Navigating dislike in healthcare: October takeover

In today's post, EPIC's Fred Cooper introduces a series of blogs on like and dislike in health care, and their epistemic consequences.

Image credit: Wellcome Collection

In his famous meditation on general practice in the 1960s, A Fortunate Man, John Berger asked how his subject, Dr John Sassall, can have his measure taken. ‘We find ourselves without a scale of standards for judging or assessing one another’, Berger argues; ‘the only standard which remains is that of personal liking – or its commercial variant, which is Personality.’ Berger liked Sassall – a pseudonym for his own GP, John Eskell – immensely, but he recognised something impoverished and flat in the tyranny of that metric.

Berger’s subject, Eskell, was the kind of GP who thought deeply about his relationship with his patients, and understood the complexities of his role as witness and consoler, meeting the ‘patient’s deep, unformulated expectation of fraternity’ in illness and injury. His apartness, Berger observed, barred him from the benefits of that cultivated – but no less authentic – fraternity, while allowing him to confer them on all of his patients, regardless of his personal impression of them.  

Contrary to Berger’s romanticised view of Eskell, and of general practice more broadly, his contemporaries seemed to have more trouble. In their 1976 study, Doctors talking to Patients, Patrick Byrne and Barrie Long conducted a close linguistic analysis of dozens of tape-recorded medical consultations, paying particular attention to how doctors’ individual questioning styles opened up or shut down lines of enquiry vital to correct diagnosis. While different doctors frequently had entrenched and observable styles, whether paternalist and taciturn, open and curious, or somewhere in between, the researchers also found a significant degree of variation by practitioner. Some interactions were easy, marked by mutual respect; others more abrupt, resigned, frustrated, and these were far less likely to allow the patient to really speak.

Inscrutable in these interviews, there is distinct politics to who gets to be liked by who, or who can and can’t access the kinds of easy geniality increasingly expected to smooth interactions along; what Teow Lim Goh describes as ‘the dehumanising politics of likability’. One curt greeting in Byrne and Long’s study, ‘you again’, gives us one clue to a set of relations probably more likely to fray than most: those between the doctor and the ‘repeat attender’, the frequent patient with no clear physical cause for their troubles. T.F. Main’s 1957 essay, The Ailment, argued that protracted, mysterious, and refractory complaints introduced novel psychodynamic problems into medical care: in his words, ‘the patient’s attendants are pleased neither with him nor themselves and the quality of their concern for him alters accordingly.’ Main discerned a pattern, again in his words, of ‘old unsettled interpersonal scores hitherto unrecognized’, including ‘guilts, angers, envies, resentments, unspoken blamings, alliances and revenges’, ‘shown now to have both animated some of the nursing procedures offered these patients, and to have been concealed behind them.’

We can see some of these concerns surfacing again in the early 1990s, in Darryl Watts and Gethin Morgan’s formulation of the concept of ‘malignant alienation’. Detailing a rapid epistemic and relational breakdown between doctor and patient, which the authors recognised as a common factor in a number of potentially preventable suicides, the article carried the subheading ‘dangers for patients who are hard to like.’ This marked a subtle – but vital – shift in emphasis on who, precisely, is bringing their baggage into the consultation room.

The next three entries in the EPIC blog unpick questions of dislike – and their epistemic consequences – across three significant pressure points in healthcare. Cristina Ganz, in her work on midwives and obstetric violence; Davy Tennison, in their research on the medical dislike of fibromyalgia patients as epistemic injustice and epistemic dysfunction; and Hugh Robertson-Ritchie, in his reflection on ME/CFS and the frictions generated by incompatible aetiological interpretations. The essays address an area of experience which has so far been black-boxed by epistemic injustice researchers, being supposedly too unknowable or idiosyncratic to make any kind of systematic sense from. Attending critically to like and dislike can take us further than simple bad luck, revealing significant – and unjust – disparities in experiences or outcomes that might otherwise elude analysis.

John Berger and Jean Mohr. 1967. A fortunate man. The story of a country doctor. London: Allen Lane.  

P. Byrne and B. Long. 1976. Doctors Talking to Patients. London: HMSO.

Teow Lim Goh. 2019. The Dehumanizing Politics of Likability. Los Angeles Review of Books. August 21. https://lareviewofbooks.org/article/dehumanizing-politics-likability/.

T. F. Main. 1957. The Ailment. British Journal of Medical Psychology, 30: 129-145. https://doi.org/10.1111/j.2044-8341.1957.tb01193.x

D. Watts and G. Morgan. 1994. Malignant alienation. Dangers for patients who are hard to like. The British journal of psychiatry: the journal of mental science, 164(1): 11–15. https://doi.org/10.1192/bjp.164.1.11. 

Fred Cooper is a historian of medicine, and a senior research associate at EPIC. He leads an EPIC case study on loneliness and epistemic injustice.