The Blue Tent: When Medicine Must Be Violent
Updated: Feb 16, 2022
Marisa Guerin, PhD – February 15, 2022; Edited February 16, 2022
Some time ago, during the early phase of my cancer treatment, I wrote a blog post on how I would desire to have a nonviolent relationship with cancer. I didn’t, and still don’t, want to have the attitude of a warrior or a fighter, even though I am determined to give medical science every opportunity to eradicate the cancer cells that shouldn’t be misbehaving in my body. However, along the way I have been learning more about the times when medicine must be violent, and how that is managed.
As I navigate each succeeding stage of treatment, I am gaining first-hand experience with being a patient and being the recipient (also beneficiary, and in some ways victim) of advanced medicine in the first world. Aside from the intense personal impact this journey has on me, it’s a fascinating ride, especially for someone like me who previously mostly interacted with healthcare organizations as a consultant to administrators who are trying to effectively manage such complex systems. I pay attention to just about everything.
For several days now, I have been ruminating on the highly mechanical, regimented, impersonal features of delivering care. By mechanical, I mean that the human body is connected to all manner of machines in the process of care, and attached to bags of fluids, syringes of medicines, and then measured every time you turn around to monitor what that mystery, the human body, is doing now. Mechanical means that every procedure has its supplies and equipment, each item swiftly unwrapped from its individual plastic packaging by the nurses, and quickly plugged in or attached or whatever needs to be done with it. I try not to think of the oceans of discarded plastic leaving every hospital every day.
Mechanical also means, at a very sophisticated level, the more invasive and actually-violent types of care: surgery, radiation, ventilation, amputations, high dose chemotherapies, etc. There is no getting around the fact that some of the ways that have been developed to cure, or at least treat, certain health issues involve first assaulting the body, and then helping it recover.
Despite very best effort, even dramatic and invasive interventions don't always work, and the risks that the health care workers and the patients accept are sometimes stressful in the extreme. My experience is confirming for me what I have learned about how people unconsciously cope with potentially debilitating stress at work. Some of the earliest research on the psychodynamics of the workplace involved studies of nurses who followed rigorous protocols even when they didn’t make sense on the surface, like waking a sleeping patient because the schedule said it was time for their sleeping pill. The insights that emerged from these studies illuminated the reality that when faced every day with life and death consequences of their work, medical people resort to unconscious protection from the psychic stress of their responsibilities. They do this, at least in part, via the socially defensive nature of their shared professional protocols. Social defenses are not consciously enacted; they emerge as useful behaviors that are unconsciously incorporated into the workplace.
I thought of that analysis the other day, as I was being prepped for the surgical insertion of a port into my neck for the collection of stem cells from my blood. The nurses strapped me onto the operating table, carefully cleansed the neck area, surrounded the surgical site with soft absorbent fabrics of some kind, and placed a blue cloth tent over my head and upper body so that the only thing the doctor would see of me was a six-inch patch of my neck. The area was numbed with local anesthetic. All of these professional routines help the doctor who is doing the procedure to stay focused on the important things and they ensure a sterile operating environment, for sure; but they also effectively serve to separate the surgeon from any personal connection or affective tie to the person whose neck he is about to cut into with a scalpel. In psychodynamic terms, the regimented and familiar routines of safe operating room procedures were simultaneously acting as social defenses for the doctor and the nurses against the difficult emotions aroused by anxiety and risk.
On that day, as I observed all of this preparation for surgery, I was touched, amused, and reassured by the first words the doctor said to me, unseen on the other side of the blue tent, as he arrived to begin the short operation. He asked me if I had relatives in New Orleans, because he knew people there with the same last name as I have. (It turns out I do not, but we had a short chat about it.) I don’t know if he was consciously intending to make a personal connection with me, or if he did something like this with everyone, or if it was just happenstance literally because of my name, but he effectively reached right through the blue tent and made me feel the human link that was so helpful for me to get through the next half hour. He was a person, then, not just a skilled expert. It made a difference.
This individual initiative, not-scripted, matters because a day in a medical center is a very different experience for the patient than it is for the caregivers. For me, as a patient, life is full of first times with this or that treatment process, and each day is an important day in my own life. Meanwhile, each day in a major healthcare center repeats the human dramas of every previous one, with a hive of medical staff and support workers and others all busy about their assigned duties as a river of patients and their families present themselves for care. The needs that appear on any day go from the anguish of a lethal accident or terminal illness, to the excitement of a new birth, to the rites of passage involved in setting a child’s broken bone. For each patient on each of these endlessly repetitive days, being personally "seen" and feeling an authentic connection with the health care provider is important.
To return to the starting point of this reflection, I realize that the highly mechanical and procedural nature of healthcare is not only due to the scientific precision that is involved in this work; it is also functioning to defend the healthcare workers from a debilitating level of awareness of the violence, pain, sadness, worry, and fear that their patients must experience. It is always a balancing act to make sure that the "normal" impersonal routines don't extinguish any emotional connection at all. There are clearly many illogical, wasteful, or apparently unnecessary steps involved in the delivery of healthcare, but when you think about the pressures the staff are under – from psychic stress to regulatory and legal exposure – they kind of make sense. In fact, in light of the intensity of their jobs, it is a wonder that so many nurses, doctors, and techs reach out with friendly words, a reassuring tone, and kindness.
Sadly, what we have seen in the last few years is the crashing collapse of these defensive routines in the face of the intensity of treating severely-ill Covid patients. It is a crisis of the first order for those on the front lines. I don’t have a solution for it, other than to hope that public health measures are more successful in the future than they have been recently, at least in the US.
From my alternate identity as an organizational expert, I have often commented on the impossibility of truly effectively managing huge and complex healthcare systems, especially in the US where there is no sensible working safety net in the way of universal insurance or accessible care. From many angles, delivering medical care effectively seems like an impossible project. But from the perspective that comes from my identity as a patient, I find myself with enormous amounts of sympathy for healthcare providers and the daily arena of human encounter that these good folks find themselves in. They make it work, over and over, and over.
I wish them, and myself, well.