The doctors, physicians, are unhappy in the United States. Not just psychiatrists, but all physicians.
The United States has always had a health care system unlike anything in the so-called Western industrialized world. Unlike our peer countries, health care is not a right affordedto every person, such as with education and a basic pension. While there have been waves of reform (from Truman forward) attempting to move this country in that direction, physicians and hospitals resisted. What we are left with is a situation where physicians have, for the most part till now, organized themselves into solo or group practices -small scale business enterprises. And, during this period, most people paid for their health care through insurance plans offered by their employers, with the poor receiving care through local government organized clinics and hospitals.
In the 1960's, the Federal government entered the health care industry with the development of Medicare (insurance for the elderly and disabled) and Medicaid, a federal-state collaboration to help insure the needy. Initially rejected by physicians, the steady revenue stream from the federally insured patients helped support the rise of American physician incomes to the elevated levels (in comparison to peers globally) where they are today. And, since then, we have lived in an unstable era. For physicians, they see themselves -speaking in the broadest generalization-as solely engaged in a professional relationship with their patients. The patients, on the other hand, face enormous costs for health care (both the insurance premiums, partly covered by the employee, and increasingly large out of pocket expenses such as deductibles and copayments for services). Neither of these parties is especially sympathetic to the payors (either federal or private insurance) responsible for distributing money -Medicare is often criticized in spite of its great efficiency, and the private insurance companies have, in some instances, reaped enormous profits, because, in a sense, no one wants to say "no" to health care. This has led the US to a health care crisis. We are spending about 17% of our gross domestic product on health care, and our outcomes--the health of our population--are not particularly good.
This crisis has led to some action by the government and some shifts in the health care industry. As the major payor for health care services, the government is exerting its power through a variety of regulatory changes in the ways in which it will pay doctors and hospitals, all of which might be generally described as new demands for accountability for payment. In the prior system, fees generated by hospitals and physicians were paid by the government, with limited scrutiny, the honor and the professionalism of the physician's actions were taken as a given. Now, in a number of different ways, the government is exerting more demands in exchange for payment -through a variety of review processes designed to ensure that the government (and, by extension, the patients) are receiving value for what they are paying for. The payors are no longer willing to pay a high price tag for a system that is not delivering quality. One component of this change on the part of the federal government is the requirement (for full reimbursement) that physicians and hospitals (or, integrated health systems) adopt electronic medical records. Paper medical records were quite common in the United States as recently as five or ten years ago, even amidst an industry that has benefitted from technological innovation. The isolation of important medical information in individual paper charts was identified as a reason for poor coordination of care, duplication of services, errors in patient care, and poor performance of the system, as a whole, in providing care for patients. Listening to physician responses to the widespread adoption of electronic medical record, or EMR, one is brought back to the reaction of factory workers to the introduction of machines in 18th century England, so well documented in the famous chapter 15 of Marx's Capital. While the EMR will undoubtedly lead to increased productivity and efficiency of health care in the long run, it has indeed prolonged the working day for physicians, now working later hours or working at home documenting their care; changed the system of compensation due to the intricate relationship of documentation and reimbursement; changed the character of the workplace, with workers parked at stations in front of their machines; displaced some physicians from jobs (as well as plenty of transcriptionists); and, also led to the development of Luddite physicians, angry about those changes (and, even, led to isolated instances of physician vandalism of computers -at least one health system was forced to implement physician behavior codes for the first time due to these problems). Physicians are very frustrated about the ways in which the EMR, the machines, have disrupted their professional lives and, from their standpoint, been forced on them, placed between them and their patients.
So, we are at a point where the world of the American physician has been turned upside down and physician morale is at an all time low.
To be continued…
René Girard who died on 4 November this year aged 91 was one of those very rare intellectuals who achieved great renown in both France and the US, two very different academic cultures and traditions. Girard, a celebrated Professor at Stanford University became, in 2005, one of the 40 immortels of the Académie Française. Embedded in the American academic system from the mid 1940s where he undertook a PhD at Indiana University on American attitudes to the French (an inexhaustible topic to be sure), Girard became one of the eminent French theorists who lit up parts of the US Academy in the latter half of the twentieth century.
Indeed, Girard opened the door to them. After spending the 1950s as a junior academic in various US institutions, Girard became full Professor at John Hopkins University in 1961, publishing his first monograph Mensonge romantique et vérité romanesque (1961, translated as Deceit, Desire and the Novel in 1966). This work famously introduced Girard’s theory of ‘mimetic desire’, the idea that desire is always mediated by another, a rival, in relation to readings of Shakespeare, Proust and Dostoyevsky. It was in the year of the translation of this work that Girard, along with his colleague Eugenio Donato, organized the ‘symposium of structuralism’ in Baltimore that introduced the avant-garde of French thought to a new generation of American academics mostly from the field of comparative literature. In fact, some of the French were meeting each other for the first time. Jacques Derrida, for example, notes the peculiarity that he had to go to Baltimore in order to meet Lacan, ‘we were introduced to each other by René Girard’.1
Girard’s own interlocutors were pre-eminently Freud and Claude Levi-Strauss whose ideas he both adopted and passionately contested drawing his greater inspiration, it seems to me, from his host nation. Girard’s oeuvre is a fascinating elaboration of some of the major themes of European anthropology, theology and philosophy of myth that are reformulated against a backdrop of the ‘primitive passions’ of America in the 1950s and 60s. For example, while it has been noted that the theory of mimetic desire bears some similarities with the desire of the Other associated with Lacan and Alexandre Kojève, Girard’s notion owes much more to Hobbes and Madison Avenue than Hegel. In contrast to the desire for another desire that provides the basis for human subjectivity that for Kojève transcends the given reality of animal desire, Girard’s interest is in a model of desire that provides the basis for imitation. In its most simple form this is the envy of the other’s objects. It is not for Girard a desire framed by Oedipal rivalry or the desire for recognition; on the contrary, it is ‘very concrete’, even Biblical, and directed towards objects that satisfy the drives – particularly when they can move up the gears of a smart car. ‘When the Bible tells you first, “Don't desire the wife of your neighbor”, that's essential’, said Girard, in an interview with Sergio Benvenuto in 2002, ‘and then, do not desire the donkey of your brother: in other words do not desire the Mercedes Benz of your brother; and the Mercedes of your brother is much more important than anything Freud is talking about’.2 For Girard these mimetic desires have a direct link to the state of nature and would proliferate in the war of ‘all against all’ if it were not that the mob, united in mutual ressentiment, eventually alight upon a ‘scapegoat’ whose sacrifice offers a moment of relief and expiation. Human civilization and order is based on the rituals that commemorate this victim and the violence that intermittently has to be renewed. No doubt reaction to the various traumatic assassinations that scared American society throughout the 1960s supported this view. The quotidian proliferation of such acts of random gun violence, however, and their link to an aesthetic-economic domain of generalized minor celebrity would suggest both that the rituals of expiation are no longer working and that the drive, as Freud maintained, is not satisfied with the goods unless they can become vehicles for that which in life prefers death.
In his remarkable tribute on the occasion of his entry into the Académie Française, Michel Serres acclaimed Girard ‘the Charles Darwin of the human sciences’. From a certain perspective it is possible to see how contemporary American society and a US Academy dominated by human sciences that seek to understand all animal and human behavior according to the same system of basic physiological functions would provide a perfect laboratory for such an approach in which the Bible, or even Sophocles, can be read as a Darwinian text. Speaking of how Oedipus’s limp encodes the predatory nature of animals in myth, Girard concludes ‘when lions and tigers choose their prey, they usually choose the handicapped prey: they are easier to catch’.3
The two police officers who in the week of Girard’s death, shot to death a six year-old boy belted in the back of his father’s car were not planning to eat him. But it is curious that in reporting the incident journalists thought it necessary to add the detail that the child was autistic,4 making one wonder at the pervasiveness and chilling relevance of Girard’s philosophy of the victim.
1 Jacques Derrida, Resistances of Psychoanalysis. Stanford University Press, 1998, p.50.
2 Sergio Benvenuto and René Girard, ‘Psychoanalysis and Sacrifice’ JEP. 14 (2002) www.psychomedia.it
3 Ibid. “Mafalda”, Quino, Ed. Lumen.
Traditional French cafes have been stalwart in resisting the Air Mac scourge that has transformed American coffee shops into tomb-like virtual opium dens. Starbucks is the only place in Paris where you can sit for hours in pure, autistic, masturbatory laptop jouissance without being bothered by a waiter or feeling bad about ruining the genital vibe with your regressive scopic jouissance. So I go to Starbucks.
Like many Americans, waiters make me uncomfortable. Their performance of servitude hypostasizes ontological difference, therefore symbolic castration, and as a neurotic, that bothers me. It didn't bother Lacan. He loved barking at waiters. Lacan understood that there is no love and desire without perversion. We can only meet other subjects on the terrain of their symptoms, and must have the courage to lash them if they demand it. But love is hard. Far easier to retreat into the Beautiful Soul fantasy that, by not participating in the S&M ritual of being waited on, I am a good person.
So, a few days ago, I was sitting at Starbucks downloading the new Mandingo scene from Blacksonblondes.com when a dynamic young woman sat down across from me and introduced herself. I could tell by her bright voice, her big smile, and the fact that she called me “tu” instead of “vous” that she was trying to sell me something. What she said to me in French might be approximated as, “Hey, I'm Charlotte. Mind if I chill with you for a minute?” Now, I am a balding, middle-aged man. I don't “chill” with anyone. I deployed my best imaginary axis-busting analytic frown. This social media speak had to be nipped in the bud quick. To Charlotte's credit, she calibrated right away to my dour mien. Her speech immediately became less bombastic and more articulate. It turned out that she worked for a talk show on France 2 called “Comment Ca Va Bien” and wanted to know if I would be interested in sitting in the studio audience for a taping. I said yes. She gave me an address in the Paris suburbs and told me to be there at five PM the next day.
“Oh yeah, and wear a solid-colored shirt!”
I was met at the door by a mean-looking security guard who led me to a holding pen with about fifty other suckers. Half an hour later we were herded towards a coat check and instructed to fork over our phones. Not just turn them off, give them up. This was the first surprise of the day. We refuse to give up our iPhones for mass, for class, for Don Giovanni, even for Grandpa's funeral, but tell us we'll be on TV and the precious phones disappear with no protest. More proof, if any were needed, that the secret chambers in which the gaze of the Other is realized are the true locus of the sacred today.
After castrating ourselves, we were herded to a huge pastel sound stage dominated by a happy-looking ovoid table. At its head sat Stéphane Bern, the dapper host, whose personal brand could be approximated as “everyone's favorite amusing and non-threatening gay uncle”. I had never heard of any of the guests present. They all appeared to be C-list has-beens: raddled meat ready for the reality circuit grinder. The “special guest” was a washed-up TV actress named Véronique Jannot who had just written a book about spirituality called “Au fil de l'autre – voir la vie autrement” (published by Michel Lafon, who refused my novel). The introductory montage showed a photograph of her wearing a flowing white gown and standing next to the Dalai Lama. At this moment our handler exhorted us silently to clap and cheer. “Please give a warm welcome to Véronique Jannot!” She walked onto the sound stage accompanied by her dog. How much did she pay her publicist to come up with this calculated quirk in an attempt to rejuvenate her own flagging brand? As soon as she got to the table, one of the other guests, a randy septuagenarian actress rendered troll-like by her numerous botched facelifts, made a big spectacle of clomping around the table on her super-high heels, hugging Véronique Jannot, and exclaiming in a raspy, Joan Rivers voice, “She's so cute...I just want to take a bite out of her!”
At this precise moment, a technician yelled “Stop!” from the wings. Everyone froze as an assistant bolted onto the sound stage. Beauty expert Janane Boudili's makeup was melting under the hot lights. The makeup guy fixed Janane's eyeliner and hustled back off stage in ten seconds flat. The actors went back to their seats. “Go!” Like an unpaused DVD, they immediately came back to life in mid-sentence. Danièle Evenou jumped up and with the same terrible enthusiasm clomped over to Véronique Jannot a second time, threw her arms around her neck with the same big collagen smile, and executed the same performance of spontaneity, with a little extra hug this time: “She's so cute...I just want to take a bite out of her!” The Tibetan Buddhist smiled in the exact same “enlightened” way as she had the first time and the program went on as if nothing had happened.
The taping went on like this for three hours. It was exhausting. We were obligated to clap and cheer on command every time Stéphane Bern uttered a predictable witticism. The benches were surprisingly uncomfortable. We were not allowed to talk to each other. The cadaverization to which we were expected enthusiastically to submit had a distinct flavor of bondage. In other words, Charlotte had roped us into a perverse scenario in which we were reduced to mute stand-ins for the Other. If the simple desire to believe in the object (a) is neurotic, the attempt to realize it via the performance of a ritualized scenario is properly perverse. The setup was even more explicitly perverse in that it substituted a mute, gazing, bound Other for a blind, incomplete, unbound Other whose last substance is nothing but an unpredictable signifying chain (which is to say, desire). Where the neurotic flees the confrontation with the Other – because he knows that the Other is his master – the pervert provokes this confrontation in an attempt to dominate the Other, or rather, to perform a fantasized domination of an ersatz Other, thereby denying his subjection to the law of desire. The goal of shows like Comment Ca Va Bien is to realize the Other and, in so doing, liquidate its Otherness.
We have all seen schizophrenics walking down the street talking and gesturing to the voices with vacant expressions in their eyes only to realize that they are actually just normal people speaking on Bluetooth headsets. A similar hijacking of consciousness was happening to the freaks on stage. The presence of the gaze, incarnated by the cameras as well as the studio audience, functioned like a Bluetooth headset beaming the Other's fantasized voice straight into their mouths. (This phenomenon is worth exploring – television as a means of transubstantiating the gaze into the voice?) The discourse of this mutilated Other flowed from them with a truly demonic smoothness. Where full speech is mined with pauses, hesitations, spontaneous gestures, changes of course, etc., the speech that bounced back and forth between the talk show guests was as bright, compact and hollow as a racquetball. At no point during the entire show did anything like a lapsus occur.
In other words, the people on stage were very ill. Their witty repartee was an absurd caricature of authentic human communication. One of the reasons Lacan gave his object the name of (a) is because it is a small piece of the big Other, A. We cannot access A without passing through (our fantasy of) (a). Clearly the people on stage believed themselves to be in the presence of (a), which of course has no positive consistency. In this sense, they formed a perfect perverse community of denial. After all, everything on stage proclaimed the overwhelming reality of the gaze, from the studio audience to the scrambling technicians to the cameras which, like any technological object that incarnates a libidinal object, necessarily generate a gravitational field of perversion. If anything, the television personalities on stage reminded me of drug addicts. Their object of predilection, the gaze, bypassed language and acted directly on their bodies, temporarily canceling symbolic castration (hence the smooth discourse) and producing a manic, euphoric state. More generally, the whole spectacle was pathetic, in exactly the same way that it is pathetic to watch a drug addict get high and believe himself to be joined with his (a).
Another curious but important detail: never once did any of the actors make incidental eye contact with anyone in the studio audience, even when the cameras were not rolling. We were...the sun. In Seminar XIII, Lacan remarks that the sun, in Plato's allegory of the cave, unites what cannot be united, namely Truth (jouissance) and Knowledge (S2), and that for this reason it is a false concept. The actors could only maintain their fantasy that jouissance and discourse intersected in (a) if they scrupulously avoided glancing at the fake sun that illuminated them.
I was lucky enough to be seated next to a psychotic woman who explained to me between takes that she regularly attended such screenings. During the course of the show, she several times exclaimed answers to the questions, mouthed the responses spoken by Stephane Bern, and commented to herself (“That's true!”). Like a child playing a video game and moving along with the characters, she was totally engrossed in what was happening. The surreal set-up – what is a sound stage if not an incarnation in space of the “open” psychotic unconscious? – probably offered her a unique opportunity to encounter a representation of her own enigmatic relationship with the Other as well as the gaze and the voice that traversed her.
As soon as it was over, we were unceremoniously hustled out the service entrance by a security guard. Goodbye, get the fuck out of here and don't try to hassle Véronique Jannot for an autograph.