Dear Marion,

Thank you for your letter. To cope with its many questions,
I resort once more to annotation:

You write:

> I find extraordinary your idea
> that a doctor should protect a patient from revealing his secrets,

extraordinary ideas are my stock in trade.

> and the cousin-concept
> that psychoanalysis is unjustifiably intrusive and perhaps voyeuristic. 

The notion that psychoanalysis should be able to provide
an exhaustive account of the human spirit seems to me
the ultimate (positivistic) delusion.
The communication of experience, on the other hand,
seems to me to be a basic human need.
The psychoanalyst is effective because he or she listens.
What's intrusive and voyeuristic is the interpretation
which the analyst projects on the patient's experience (Erleben).

> I've never come across a similar idea

but now you have!

> What has developed in society is the tendency to place physicians
> outside the social norm, like the confessor,
> so that one can let him see aspects of onesself
> that one carefully hides from others. 
> Taking care to protect the patient's secrets
> even from the doctor implies that it is healthy
> for the patient to maintain such secrets. 
> Is it?  assuming that what the patient tells the doctor
> will remain between the two of them? 
> Or is the problem that keeping secrets private is unlikely to work? 
> Or that the patient will feel uncomfortable with the doctor
> once secrets have been divulged?

One mistake, as I understand it, is the assumption 
that the universe of experience consists of, or can be expressed
as, a set of verbal propositions which may or may not be shared
between patient and physician, and that the "secrets" of the
individual's existence are susceptible to disclosure:  

_     "In ihrem Fach, sollte ich meinen gilt es doch als
_     eine Binsenwahrheit, dasz das Aeuszere nicht das
_     Innere ist." sagte er. "Aber man kann das Innere
_     doch nur ueber das Aeuszere erkennen," protestierte
_     Doehring.  "Man kann das Innere ueberhaupt nicht
_     kennen," sagte der Mensch in der SS Uniform.
                                      Das siebte Kapitel

> It seems as though many people want to talk about their secrets
> with someone where the revelation will have no adverse consequences. 
> People probably benefit from talking about what's steeping inside them,
> if it can be done safely. 
> This is why people seek out "therapists"
> and counselors to discuss matters and get advice,
> and pay handsomely for the privilege,
> when they often have friends or relatives
> who would be at least as capable of listening and counseling. 
> Do you prefer that patients keep their secrets hidden
> because you fear they will be misinterpreted,
> mishandled by the physician or psychoanalyst?
>  
> In any case, I hope you will elaborate. 

The notion that one has "secrets" which one can reveal
or communicate by expressing them directly in words or
sentences is illusory. "Confessions", be they in the
context of religion or psychiatry or law enforcement have
meaning only in a conceptual world which is artificial
and which has limited dimensions.

I do believe that conversation between patient and physician
is of much value, I believe it to be presumptuous and potentially
destructive for the physician to lay claim to the patient's
"secrets". The irony of your argument is that the modern robotic
physician is literally incapable of listening to his patient.
It's more efficient for the secretary to get the patient's history,
and even the secretary doesn't want to bother listening to the
patient, - and doesn't know how, - but gives him or her a
questionnaire to complete. In order to facilitate the data entry
into the computer, the questionnaire demands multiple choice if
not indeed true/false answers, thus almost entirely masking the
patient's individuality.

I interrupted this letter just now to see a patient, a 79 year
old woman whom I am treating for glaucoma. She wanted to tell
me about her 85 year old husband for whom she is caring at home
while he is dying of some malignancy that she doesn't understand.
She said the doctor thought he had only a few more days, at most
a few more weeks to live. Before she left, she hugged and kissed
me on the cheek - not my preferred expression of affection - and
said to me, don't die before I do. The scene reminded me of our
recent exchange of ideas about the practice of medicine.

> Thank you for pointing out that chronic, debilitating,
> sometimes fatal diseases are where a continuing personal relationship
> with the doctor is important. 
> That's profound, and not an understanding I had come to myself.

I suspect emotional support from a physician is of major importance
in enabling patients to comply with the tedious life-long glaucoma
treatment, and that a large fraction of the failure of medical treatment
of glaucoma is attributable to the circumstance that the robotic
ophthalmologists are unable to empathize with their patients and
being surgeons, and wanting to perform surgical operations, have
a professional interest albeit unrecognized even by themselves,
in having medical treatment fail so that they can get to do another case.
In the several decades that I practiced surgical ophthalmology
I cared for many patients with glaucoma, almost all of whom responded
to medical treatment.  The surgeon, Bradford Shingleton, to whom I
now send my cataract patients for operation is listed on the masthead
of one of the throw-away journals as a specialist in glaucoma
surgery. In patients who have both cataract and glaucoma, he sometimes
performs "combined" cataract-glaucoma surgery. He never sees these
patients post-operatively, he never asks me how they are doing, so
I don't need to embarrass him by telling him that, so far as I can
remember, all of his glaucoma operations have failed.

> I greatly enjoyed your vivid parable. 
> The neighborhoods of my mind are now dotted
> with innumerable bright yellow packages.
> Yet if the diagnoses and medical therapies
> are so shot through with shoddiness, error and fraud,
> surely we can't unload the entire responsibility
> for sorting through this mess on the individual physician. 
> It would be overwhelming. 
> Sorting the useful and accurate from the nonsensical,
> useless and dangerous would have to be an organized group effort.

You have it backwards. Scientific discovery or invention is
never a committee project. A discovery or an invention is always
the product of an individual mind: cf. Galileo, Kepler, Copernicus,
Leibniz, Newton, Darwin, Einstein. If the discovery is accepted by
society, the discoverer is ushered into a pantheon; if it's rejected,
he's denied tenure or in the worst case, burned at the stake.
This precisely defines the limitation of the government's current
attempt to institutionalize medicine: Mediocrity, and only mediocrity
will survive the test of consensus, and unavoidably it is mediocrity
which is then enshrined as the standard. Mediocrity, the canonization
of the average, is what characterizes contemporary diagnostic schemes
and therapeutic "guidelines."

I don't believe it to be worth your while, but if you're
interested in how I wrestled with the incongruities of
diagnostic nomenclature, the Glaucoma Letters that I put
on the Internet will give you hints. (I apologize, just
in case, for the editorial sloppiness. I guess when I wrote
the Glaucoma Letters, I was too busy with my patients.)

> From the brief reference you made to Klemens' work
> with the software (?) company in Tennessee,
> I figure he might be directly involved
> in designing software to complement medical diagnosis and treatment. 
> Is he? 

So far as I know, his efforts are directed largely at facilitating
the medical management of dialysis patients, keeping track of
diagnostic and therapeutic data, and assuring compliance with 
the maze of regulatory requirements.

> Do you discuss these ideas with him? 

Yes

> Does he share your perspectives?

Yes. He has adopted them with few if any reservations.
In his teaching of residents and post-graduate fellows
he frequently cites my style of medical practice,
as in this excerpt from a letter of his to the Chief of Surgery:
 
_      "You describe the surgeon-patient contract.
_      This is a very familiar and very real to me.
_      My father, no longer operating, is an ophthalmologist
_      who takes his commitment to his patients
_      extraordinarily seriously.  Many family vacations
_      were postponed or cancelled to stay around because
_      of one post-op patient.  I have tried to practice
_      internal medicine that way.  That's why I give out
_      my home telephone number, try always to visit my
_      hospitalized patients, why I lump together my weekends
_      on call with my weeks, to give some continuity.
_      In the era of 4-5 day average length of stay,
_      it works for most patients, though not for the outliers, ...
_      who need it the most."

> Did you and Klemens learn programming together?

No. I wrote programs for my medical management and record
keeping system in 1982 in C language. I never needed to
write in assembly language. Klemens does the "systems analysis"
for his dialysis company; their programming, a multi-million dollar
undertaking, is done by professional programmers.

Jochen