All The President’s Doctors

All the President’s Doctors: Walter Read and the Collusion of Anonymity
by A.R. Pito

Even today, Michael Balint’s seminal book, “The Doctor, His Patient and the Illness” is essential to understanding how patients are managed and treated by physicians and caregivers.  When one considers Team Trump at Walter Read we see this on a granular level.

Excerpts from Balint’s book:

Chapter 7: The Collusion of Anonymity
In difficult cases, the general practitioner [PCP} does not, as a rule, carry the burden of responsibility alone. The appearance of consultants introduces a number of new factors in the doctor-patient relationship

The term the collusion of anonymity refers to who is responsible for the patient – the general practitioner, the surgeons, the other physicians, psychiatrist, or all the various assistants. The collusion of anonymity leads to the fact that vital decisions for the patient’s wellbeing are taken without anybody feeling fully responsible for the patient.

Chapter 8 The General Practitioner and His Consultants
There are many complications caused by the entry of a consultant into the doctor-patient relationship. This may lead to dissipation of responsibility. Important, often vital, decisions are taken without anyone accepting full responsibility. If the two doctors involved are a specialist and a general practitioner, the relationship can be summed up as the perpetuation of the teacher-pupil relationship. The general practitioner looks up with ambivalent respect to the consultants. It is true that some consultants are more than willing to preserve this teacher (professorial) status. This status does not enhance patient care for the most part

Many consultants feel obliged to pretend to know more than they actually do. In many instances, the general practitioner looks up to the specialist as to a superior being and allows him to treat the GP [PCP] as a kind of dispenser of drugs.  Particularly in busy outpatient departments, verbal instructions are often given not by the consultant himself but by one of his registrars (lackeys), or perhaps even a houseman. What the junior staff says to the patient after the examinations have been done is, with rare exceptions, left to their common sense or power of imitating the “great white chief.”

Chapter 9. The Perpetuation of the Teacher-Pupil Relationship
[When] the burden of responsibility is much too great and everyone, including the patient, naturally tries to lighten it by involving someone else, or, if possible, a number of others. This may be described as the process of dilution of responsibility.

[An emergency medical colleague told us that “no one wants to carry a coffin alone!”]

If all goes well with this collusion of anonymity all parties concerned feel justifiably proud and gratified. If anything goes wrong nobody is individually responsible.

The collusion of anonymity is one method of lightening the burden of responsibility. The present day practice in medicine is hardly more than the sum of the various specialties.

Nowadays everybody preaches that when a patient is ill the whole person is ill, not only his skin, stomach, his heart or his kidneys. This truth, while constant lip service is paid to it, is unfortunately ignored in every medical practice. A very experienced and disillusioned GP said, “Nowadays, it is enough for a doctor to know about 20 prescriptions and the addresses of about 30 consultants.”

Look at the last two — Isabel Wilkerson’s “Caste” personified!
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About David Elpern

The Online Journal of Community and Person-Centered Dermatology (OJCPCD) is a free, full text, open-access, online publication that addresses all aspects of skin disease that concern patients, their families, and practitioners. ​It was founded in 2012 by Dr. David J. Elpern, M.D. in Williamstown, MA. with technical help from Inez Tan.

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