Anatomy of a Medical Examination
"Patient Observation, Diagnosis and Transference"

People love tutorials like the 10 things you need to know ...

Dentists want tutorials about how to get their patients to spend the money for dental care. To push sales. To market themselves. Possibly to some rich Joe. Who does not trust them. The dentist feels disappointed. He has debts: his own enterprise.

 

C. is the first booking of today.

I look at her, I ask the only question I'm interested in:

- Who sends you to me, with all the dentists all around?

She answers - P., not her, a common friend.

P. is a dear patient of me, a fan.

The big secret of dental marketing: what do people say about you. The word-by-mouth. On the Internet too. But we careless fools post on Facebook any kind of crap lurking for approval out of a huge self-esteem problem. Like beggars in the courtyard of the church at the end of the Sunday Mass. Academic titles, scientific publications no one cares on socials. Office in downtown, luxurious furnishings, expensive cars they build no ranking. People look for the real You. They want to know who you are. They can get it easy from what you write. How you write. No communication-guru or ghost-writer can do it for you. What if I can't write? Learn or let it. Just relay on the word-of-mouth of the doorkeeper of the building. Do not copy and paste from someone else's website as some fools were doing with me over the years. Because when you show up in reality in front of your Joe and you open your mouth, there will be something wrong with you. Some clashing, kind of cognitive dissonance between what he has read on your copy-and-past website and the "cruddy-cheater" in front of him. But Joe feels it. He is suspicious after all the daily rubbery he incurs into. That is, he will just say thank you for your beautiful treatment plan. He cognizes the knowledge... but he needs time to think. Do Svidania.

I'm standing. She is scanning my eyes looking for some positive feelings after her response.

She has horrible teeth. She is a beautiful woman. Tall, skinny with fine features, beautiful face, big, blue eyes.

- Of course, P., great personality and a dear friend.-

C. is 59 years old but looks younger. Straight shoulders. Of someone doing sports. The gait is harmonious with sort of compound consciousness. She is impeccably dressed. Sober but with a fine taste. She smiles with her eyes not showing her teeth. We shake hands. Sincerely. Not that dead hand almost elusive, which means I give you the honor to treat me, you dentist, you sort of a hairdresser with a degree but always a servant on the payroll of someone. And you please don't touch that hand too much. And possibly show a little more your servitude bowing down with deference. I pay and you serve me.

A handshake tells you more than any NLP (neuro-linguistic-programming) bullshit.

To catch the endless amount of details blossoming from a human handshake you need time, mood and the gift: to be focused.

I ask her what she is doing for a living - I write children's books – she answers - I live between Milan and Hong Kong because of my husband -

She is no middle-class dweller. She's is wealthy. Perhaps very much wealthy. She does not impress me. It would be a serious mistake.

I ask her about children - 3 – her reply - unfortunately. - That makes me even more curious.

- I fell to the common credo: to have children is the only way to feel a woman.

- welcome to the club - I reply - I have 6. I also thought the more the children the bigger the honor! So ... the one in Hong Kong is a second marriage? - I guess.

- Yes, with the first one ended up in a bad way. But for his own sake. He was bored -

Suddenly she turns back to the dental topic softly smiling:

- I know you are a bad tempered and you don't accept new patient easily. But I really do have a serious problem with my teeth -

She knows I'm analyzing her. Is no financial rating. It's all about human minds.

I ask her - do you know Nassim Taleb, the writer ? His books The black Swan? Antifragile? I understood late in my life the difference between a scalable and non-scalable job. Mine is a non-scalable one. As far as I do prolongue my working time I will hit a ceiling. No way for the big money. Indeed I didn't make it. I have only 2 hands, my time is finite, my energy as well, I'm close to 57 and less than one third of life left, perhaps a dozen years still in good condition. That is why I select only patients who do not engage too much my neurosis. And money is not a priority for self-injury.

She is trying to read my mind. She is very attentive. Humble but not shabby. Determined but aware of her weakness. With an urgent need to dump her fragility to someone. I suddenly break the silence:

- what zodiac sign are you? I noticed that people borne under the same sign they share common features. I read a book some years ago by Kary Mullis. A real genius. Nobel Prize winner for discovering the DNA polymerase. He made statistics ...

- I'm a Libra

- oh...like me, now I understand ... the good taste the pleasure about details, the creativity ...

Minds are on stage. I drive her, she follows me. We are tiptoeing the non-verbal communication ballet. She anticipating my questions. A rare synchroncity. We're communicating in a code. Encrypted and comprehensible only to the both of us.

I start to visit her. I put her laying and pull down the third eye, my microscope. She is scared. My assistant wetting the mirror.

There is nothing worse at the beginning of an oral examination than to pull open a dry mucosa with a dry mirror. And maybe even miserably. Sourly. Without caring about the disconfort of patient. As if you were handling inanimate matter. The human being, of any social cultural level, unconsciously perceives it as indifference or poor attention or even worse as a lack of skill.

Just touching the tongue she reacts with the muscles of the lips and cheeks. She is resisting to me and my assistant. I stop. I do not insist. I remove mirror and probe from her mouth. I lift the microscope and look at her. I see the helplessness surfacing. Eyes half-closed, as on the psychoanalyst's chair. She talks

- I know ... I'm not easy to treat and I'm scared ... I know I'm not the ideal one for the dentist. You just make me sleep and do what is needed -

I normally do not treat patients if they can not stand a dental cleaning. Her girlfriend told her. But she is so humble and kind, one of those people extremely polite in showing their own weaknesses. She arouses in me the feeling of compassion. To care about others a priori as a remedy to the existential misery (Otto Rank).

I'm trying to unravel the dental riddle.

- You have a big problem, seems a big job is needed –

checking her reactions - I do not understand how you could have come to this point. Or your dentist hated you and wanted to get rid of you or you didn't pay him - I add, smiling.

She smiles. She says she has got only some dental cleaning of her teeth. The dentist never tried anything heroic in her mouth.

Maybe she frightened him so much that the poor man was well scared about taking any kind of decision.

- Better the policy of delaying than preventive-positivist interventionism, - I replied, - so beloved by doctors and from masochistic patients.

Nothing is foreseeable. At the very least the individual reaction of a human being. Diseases heal by themselves in 95% of cases. But nobody cares because there is no profit in self-healing -

I'm provoking her with a bit of cheap conspiracy. She does not understand well, but she realizes that there is a bottom truth in what I say.

She has lost teeth and there is no bone to make implants in the upper left quadrant. I explain her briefly the two therapeutic alternatives I have in my mind.

I tell her that what I see today is not what I'll see tomorrow. That my observation can not be objective because it's influenced by many things. From my physical status of today. From her behavior as a patient during examination. From what she wants me to see or not. Even memories in my brain may affect my perception, my vision. Or a book or a paper I have read may influence my judgment. What I say today could be different tomorrow. Perception is the result of the recordings through the 5 senses. In the central nervous system informations are filtered and integrated with past memories and emotions: the result is far from being real. Diagnosis indeed is a mystery. Is kind of ars that requires some degree of consciousness. That is, to be aware that there is one's own mind and that it can be influenced by the patient's mind: the counter-transfert of psychoanalysis. But medical doctors, dentists too, seem to ignore it. We are in our daily job at the mercy of psychological issues that have been analyzed studied classified and largely solved for 100 years. Freud, Jung, Adler, Rank, Fromm, Becker, Klein, Popper ... nobody talks about them in the medical domain. What you don't see on an x-ray or in blood tests - does not matter. Then you feel lost if patient does not heal.

Positivist science and Objectivist technology have been proven enough of their weakness. Pretending to solve everything. Pretending everyone can make proper diagnosis and heal people.

I go back to the result of my observations.

- The bone defect is huge. One possibility of treatment is surgical, with bone graft from the iliac crest and a long healing time. The other one is only about crowning teeth. Just Prosthodontics and with a quick scheduling. 2-3 months and game over -

She has no doubt: she does not want the pain, she does not want the waste of time. She is nearly 60 and thanks the good genetics she is still a beautiful woman. She is short on time. She wants everything now. She asks the success rate of both possibilities. She wants numbers.

I remember her about the Seneca's barbell: odds are numbers generated by human minds and therefore fallacious. What matters is to assess the seriousness of consequences in the event of failure of one or the other hypothesis. A surgery failure causes pain, a huge loss of time, complications such as a sinusitis, infections canceling the possibility of future fixed teeth. With the only-prosthodontics hypothesis, that is, a long bridge with a cantilever of 1 or 2 teeth in case of failure nothing bad happens. The surgery-implantology-thing is left to the next unforeseeable future.

I stop her again. I want to get her away from the topic:

- I love the writing, I'm just an amateur. I would love to read something of your books. I'm curious.-

She is smart. She is dangerous. Not hostile but you can't pretend with her. Cheating is not an option. Willingness and commitment are mandatory. She wants to surrender unconditionally to the doctor. She wants the transfert. What psychoanalysis names transference: the way the patient hands over to the doctor all her anxiety, all her taming of life and death (Ernst Becker).

I'm thinking.

The cost of time and energy is huge. Responsability is killing you. You have to take it into account when you charge. Otherwise you go broke economically and physicallly. You set the fee for your own brain-damage. The transfer of a patient like this is terribly harrowing. She will stitch to you forever.

The better the result the longer the relationship the heavier the transfert .

"I have 20 full-mouth rehabs work in progress since more than 3 years and some of them will not end-up before 10 years!" tells me a colleague about a third one so proud of his heroics. I shiver. The guy is totally unaware of what he is doing. Of how much misery will be transferred to himself. Of how much brain damage. People wonder why dentists are scoring high for premature death.

C. has already decided.

Without a mock-up.

Without showing her my best pieces of heroism.

Without DSD.

Without condylography or CBCT scan.

She trusts: she is transferring on YOU all her fears doubts responsability of decision and helplessness.

Exactly at that point I become God for her. I'm empowered to predict the future. I am overwhelmed by the immense burden of the decision. Of the responsibility. I fear her submission. She looks for shelter against the unpredictable frightening Nature. She wants to lose herself to a higher entity that will solve everything. She feels helpless. Weak. At the mercy of the unknown. She feels guilty. I look at her. It is the guilt of being a human creature, perishable, helpless ... food for the worms at the end of the story (Søren Aabye Kierkegaard). It's quite similar to the first period of the falling-in-love situation. When you confer the keys of your own heart and soul, that is, of your existential discomfort to the beloved one.

She recognizes I am well trained in negotiating.

By mean of role-playing. Me, the overconfident doctor, pretending to be the allmighty creator who will restore her lost beauty. Though I'm perfectly aware of my human limits. I may accept the burden of enduring the transfert, that is, your existential anguish. There is no money to reward such a psychological hard work.

The only way out is to quicken procedures as much as possible. The faster the care the less the psychological bothering for both, the patient and the doctor.

Because that psychological cosmical dependance from a medical-deity is absolutely dangerous: at the first mishappening you are no longer God. The patient will regret furiously why she trusted you. She will feel guilty about her naive yielding. Abrutply and unconsciously the former operator's dependence shifts into anger, disdain, hatred.

Like a rejected girlfriend.

Because you're no longer God. You are no longer the Hero. The Good Almighty Father. Actually you never were. But patient's mind didn'trealize it. Only now. Suddenly she understands your fallibility. Your being human. She feels betrayed. The self-confident incautious narcisistic operator at this point is terrified. He also too is now conscious of his own helplessness. Of his being mortal. Fallible. He starts to panic. It's the dawning of the up-coming disaster. The doctor-patient relationship transforms to hell. The Negative Transfert kicks on: you become the target of all anxiety and fears of the patient. You are the devil. The primary cause of all existential misery. I have witnessed, as a law-court consultant, patient requiring psychiatric treatments because of alleged dental mistreatment. The poor dentist convicted to pay. Butchered. Like in a slaughter-house. Lawyers around you like sharks. Jackals of human psyche.

C. keeps silence. She is waiting. I'm listening to my voice almost melancholic, fully aware of the ongoing negotiation. I don't want the burden. She smiles gently. She knows the money-leverage is not gonna work. I wiggle out of her kindness . - we will do a dental cleaning first. I will do it myself. To know each-other. I need time to focus the problems. I want to feel them with bare hands. -

I explain her - ... because in any case, the right treatment plan will unravel by itself during the work in progress. I am not God and I may be wrong. There is no instrument or exam that can give you certainty. There is no therapy fully predictable about outcome. There is no decision that can not be proved wrong. I am just a little, helpless human being at the mercy of an immense biological universe. The individual factor, the healing ability, the willpower to recover of the patient are crucial throughout medicine.-

Deep in my mind I just want to figure out whom I am dealing with.

Because the burden of responsibility is just mine. Only mine. The cruel solitude of professionals. Alone in their dental offices.

She does not listen anymore: - do as YOU think is ok - she says straight to the point - I trust you more than myself. Also for aesthetics. I understand you know more than me. The only thing I care ... let me sleep... please! Life is already a misery. If you relieve me the game I would be grateful-

I'm thinking again.

In dentistry, not one word about the human mind. The most complex and powerful tool we have at disposal. She can heal or make you sick.

She can mend or kill you. A iatrogenic devil.

Of course she overestimates my skill. I am aware of it. I am yet worrying about the hero-game. I know it very well. I'm figuring out how much mental and physical energy to do the job.

C.G.Jung says the transfert is necessary to help people healing.

Medicus Ipse Farmacum, official Science admits it: Psycho-Neuro-Endocrine-Immunology. The mind of the physician through the transfert affects the mind of the patient by stimulating the immune system and consequently the ability to self-healing and self-regeneration. The doctor is kind of Shaman.

The physician is supposed to put on work the transfert.

But not everyone can. Not everyone will. Not everyone has the power.

Is not enough to get courses or to buy the intra-oral scanner or a Microscope. And you should be taught about the side effects of it. When I got patient saying like "YOU are unique" or "YOU are God "or "I want only YOU touching my teeth no one else " I felt accomplished. My self-esteem rocketing. Ten years ago I had a dear friend. He died unfortunately of cancer. He was a Catholic Bishop, Monsignor Maggiolini of the Diocese of Como. He had a complex jaw-surgery with me. A challenge for me. A Bishop and at the same time an old man with many medical issues. No one wanted to operate him. After 7 days he came to remove stitches. He got a miraculous healing with no pain and no swelling. He gathered all my staff in my office, made them kneel, silent them all and blessed my hands, declaring them as a holy gift from the Lord. I was of course proud and relieved but at the same time exausted. I told him to be agnostic. Nonetheless he asked me to get the privilege to have me to dine privately with him in his Diocese of Como. He was very grateful. He knew what happened in those 3 and half hours of surgery. He was a man of great knowledge, a philosopher and theologist. A Jesuit father. A powerful mind. We had a great time discussing about philosophy, sociology, anthropology, politics. I felt a hero. Hence I did not understand what I had done. We were close friends until his death.

 

C., cleverly, gives me the final kick. She does not even ask my fee. I don't care about the money, but I feel honored. She just asks to be emailed a draft budget. She wants to pay.

My mind smiling about the DSD - I-Pad theater. Thinking about the people working with me. The dental technician who will do the job. Those who live next to me. All patients texting you on Saturday evening because with no mean but to get rid of fear. All of them don't know the psycho-horror of our job. They can't. No one explains them. No one cares. Only when psychologists draw statistics they notice how much people screw-up. The adagio is: the doctor got tired because of stress. It's all about depression. And his bad temper. He is getting Antidepressants...

One of my closest co-workers a few years ago shoot himself. He had been sick in the brain for a long time, people said. Unlike many others, silently dieing. Day by day. A heart attack. Or a stroke. Or cancer.

The burden of medical responsibility is pure heroism. Especially for a dentist. He is (that's the law) responsible for 10 years (in Italy) for his work. A life sentence. Totally untrained. A daily burden. Unready especially the young and inexperienced professional. A life devoted to defend your agency. Documenting obsessively everything. Desperately striving to validate your work appealing to guidelines and protocols. Relentlessly looking for more education, more technology but above all for a leader to definitely get relief of your own anguish. Going delusional. Beyond the magic he posses, the leader, he is not God. He projects onto his followers his inability to stand alone, his own fear of isolation.

The problem is not a shoulder or no-shoulder election day. The problem is somewhere else. The problem is in our minds. We look for a cheap heroism. Really feeling we can control fate life and death just doing a beautiful filling. With the leader's image stamped on our psyche. But is just illusion.

One morning you don't want to stand up. To face all the misery of life. Like in Metamorphosis (Die Verwandlung) of Kafka. I read the book in my teens but didn't understand.

The problem is how to survive your own anxiety, together with the one of your patients. 2 or 5 or 15 patients a day. Lifelong.

Without getting stoned with alcool, joints, cocaine or psychiatric drugs.

Being sober.

That's real heroism.

Gestalt psychologists advise their adepts to call the patient clients. To prevent the transfert. But we are doctors. It's not ethical. And even worse, the patient is disappointed. Like a child who can not get the mother's full attention. He will turn the sitting into hell.

No one has ever taught us about the human mind. I started late on my own. Now I can't any more. I have no place for anybody's transfer. For somebody's anguish. Not even for my own.

C. treatment lasted as planned 3 months. She was a great help. She tried to support me during the long treatments sessions. Despite the excellent result I informed her of all the problems and the compromises. Even of the un-visible ones. I did not guarantee anything. But promised to help her to solve any kind of future problems. She understood. She asked to call me by name. Again a transfert request. Sounded like an abandoning syndrome. She told me she will not be touched by anyone else than me, not even for the dental cleaning. I wiggle out. I answer anyone with a bit of care can do it. I know is not true.

It took me a long time to recover from the psychic and physical fatigue.

I know I will have to do it again.

To accept someone else's humanness.

m.m.

 

P.S.

It took me 30 years of profession to understand who I am and what I'm really doing. I discovered late Walter Lippmann, a journalist, the American theorist of liberismus. He was already writing in 1920 : "The specialized middle class is made of a small number of technocrats who have the task or rather the responsibility for running society. They are engineers, intellectuals, entrepreneurs, politicians and doctors who analyze, execute, take decisions and run the political-economic-ideological apparatus."

With all the colored ribbons and medals of the social hero-system.

We belong to them.

Below us are the others. The majority of citizens: the bewildered herd, as he calls them. The confused, frightened, stunned horde. Dumb and incompetent. Their function in a democracy is to be just spectators. Innocent bystanders. Occasionally manipulated to lend their weight to one or another member of the specialized class: that's called an election (Noam Chomsky – Media Control). They have no free will at all. Corporates influence what they think what they dream ... what they eat. Through propaganda: TV, newspapers, internet. It's a soft brainwashing starting at birth. Like described by Aldous Huxley 50 years ago in The New Brave World where newborn babies are repeated with a recorder under the pillow always the same message: "Freedom is useless and damaging."

Above all there is the True Power: the Elites.

A scattered number of human beings who is in charge for this gigantic theater of normality where we are allowed to live by suffering even more than necessary. The unimaginables. The untouchables. Concealed to the average man.

A water-proof casta.

But, unlike the other categories, the bewildered herd has an advantage:

they have no responsibility

they are oblivious

If I knew maybe I'd choose different. The comfortable and protected routine. The trivial. The obliviousness. Sheltered from the burden of responsibility of decision. Avoiding the imbecile psychiatrist who would maybe naively rip apart the illusions over the misery of living (Freud).

Humans can't live without illusions.

 

 

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