has to be done–we always use one and the same method for every patient, no matter who.” Everything was just as it was in court. The celebrated doctor dealt with him in precisely the same manner he dealt with men on trial.

The doctor said: such and such indicates that you have such and such, but if an analysis of such and such does not confirm this, then we have to assume you have such and such. On the other hand, if we assume such and such is the case, then… and so on. To Ivan Ilyich only one question mattered: was his condition serious or not? But the doctor ignored this inappropriate question. From his point of view it was an idle question and not worth considering. One simply had to weigh the alternatives: a floating kidney, chronic catarrh, or a disease of the caecum. It was not a matter of Ivan Ilyich’s life but a conflict between a floating kidney and a disease of the caecum. And in Ivan Ilyich’s presence the doctor resolved that conflict brilliantly in favor of the caecum, with the reservation that if an analysis of the urine yielded new evidence, the case would be considered… From the doctor’s summary Ivan Ilyich concluded that things were bad, but that to the doctor and perhaps everyone else, it was of no consequence, even though for him it was bad. And this conclusion, which came as a painful shock to Ivan Ilyich, aroused in him a feeling of great self-pity and equally great resentment toward the doctor for being so indifferent to a matter of such importance.

This characterization may require a closer inspection of Tolstoy’s perspective. First, Tolstoy wrote this short novel in the mid-nineteenth century, before the advent of Germ Theory, the rise of hospitals and academic medical centers, and the development of a more rigid link between scientific discovery and medical practice. Secondly, although it is unclear whether or not Tolstoy himself had similar interactions with contemporary doctors, he did have a long and agonizing obsession with the subject of death and the process of dying.

With that in mind, what does this characterization mean to a physician-in-training in this day and age? I’m concerned that as much as I would like to think of physicians as a relatively tight knit professional group in comparison with other fields, there is still a degree of heterogeneity that is recognizable not only to members of the field but also to patients. I think this heterogeneity has less to do with diagnostic and technical skill and more to do with being personable and approachable. When we talk about “good doctors” and “bad doctors,” we are usually referring to their manner rather than their ability (since patients are not necessarily good judges of diagnostic or technical ability, especially since a “bad outcome” may be the result of an excellent physician working with an intractable case). Reflecting this notion, Tolstoy’s protagonist finds his only question unanswered and his only need unfulfilled by the physician’s approach. In this case, the physician failed to address the patient’s concerns. It is a failure of empathy rather than communication: Ivan Ilyich’s question of the seriousness of his condition was not difficult to convey, but the doctor did not take any measures to properly address the patient as a person (rather, he focused on addressing the body and its mysterious disease) and affirm that his concerns are important.

I think this is a relatively simple lesson for physicians-in-training: always take a moment to walk in the shoes of your patient. I think this is not difficult for many physicians, but many others do fail at this task for a variety of reasons: through a failure to be open to questions, a failure to address the patient’s understanding of his or her condition, or a failure to consider the person as well as the diseased body.

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