The PANY Bulletin

Psychoanalytic Association of New York
Vol. 40, #2, Summer 2002

Scientific Meeting Summary
37th Freud Anniversary Lecture
May 20, 2002
On Knowledge and the Physician's Ideal
by Eugene Halpert, M.D.
Reporter: Stephanie Newman, Ph. D.

Physicians want to know. Knowledge—especially about bodies, illness and dying—allows them to defeat death, rescue others, master old losses. Doctors and their patients expect the doctor to have knowledge the patient does not, and “it is from this particular expectation that the power and prestige of physicians has always in some great measure, derived,” said Dr. Halpert.

Dr. Halpert divided his talk into four sections: History, Interviews with Physicians, Clinical Material, and a Discussion of these topics. In discussing the history of medicine, Dr. Halpert noted that the ancients believed doctors had “magical powers” were “godlike,” and possessed “perfect knowledge and omnipotent control.” Physicians were subjected to punishment or death for losing a patient. Under Hammurabi’s code, for example, if a patient died or lost an eye during a major operation, the doctor was punished by the loss of a hand.

After providing a historical perspective, Dr. Halpert shared findings from unstructured interviews conducted with 20 physicians who treat deadly illnesses. Common themes were the desire to know about the biological sciences and an intense relationship to those facing death. Each physician spontaneously described a childhood motivation to be a doctor, he noted, and when prompted, each offered thoughts and feelings about, defenses against and expectations of themselves in regard to illness and death. The doctors also spontaneously mentioned an interest in knowing about the human body.

To illustrate the physicians’ interest and motivation to study and practice medicine, Dr. Halpert offered several vignettes, including that of an oncologist who dissected a sheep’s brain as an elementary school student and who visited brain injured patients as a child of 11, but who never connected these childhood interests or considered their relation to her current medical practice.

Such conflicts about knowing were the focus of Dr. Halpert’s next part of the presentation, the discussion of clinical material from two former patients. The first who had been in practice for several years (both patients were disguised for reasons of confidentiality), reported early in the treatment having the same nightmare which he had dreamed before a major med school exam: he was standing in front of a wall which forbade entry, but somehow got inside, he was “running up or down stairs [in his primary school],” and “he was going to meet something terrifying.” He then woke up screaming. His associations included an uncle, a doctor to whom “everyone looked up to as someone all knowing, because he was a doctor.”

The dream allowed Dr. Halpert and his patient to explore what had been walled off. The patient had a history of obstacles against knowing, in medical school and during his childhood. He feared they would prevent him from knowing in the analysis, too. Indeed, it was only after recalling the day residue from the day of the exam (his mother bending over to reveal a view of her “large buttocks, the crack between them and the circle around her anal opening, as well as the suggestion of the vaginal opening”) that he began to recall repeated instances of over-stimulation by his mother during his childhood. As the treatment progressed and the material deepened, he remembered seeing her naked breasts after she had showered, and realized he had covered up his longing for her. He recalled curiosity about her body and shame and guilt relating to fantasies about touching her. It was only when he knew he desired his mother, when he realized that he had wanted to explore her body, that he could connect his early wishes for her with his unconscious motivation for becoming a doctor. “To gain the knowledge of a doctor and to know anatomy, to become like his uncle, was to satisfy his guilt-ridden oedipal fantasies to enter his mother,” said Dr. Halpert.

A second patient entered analysis with Dr. Halpert for reasons unrelated to his career, but began to discuss his conscious motivation for becoming a physician: to rescue a father who suffered from a history of cardio-vascular disease, as well as to reverse feelings of helplessness. As the treatment progressed, this patient began to notice that his parents held the highest standards for him, expected him to be perfect, and that he engaged in self-defeating behaviors such as poor academic performance in school as a way of acting on his hostility and fantasies of revenge against them. His need to know as a doctor and his wish to save everyone was a defense against the wish to murder his parents. He also feared being sued. “If I’m a hair’s breadth less than perfect somebody might die or have a less than optimal result.” During the analysis he slowly became aware that this preoccupation with being sued was an expression of a fear that he’d be less than perfect. This fear was, according to Dr. Halpert, a “defensive reversal against his murderous rage towards his parents, more intensely his father… [Who both was pleased about and envious of his son’s brilliance].” At the same time, his grandiose fantasies allowed him to repair his self esteem which had been harmed by vicious attacks from his father, according to Dr. Halpert.

In discussing his clinical material, he noted that though the psychology of physicians is “complex and over determined,” the physicians he interviewed and treated all had in common the desire to possess knowledge. Referencing Freud’s comments about the “Irma” dream, Dr. Halpert maintained that physicians want to live up to an ideal that they are saviors. They feel guilt when they don’t succeed, when their patients die. In order to master their guilt and hopelessness and in an attempt to understand their feelings about life and death, “physicians create a reality in which bodies can be examined, death can be confronted, rescues can be performed, and knowledge of the body continuously increased.”