Car Mechanic vs. Doctor (not another Marvel comic strip)

Some time last year, my car’s odometer reached 150,000 miles, a milestone I had anticipated for some time, mostly with dread, knowing this meant it was due for maintenance. Previously, I had lived close enough to drive to my parents’ trusted mechanic who they patronized for years, but now I lived a twelve hour drive away, making this arrangement impossible, or at the least, implausible. For months, I tossed around various ideas: I had once met someone who works on cars out of his garage...but that sounded unreliable... once I think I googled nearby mechanics. But I knew, deep down, I would never take the car to any of these people of my own accord because I simply could not overcome my seething dislike of its potential future caretakers. There had to be an alternative.

The only reasonable option, I concluded, was to have my dad take the car to the mechanic. So I started to lay the groundwork: now that he was retired, of course he wanted to take care of his only daughter; what better than a trip to Portland? I knew it would take some time and consistency, but he finally pitied me – or perhaps my car – enough, to fly up and take the car in for scheduled maintenance, crazy though he said it (or I) was. This way, he said, I would be established with a place.

I have not been back since.

Problem is, I distrust all mechanics, along with everyone else who deals with cars (this includes car salesmen, car rental salesmen, and car washers), because they are no-good, double-dealing, two-faced swindlers. An illogical viewpoint, I am aware, but my sentiments nonetheless. I added rental car salesmen to the list after an hour-long discussion with one in which I finally acceded to a Prius in order to be able to stop talking. I did not like the Prius. My distaste for car mechanics probably started in college, when I was thrust into the world at the naive and unripe age of 18, along with a car that I loved, but was, for all practical purposes, falling apart. One mechanic suggested doing a study, not unlike a tagged red blood cell test, that tracked where the oil leaked, and cost much more money than I had (essentially none). After much consultation with many other people, my dad included, I declined, but have never forgotten the sneering way in which it was pushed upon me, as though to make me feel the dupe whether I purchased it or not.

There are countless stories – surely everyone can recite at least one – of vastly incongruent price quotes from mechanics for the same repair, or, what the ignorant dread, being charged for fixing what was not broken. It is enough to make even the gullible believers (me included) distrustful. Of course, consumers expect to be deceived, nickel and dimed, and left to feel helpless in the battle for things, but generally the deception starts far away, up high somewhere in some tall building by inscrutable businessmen against whom they have already lost the war. But with mechanics it is personal: they look you in the eye and are the creators of the con. There are no dancing figures on computer screens or innocent store clerks to intercede between the cheaters and the cheated. And that makes it harder to swallow.

As I continued to actively avoid the car mechanic, I began to wonder if this is how some people feel when they visit the doctor. Certainly there are enough stories out there to chill anyone’s trust in healthcare: Tuskagee trials, Big Pharma and conflict of interest, HMOs of the 1980’s. Admittedly, desire for power or wealth has gotten the better of a doctor or two, as it has many humans for thousands of years, but I like to think these are the minority, spotlighted for dramatic effect, and that most doctors are respectful and honest. As a physician myself, I must think the best of my colleagues as I wish to be immune to temptation myself.

The first time a patient’s father told me point-blank that he believed doctors are in conspiracy with the drug companies and that was why he did not want his child to receive vaccines, I was speechless. To me, the accusation was utterly ridiculous. First off, because all the hospitals I have worked in are Pharma-free, meaning the hospital and its employees do not take anything from pharmaceutical companies in order to avoid the feeling of due reciprocity. Plus, vaccines are given worldwide, often at the expense of governments, in an effort to prevent future expenses of caring for diseased children, because they work! Then I was offended. The

implication was that I, me, a pediatrician who has sacrificed years of my life to learn about childhood afflictions and their cures, had no qualms risking the health of thousands of children in order that I could make a few bucks in collusion with pharmaceutical companies. I was appalled. Yet this father is not alone in his opinion.

How is it so many people distrust doctors? Perhaps it is the position of authority, which the 1960’s taught should always be questioned. More than that though, there are many striking similarities between doctors and mechanics. We both care for a complicated fusion of mechanisms and mystery that people treasure, are willing to pay a great deal of money to take of, but generally know very little about. I know nothing about combustion engines, so I rely on what I am told to do, same as many others know little about nephrons, but takes their ‘kidney pill’ to prevent diabetic nephropathy. People are reliant on their doctors to ‘fix’ things they do not understand. Ignorance, and sometimes misinformation, is a breeding ground for distrust. If I understood anything about fuel injectors or spark plugs (words I have heard tossed around before), I could confidently catch any lies; but as it is, I am entirely at the mechanic's mercy, resentful for the power he holds over me and can easily abuse. If I blindly trust mechanics and do everything they say, we could call it “paternalistic auto care” just as doctors sometimes practice “paternalistic medicine”. (Though in the United States this is now considered old-fashioned, it is not so uncommon as we think, and is more common in European countries in general.) As a medical student, I once overheard a woman who was about to have her gallbladder removed ask her nurse what the gallbladder was. He also didn’t know. Neither she nor her nurse were brave enough to ask the hoard of doctors and students who had piled into her room for five minutes of rounds. But she certainly had her gallbladder removed anyway, and consented for it. It is no wonder people are suspicious of physicians if they never understand what is said from the beginning.

This is an age-old problem. Tolstoy expressed it eloquently in Anna Karenina that "they tried to tell her what the doctor said, but it appeared that though the doctor had talked distinctly enough and at great length, it was utterly impossible to report what he had said."[1] Patients are in a vulnerable position, their own bodies subject to the decisions of someone else. A woman I know tells mechanics her car is someone else’s so that she can act as though she has no stock in what they do and thereby avoid unnecessary repairs, but I have yet to meet anyone who can believably claim their attached body is that of someone else. In doctors' busy rounds and schedule, how easy it is to forget the fear implicit in trusting someone else with the one thing you should have control over, how easy to give a diagnosis and neglect to explain – the gallbladder excretes bile that breaks down fat, but sometimes it gets clogged and causes pain because the bile cannot get out. The fuel injector is necessary to get fuel into the internal combustion engine (I had to look that up on Wikipedia), and there is probably something bad that happens when it does not work.

In medicine, we often talk about how to get the patient to “buy in” to the diagnosis and treatment, or prescribed disease prevention. Is this different than how mechanics convince customers that their car needs improvements or maintenance? “Well checks” are just as bewildering as regular car maintenance. Everything is going well, you make the effort out of the goodness of your heart, trying to do the right thing, and suddenly you need blood tests and a colonoscopy, new brake pads and the windshield wipers are always old even though you replaced them last week. The medical world has made great strides in preventative care and screening tests, and has begun to improve patient education, but we cannot continue to delude ourselves that it is easy to understand. Sometimes I find myself relying on primitive scare tactics to promote regular care: We encourage regular check ups because we check for such-and-such terrible things that rarely happen but could happen if you don’t come see me. It is part truth, part plea, and honestly part manipulation to assuage my own fears that these terrible things will happen to the one patient I do not see.

Even more challenging is explaining the ambiguity that is inherent in the human body and its functions, unique to every individual and yet predictive.

This antibiotic often causes diarrhea, which you may or may not experience.

Not everyone who has this gene will develop the disease, but it is associated.

There are also endless debates within the medical community, such as how low LDL should be or whether to give antibiotics for ear infections or if lingual/labial frenulums should be cut. The fact remains that though there have been great strides in science, there is that much more that we do not yet know, and recommendations change frequently. Of some things we can be certain, but it can be difficult to sound convincing when not all is certain. The art of medicine lies in learning to be comfortable with the onerous ambiguity of the human body.

As much as I would rather my patients walk in with an already laid foundation of trust in me and the medical system (along with enough grace to bear with the ambiguity of the human body and decision making), the truth is most probably will not. They come with their own ideas. But that is no excuse for me to withhold my knowledge and skills which may help, to attempt to explain preventative measures that may save a life. When my exam room transforms into a classroom, and my “students” become more and more obstinate at every word of my “lecture”; when I quote scientific papers, personal anecdotes, consensus statements, only to be outdone by one outspoken famous woman on the internet or one man who wrote a book full of opinion; when I am no more than a resounding empty gong, it would behoove me to remember that feeling of going to the mechanic. Then I might understand that I have no clout as a healer until something goes wrong and I can fix it – the beautiful and unfortunate prospect being that I likely will not see many preventable conditions (measles, hemorrhagic disease of the newborn, kernicterus, etc). And that is what I hope for these patients. If they will not trust me, I can at least hope they will have a healthy life without my intervention.

Perhaps car mechanics feel the same about me and my car...

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[1] Tolsoy, Leo. Anna Karenina