The Web of Relations: Thinking About Physicians and Patients

Like the other contributors to this symposium, I owe a profound debt to Jay Katz for his intellectual rigor, his gentle but firm Socratic pedagogy, and his unparalleled generosity of time and friendship. I first met Jay during my last year of law school when, at the urging of friends, I enrolled in his seminar on informed consent. By that time, he had collected most of the materials on which he based his important book. Not surprisingly, a single semester could not contain all of that material, so many of us continued on into the second semester.

During that time I learned a number of things, but largely in the abstract mode that often characterizes the law school classroom. Fortunately, I had the opportunity after my first year in medical school to work on Jay's book, The Silent World of Doctor and Patient. I am not sure that I contributed much. I have always viewed that summer as Jay's effort to create a tutorial designed to make sure I "got it." Even so, it required actually taking care of patients for the last twenty years to bring some of his lessons home.

Over the years, I have come to see the physician-patient relationship not simply as a dyad of autonomous individuals, but as one part, albeit an important and complex part, of a web of dynamic interactions that influence both parties. This perspective has important implications. The work of Barabási and others has shown that networks are fluid, self-creating, and always changing. At the same time, networks tend to respond poorly or unexpectedly to deliberate attempts to induce change.

Pressure at one point can lead to a countervailing response at another. This understanding provides additional insights into people's actions and suggests both reasons for resistance as well as the possibility of support from unanticipated sources.