Counseling, doctor visits, and why it can be so hard to find good help

I came across this post via Brute Reason. The author is a counselor.

The course I hated most in grad school was taught by a professor who said, “If your clients talk about the outside circumstances that keep them down and make their lives horrible, about how they’re so hard done by, they can’t ever take responsibility for their own lives.”  It was supposed to be a course on marriage and family therapy, which is a topic I love a lot on its own; but most of what I learned was about the use of institutional power, from a rich moderate liberal white guy who thought that talking about inequality of any kind was actively harmful to therapy.


I had to noticeably hold the door open to conversations about inequality.  There is a lot that subjugated groups know about their experience that they likewise know isn’t safe to talk about with people who have privilege over them, whether the power differential is sex, race, disability, or anything else.  In therapy, clients fear that relationship-shattering moment when their therapist–someone who has so far been a warm and supportive figure–strikes out at them from a place of privilege to enforce social norms.  If I say, “Oh, let’s not make this a race issue, not every white person is racist,” I’m proving that I, at least, am a white woman it’s not safe to talk race with.And often when I opened the door, the immediate and enthusiastic response was the equivalent to, “I’m allowed to talk about racism? OH MY GOD LET ME TELL YOU ABOUT THE RACISM I’VE SEEN.”

Now, the original author was writing about racism, and I’m going to take that ball and run with it a bit. This dynamic exists in medicine, too. Perhaps the easiest example is where the tone of your doctor visit switches, as he/she tells you that you need to quit smoking, or lose weight, or exercise more. If you’ve never had a visit like that, congratulations! Keep doing whatever you’re doing. But for everyone else, this is often an uncomfortable experience. It’s uncomfortable for many doctors, too.

But it’s certainly true that there are elements of privilege here. If you look at AMCAS data for medical student demographics, you’ll notice a lot of medical students have one thing in common: wealthy parents, usually a stable upbringing. And this is in addition to the ability you need to get INTO medical school: reasonable intelligence, a solid work ethic, etc.

Maybe there was a time where medical students were mostly bookish and not super physically active. I’m not sure that’s still the case; at my school, many of our really good students were also generous volunteers who were also in great physical shape who also had good relationships with their family who also had research interests… you get the idea.

I would hazard that the reason these “let me tell you what you need to do” moments is not because what the patient is hearing is uncomfortable or unwanted advice. It’s because there is a ton of privilege being conveyed all at once. You’re a Black woman. Your doctor is an older white guy. He’s about to give you advice on how to live your life better. How awkward is that?

Okay. Now let’s turn things up a notch. Your doctor is a somewhat conservative guy. What does that mean for you?

Keep going. Your doctor is a very conservative dude, who loves talk radio, boats, and by the way he’s an OB/GYN. Shit, is it Ron Paul?

We’re switching gears. Your doctor now loves NPR, organic food, and yoga. And your doctor is now a white woman. Will this affect your doctor visit? Are you sure?

Now, this sort of stuff doesn’t matter in many situations. If you’re diabetic and discussing what medication/diuretics you need, great! If you’re discussing your cancer progression, again, hopefully this won’t matter. Or will it? Wait! What if your cancer is causing you pain? Uh oh.

Racial/ethnic minorities consistently receive less adequate treatment for acute and chronic pain than non-Hispanic whites, even after controlling for age, gender, and pain intensity. Pain intensity underreporting appears to be a major contribution of minority individuals to pain management disparities.

Why is that? I mean, surely we’re dealing with purely medical matters–pain is, after all, considered by some to be “the fifth vital sign”–so surely treatment shouldn’t vary, right?

So to sum up this mess of a post… you’ve got a lot of privilege if you’re a doctor, or counselor, just by virtue of your role. There is an excellent chance you have other privilege–wealthy parents, a more stable upbringing than most, or just the fact that you’re goddamn smart and hardworking.

As a result, when you’re a patient going in to see one of these people, it can be damn uncomfortable. When I first started seeing doctors at my school, they treated me like one of the gang. It would have been great, except this mostly involved quizzing me on trivial bullshit, or asking me what I would do to treat myself (yes, really). I was one of them, just having some temporary setbacks!

And then I kept being sick.

And slowly, things changed. I was depressed and in need of attention, or something. I wasn’t a medical student like my doctors were, no–I was struggling, or clearly uninterested in being a doctor. For shit’s sake, autoimmune diseases run in my family. If someone has the flu you don’t ask them if maybe they just don’t like their job, do you?

And then I was just another patient, one of those weird people who shuffle in a few times a month to get some pain pills or emotional validation or who fucking knows. I was usually a good two decades younger than any of the other patients, so that was unusual, but otherwise I filled a similar role.

Over the course of two years, I basically got to watch my doctors’ level of respect for me slowly drop. When I first switched to my current one, she was excited. A sick medical student! I just needed some proper TLC and then I’d go pass Step One and be a cardiologist or neurosurgeon or who knows. A fixer-upper! A project! Yes!

And then I kept being sick. And I was less exciting. And more of a pain in the ass.

And that’s where I still am today, unfortunately.

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