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La Clinica: A Doctor’s Journey Across Borders by David P Sklar Book review by Sara Nelson, MD, and Howard King, MD, MPH, FAAP Albuquerque (NM): University of New Mexico Press, 2008 |
The older a physician becomes, especially these days, the harder it is to find time to read a good book. If we are lucky, we find a Moby Dick with good plot, development of character, and implications for our life goals. Such a book is La Clinica: A Doctor’s Journey Across Borders, an autobiographical work by David P Sklar, MD, Associate Dean of Graduate Medical Education at the University of New Mexico (UNM) School of Medicine in Albuquerque, NM.
Like many physicians, Dr Sklar chose medicine as a career because he wanted to help people. His initiation into medicine began six months prior to starting medical school. He had volunteered at La Clinica, a small, free clinic in a Mexican village where, interestingly, the patients’ needs had multiplied with modernization. The book juxtaposes Dr Sklar’s time at the clinic in Mexico with his life, 24 years later, as Chairman of the Emergency Medicine Department at UNM Health Sciences Center. Implicitly, it questions how we train physicians.
Physicians recognize that becoming a medical doctor is a long and demanding journey and entails many sacrifices. Initially, the practice of medicine deprives us of sleep and much of our youth, but most of us are eager and proud to give these up in exchange for the knowledge and opportunity that we anticipate will become more meaningful over time. But many of us will discover that this medical education exacts a significant cost upon our lives.
For many of us, irretrievable moments with spouses, children, and friends increasingly slip out of our hands. Others may give up on their idealism and turn to cynicism. And for some, the sacrifices are too great; they turn to the material wealth and power that being a physician can bring. Some make it through the journey unscathed, but we haven’t met many.
Unlike many physicians who train and practice in the US, Dr Sklar wasn’t seduced by the money and power that being a physician can bring. He did what many physicians only hope to do—he created a community of caring where people helped and taught one another at an academic medical center in the US. However, like many physicians, Dr Sklar paid a steep price. The personal costs were significant, and included his decision when he suspected that his idolized mentor might be sexually abusing an adolescent child. Another occurred when his spouse contemplated divorce in response to the loneliness she experienced from his excessive dedication to his work.
Physicians begin their medical careers learning to elicit a description of symptoms from patients, learning to think in terms of differential diagnoses, and developing the skill of prescribing medications. But how do they learn to take care of their patients or, for that matter, even of themselves?
In comparison to medical school, Dr Sklar describes his volunteer stint in Mexico as the place where he actually discovered how to be a physician. La Clinica suggests that the traditional medical knowledge for which one sacrifices so much may often be lacking in certain insights and experiences. Like Dr Sklar and many others, I (SN) became a physician to help people. But, in many ways, my years of training in medical school and residency did not prepare me to take care of the true needs of my patients.
Most of my patients present with simple medical problems but complex social issues. The medical problems are easy to fix and don’t require years of training to memorize their solutions. It is the social issues that motivate most of my patients to keep coming back to my clinic. My colleagues and I sometimes feel that we are just treading water to stay afloat. We seem to make little progress on our patients’ biggest health issues— obesity, teen pregnancy, and asthma to name a few. These are medical issues that are difficult to fix without identifying and improving the underlying issues; skills that I was not taught in medical school.
For instance, a major study out of Kaiser Permanente (KP)1 discovered that 22% of KP patients have been sexually abused as children. How does that affect such a person later in life? How does it show up in the physician’s office? What does it mean that such sexual abuse is usually never recognized or acknowledged? Have physicians limited themselves to the smallest part of the problem, that part where we are comfortable merely prescribing medication and making diagnostic decisions?
In medical training, we are taught specific rules that guide our interactions with patients. We are advised to wear certain clothes. We learn to think in paternalistic ways about our patients. These actions set us apart from our patients and serve to protect us from their pain so we can seem to maintain our objectivity when determining their treatment. They also set us above our patients and allow us the authority to advise them how they should proceed with their lives.
But setting these boundaries may have detrimental effects as well. The gap may become too wide between us and our patients with the result that we may not ask uncomfortable questions. As a result, we may fail to acquire the necessary information to help them gain mastery over their lives. These rules may also end up distancing us emotionally from our family and friends.
One conclusion we might derive from La Clinica is that we need to alter these boundaries by placing physicians closer to their patients. In the course of describing the many relationships in his book, Dr Sklar challenges us to reconsider the traditional physician/patient boundaries and the usual ideas of what it means to be a physician. He presents several typically taboo relationships in such a way that one has to reconsider whether they are truly unacceptable.
These relationships remind us that no matter how evidence-based the medical profession wishes to be, the practice of medicine is only as pure as the humanity that drives the mission. Even the free clinic in Mexico that Dr Sklar measures his life work against has a dark dimension that runs counter to conventional altruism. Medicine is mystical to the uneducated and a powerful tool for those schooled in its ways, but human relationships are equally complex and influential.
Perhaps as physicians we need to revisit the boundaries that we have collectively agreed to as a profession. Are we too focused on maintaining our distance from patients instead of finding ways to ask them difficult questions? Do our rules prevent us from finding the time to genuinely care for our patients? If we modified the boundaries with our patients, would we more likely be able to unearth the true illnesses that plague our patients?
We may need to approach our patients differently in order to help them improve their lives and find ways to interrupt those cycles, which often lead to chronic poor health. Can we find another medical model, which might demand fewer personal sacrifices of a physician but might also provide more appropriate care for our patients?
Reading Dr Sklar’s book forced me (SN) to reconsider the experiences that had drawn me into medicine and to reassess my own idealistic goals in becoming a physician. I found myself compelled to evaluate the distance I had traveled in my career and where I now find myself, twelve years later. Reading La Clinica I was obliged to ask myself, “Where do I want to go now and which path should I travel to get there?” Other physicians may find this question familiar.
Finally, the book left one of us (HK) pondering, how can my fellow educators and I teach young physicians and nurse practitioners to improve their ability to assess the emotional health of families without encouraging them to consider their own personal and professional history? Can we be successful only by teaching the use of psychotropic medications?
Isn’t it equally important to be willing to trust trainees and ourselves to reflect upon the impact of our own historical and family experiences? As was asked centuries ago, “If not now, when?”
Reference
1. Felitti VJ. [The relationship of adverse childhood experiences to adult health: Turning lead gold into lead.] [Article in German.] Z Psychosom Med Psychother 2002;48(4):359-69.
