Great expectations

Every time i meet a patient i make a judgement on them. I listen to how they speak, the words they use, trying to work out their level of intelligence.

I look at their clothes, make up, their address, trying to work out if they’re working or middle class, trying to scope out high or low income. I ask what they work at – for occasional pure pathological reference but mainly to judge them socially.

I check out the tattoos, the piercings, i look for the tobacco stained fingers.

I put all the picture together and use it to try and figure out what could be wrong with them.

Now you’ll be glad to hear that i also ask them about their symptoms and do that magical, mystical doctor examination thing (which is largely just poking and prodding them to see if it’s sore) – before i decide what’s wrong with them.

But the first bit still has relevance.

Virtually everything i do is a probability judgement. There are a few definites – the off ended bones going in different directions on your x-ray are definitely broken, but can i tell you that your tummy pain isn’t appendicitis – not unless i take your appendix out. All i can give is a probability judgement

The majority of what i do is guesswork. Expensive and highly trained guesswork but guesswork all the same.

And the guesswork is highly influenced by how i judge you as you walk through the door, by all the social and physical characteristics that i rate you by.

If you are from a poorer socio-economic background you will have poorer health. In America, if you are black or hispanic you will have poorer health. Or is that just cause you’re poorer with no insurance…

My job exists at the border of what in most circles is considered pure judgementalism – ‘they look dodgy, they might steal my BMW” and pure science, “yes your IV drug use makes you more at risk for infected heart valves and hepatitis C”

I ask more eastern european immigrants about cocaine use in relation to their chest pain than i do of nice looking middle class northern irish guys.

the question is not whether nice middle class northern irish guys in portadown use more or less cocaine (some do, though most don’t have access to it, different story in antrim and belfast and the rest of the UK. The eastern europeans are in a much smaller community where cocaine is more prevalent), my question is more about the morality of my judgements.

How do i divide the judgements i make – how do i work out which ones are bordering on racism and presumption and how many are “clinically justified?”

How is it different from a police man who pulls over more eastern European drivers on a sat night because he knows that “they’re all drink drivers” and me asking questions about sexual history and illicit drug use to guys with tattoos?


5 Responses to “Great expectations”

  1. 1 hedgemonkey August 12, 2009 at 1:00 am

    With that post you reaffirm your place as my favourite Doctor ever … (and let me tell you that is an exceedingly short list).

    It is a sad truth that our brain’s work best with associations and by wandering down dark avenues which join up assumptions. I am not immune to caricaturisation but I do take more delight in the loquacious dread locked crusty than most. Also, perversely it is healthy to remind folk that ‘white collar’ crime damages more of the populace than ‘blue’.

  2. 2 Nelly And I August 12, 2009 at 8:55 am

    With you on that one hedge

    when i judge a patient by looks (which is so much of what i do, ie “they look jaundiced, they look gaunt, whatever) then i try to pretend that it’s all “clinical” when in fact it is a profoundly moral judgement that i make most of the time.

    I continue to become more and more of an ardent socialist as time passes, though i just can’t do the dread locks and the facial hair, will keep trying though…

    PS i always loved your crusty locks…

  3. 3 hedgemonkey August 12, 2009 at 9:41 am

    Chairman Mao had neither dreadlocks nor facial hair so there is hope for you yet my friend.

  4. 4 Nelly And I August 12, 2009 at 9:47 am

    It’s good to be in fine company then…

  5. 5 Roads September 3, 2009 at 5:06 pm

    Fascinating post, Andy. I’ve often wondered about those split-second judgements that you have to make. I guess that doctors would make great Customs Officers, then?

    As a student geologist, I once had a few problems with them. ‘What have you got in the back of your car, sonny?’ ‘Just half a ton or so of rock.’

    Cue two hour wait while drug-sniffing sniffer dog is called. Arrives, and checks my car to find half a ton or so of stones. Which I had oh so foolishly referred to as ‘half a ton of rock’.

    We live and learn. I must have looked dodgy then, in my ageing rusty Fiat. At least to a doctor or a Customs Officer, anyway.

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