Doing 60, 90, 120…ignoring or liberally interpreting the yellow “RIGHT LANE ENDS, MERGE NOW” sign, the driver of a white pick up truck scattering gravel in the break down lane passed us and cut us off, the raised bumper inches from ours, the dual exhaust rumbling. I was captaining our station wagon. My beautiful wife sat next to me, her hand proffering reassurance to my shoulder.
“Just ignore him,” she said, reading my mind (the lower, primitive regions of the limbic system, amygdala and hippocampus) or the adrenalin gauge (not on the dashboard) with its indicator at the redline.
Instead, I ignored her, tailgating and then swerving in front of the truck at the next available opportunity—a straightaway after a service station where the road widened from one lane to three, allowing for left and right turns into strip malls, as well as the occasional drag race. The lackadaisical evening traffic and numerous stoplights, however, made this particular use tenuous.
Fortunately for us, the driver, after gunning past one more time, swooped off the road into a liquor store parking lot without taking further heed of my challenge. He probably had a jiggling beer cooler on the front seat in need of replenishment, to go with a (fully legal) handgun in the glove compartment. I escaped the confrontation with only an earful from my wife for risking my life, and hers: minor damage.
In fact, I’ve mostly gotten pretty good at defusing such situations, mostly by defusing myself in time. But sometimes caught in the wrong mood at the right moment…I…The funny thing is, were I to come across the obnoxious operator of said truck at a revolving door or in a movie line, each one of us might well have said, “after you.” Somehow, climbing into a car’s personal space with its anonymity and raw power deactivates the courtesy that keeps us from each other’s throats.
Manners, as a word, suggests a kind of officious veneer associated with prep or finishing schools, a gratuitous expertise in the social graces. The well-mannered individual always uses the correct fork for his salad, and gets his thank-you cards written punctually. But I postulate here that at least on the roads and highways of America good manners can save your life. We’re a short tempered and irritable society (at least while motoring) and a violent one. Perhaps there’s a connection? According to the National Highway Traffic Safety Administration, aggressive driving accounts for one third of “accidents” (my quotation marks) and two thirds of automobile fatalities. That’s frightening. On the Pennsylvania Turnpike, a thoroughfare I frequent, two women were killed a few years ago after the driver of another car, angered and retaliating over an unintentional “slight,” caused theirs to lose control and crash. If he’d displayed just a hint of the gallantry he might have on foot, he’d be a free man today and two women would still be alive.
According to Freud, we are motivated by sex (Eros), and death (Thanatos). I would agree with the first at least, though I think there are often less elaborate, in fact stupidly simple explanations for our behavior. For example, much has been written about the so called Oedipal conflict, which Freud hypothesized, where a boy subconsciously wishes for his father’s death because he harbors repressed desire for his mother. Sex and death, death and sex. But if we go back to Sophocles, the ancient Greek dramatist, and his Oedipus Rex, we find a much more banal kind of human foible at work.
Remember the story? An oracle forecasts that Laius will have a son who will grow up to kill his father. So Laius disposes of this son, Oedipus, binding his feet and leaving him on a mountain to subvert the fate decreed by the gods. The infant Oedipus survives and years later, as a grown man, finds himself face to face with his father. Except neither recognizes the other. Oedipus believes his father is the shepherd who raised him as a boy. Laius thinks his child is dead. So they are in essence strangers when they argue at an intersection over who has the right of way.
When Oedipus kills his father it has nothing to do with the superego, or the id, stifled libido. It’s a simple case of road rage, and fatuous as it sounds, bad manners. Had either one of them waved the other past with genteel deference, there would have been no bloodshed, no humiliating abdication, no suicide by Jocasta, no self-mutilation by Oedipus in his shame and grief and guilt. This variety of Oedipus complex isn’t complex at all. Unfortunately, like fate, neither is it trivial or easily avoided. And it takes its toll off the road as well, has done so for centuries in petty struggles over honor, pride, saving face. The gods and the playwrights could always count on us to be impulsive, ill mannered, and self-destructive. They still can.
What’s wrong with the current system? Gross inefficiency, redundancy of services (generally lowering overall quality because the added programs lack adequate proficiency and don’t significantly improve access), irrational deployment of resources (i.e. too many specialists and too few primary care physicians, simultaneous physician gluts and shortages in different geographies, an excessive density of programs providing complex high cost care in some locations, a dearth of such programs in others), inadequate provision of primary care, psychiatric care, & translational care facilitating recovery once the patient is released from the hospital), increasingly arcane and inscrutable bureaucracy associated with fees and payments, antiquated processes (incomplete and disorganized medical documentation via pen and paper, versus (fully) electronic record keeping utilized by other countries), inadequate validation of processes, a lack of quality assurance, excessive negligence, inadequately investigated bad outcomes, inadequate trending and statistical analysis of outcomes, inadequate safeguards or remedies for negligence, runaway litigation, physician incompetence and impairment, inadequate regulation and/or control of insurance company practices, lack of adequate preventative or therapeutic care for the poor, the elderly, or children, a distorted focus on procedures versus outcomes, a failure to consider the whole person when treating patients, an inadequate focus on the psychological dimensions of illness, on the social and employment aspects of illness, inadequate mechanisms for addressing pain control, especially in terminal illness, inconsistent and arbitrary approaches to end-of-life-care (if you think your grandmother isn’t already refused adequate or compassionate treatment as an elderly patient, you’re sadly mistaken), inadequate recourse for patients denied choice or coverage, inadequate recourse for physicians or hospitals denied payment for indicated services or procedures. I could go on with the list, or expand any of these items in detail, but that would only add to the tedium of this already languid litany. I suspect most of the charges I’ve leveled will not sound unfounded or unfamiliar to you.
I won’t lie and say the moment was transformative. I’d always had compassion for my patients, even the less sympathetic ones. On my psychiatry rotation, I received a tongue lashing from my resident for being disorganized–spending extra time with the retired subway driver who’d attempted suicide after secretly battling depression, and now wanted to talk to someone. I objected mentally if not aloud when my attending stood over the alcoholic lying in the ER in an encephalopathic daze, and poked and prodded her with grim harshness. He was “teaching” me the signs of endstage liver disease, and he was also showing me his position of power and contempt. But my own paternalistic sympathy had given way to fraternal empathy. I had something in common with my patients, even the “charity cases” who showed up on clinic days, an inkling at least about their helplessness and shame.
Daniel Haller, Julius Mackie, William Powlis—these three men saved my life. I was 25 and in my final year of medical school. I’d had a nagging cough for several months and my friends urged me off and on to get a chest X-ray, check it out, though they half laughed when they told me. No one, I least of all, imagined anything would turn up. I was interested in radiology at the time. It seemed like a good specialty. New technology and a growing field—MRI was really taking off—great hours, a residency that wouldn’t kill me with years and years of on-call, plus I really liked it and was pretty good at reading films. So when I put my own chest film up on the light box the last thing I expected was a large mass—as we call things that shouldn’t be in a person’s body. The word has such connotations of size and weight, Newtonian physics, a cold, precise world where everything ends predictably.
