I catch a half-smile, a hesitant wave, and a curt nod, and I realize I am supposed to recognize this person. I return the gestures, but my memory refuses to be jogged. Finally, they approach me close enough for conversation, and say, “Dr. Weinkle, how are you?” After caring for a few thousand people in the course of my career, I cannot hold all the names and faces in my head any longer. “I’m so sorry,” I reply, “please remind me of your name.”
If only I had chosen to be a judge. According to the Torah, they’re not supposed to recognize faces – it says so right in Deuteronomy 16:19, when Moses is explaining the meaning of “judge the people with righteous judgment.” Among other things, he says, “thou shalt not respect persons,” meaning not to show favor to a rich person because of their status, or to a poor person out of pity. Equal treatment under the law is the meaning of righteous judgment. But the Hebrew phrase that he uses to say this is lo takir panim – literally, “don’t recognize faces.”
But healers aren’t supposed to be blind like justice, are we? We’re not meant to be impartial – we are meant to be completely partisan advocates for our own patients. Haven’t I written a whole book, and dozens of blog entries, about how I want my colleagues to feel a certain amount of love for the people we care for, to really care instead of just “providing care?”
Knowing the face, being familiar with the person, is the essence of individualized, person-centered care. You can’t be a “healer who listens” without understanding the uniqueness, “recognizing the face,” of the person you’re listening to. By extension, you can’t know which person needs hand-holding and which one humor, which one deliberation and which one decisiveness, unless you know their “face,” the way they prefer to interact with the world.
But when you have a busy practice, how many faces can you “know?” Can I be fully present for every single one of them, know all their preferences and tailor all my treatments to their needs? Does every one of them get my equal passion? Or are there a few faces that inevitably end up getting more attention?
Put another way, like that encounter on the street, there may be a limit to the faces I can recognize at one time. So which faces am I going to end up seeing?
Over 11 years of my career I’ve seen myself default in a whole variety of directions. Sometimes I “see the faces” of the people who happen to be in the office that day, to the detriment of those calling in from home. Other days I dive into the first appointment of the day with 1000% commitment, only be insurmountably behind schedule by 4 pm, unable to see the faces of the last two or three people on the day’s schedule. Still others, I am so consumed by the faces whom I can’t get out of my head at night, from the constant worry about their well-being, that the simple needs of the faces who just need a moment of my time are never seen. And yes, sometimes I recognize the faces of the squeaky wheels and spend my time putting grease on them while the patient patients continue to languish.
My children might tell you that this arrangement is OK, because they’ve often heard me tell them, “Fair doesn’t mean equal.” Not everybody gets the same amount of something, and that can be OK – but only if everyone gets the appropriate amount for them.
“Recognizing faces” can have consequences beyond just how we allot our time, though. Recognizing certain faces, and failing to recognize others, directly impacts the care that we provide. We’ve all seen a child in pain; most of us who have our own children can even tell when they are really in pain and when they are simply shocked and betrayed that one of their siblings has whacked them with the broom. Yet somehow when black children come into the emergency room with appendicitis, we find their pain harder to recognize than that of white children.[i]
Recognition often becomes easier when the face is one that looks like our own, a phenomenon called concordance. There’s evidence that concordance can significantly improve care, reducing alcohol consumption in the aftermath of a traumatic injury, or leading to more rapid follow up of abnormal cancer screenings in populations where the patients and physicians are from the same background, where looking in the healers face feels a little more like looking in the mirror.[ii] Recognizing faces can save lives, too.
Still other times the recognition can go too far. We may be loath to admit it, but all of us have at some point cared for a person who was a “VIP patient,” whether a close friend, a famous person, or someone with an “in” at our place of employment that made them feel entitled to more expensive, more rapid, or more cutting-edge care than the other patients. If we’re going to talk about recognition, let’s recognize what’s going on when we do a test we know doesn’t need to be ordered, acquiesce to a demand for an antibiotic or an opioid that isn’t called for, or change our practice that we do the same way, every time, “just this once” because we give too much recognition to one particular face.
Orchot Tzadikim (a text from the musar, or ethical, tradition of Judaism) relates how learned people can shame the very holy texts they are studying when they do not act accordingly. The example given is of when one studies the line, “You shall not be prejudiced in favor of the mighty,” but then does show favor to a wealthy person in court. When we study the evidence and learn best practices, then toss them out the window when caring for a VIP patient, we bring shame on medicine as well.
There’s no easy way out of this conundrum. When I wrote in Healing People, Not Patients about creating my worry list, I wondered how I could ethically, fairly decide who I was sufficiently worried about to put them on the list. I initially wrote that chapter three years ago; I’m still struggling with the question. How do you create the oxymoron of “universally individualized care?” How do you do the “right thing, for the right patient, at the right time, in the right way,” to quote the patient safety mantra, without inevitably having your individual relationship with the patient push someone else out of the way, or cause you to behave differently for that patient than you would?
While you think that over, I’m going to go grease some
[i] Goyal, MK et al. Racial Disparities in Pain Management of Children With
Appendicitis in Emergency Departments. JAMA Pediatr. doi:10.1001/jamapediatrics.2015.1915
Published online September 14, 2015.
[ii] Poma, PA. Race/Ethnicity Concordance Between Patients and Physicians. Journal of the National Medical Association, 2017-03-01, Volume 109, Issue 1, Pages 6-8. Poma cites numerous other studies in his review; the two referenced here are by Field and Caetano and by Charlot, Santana, Chen et al.