There is a scene in the critically acclaimed television show “Louie” in which the (almost) eponymous main character and severe odontophobe Louis CK visits the dentist for a check-up. Ironically, the dentist too shares CK’s profound fear of dentists, and has made it his life’s work to assuage his patients’ anxieties. In an unsettlingly homoerotic sequence, capped by a suggestive ending shown here, CK flits in and out of consciousness as his dentist “inspects” at his teeth (I can’t really think of a good euphemism here, but you get the drift). While sedated, CK’s mind is transported to a barren desert, where he converses with Osama Bin Laden and members of the terrorist’s inner circle. In a hilariously candid conversation, CK admonishes Bin Laden’s decision to carry out the 9/11 attacks, saying that it simply “wasn’t nice” of him to do, and that it was plainly a “bullshit move.” Shockingly, CK’s fictive Bin Laden agrees that he has acted like an “asshole,” and Louis is left wondering whether he had just talked the founder of Al-Qaeda out of being a terrorist.
This is one of the more disturbing sequences in a show that is invariably unafraid to tackle uncomfortable topics head-on, such as terrorism and sexual misconduct. The fact that this also happens to be my favorite sequence in television might warrant a discussion with my therapist. But that’s neither here nor there. Notwithstanding the resounding innuendo of the unpeeled banana, CK left nothing for the viewers’ imagination as he dreams of a scenario in which Al Qaeda finally understands the merits of liberal society. Had the dentist not interrupted this dream sequence with his “banana,” CK may have cemented groundbreaking diplomatic relations with America’s former ally-gone-rogue. Alas, as viewers, we are jerked from this drug-induced vision quest to an equally absurd reality in which the dentist is hastening to zip up his pants and send CK on his way. Dentally, but certainly not coincidentally, CK’s teeth still hurt after the visit.
Comedians like Louis CK, Dave Chappelle and Larry David are masterminds in the art of distorting human relationships. In his television show “Curb Your Enthusiasm,” Larry David compulsively creates redwood-sized conflicts out of the seeds of annoyance, like the time where his crusade to find a perpetrator of a coffee stain irrevocably damages his relationship with his soon-to-be ex-wife, Cheryl. Meanwhile, Chappelle cleverly puts racial microaggressions under a magnifying glass by imagining a white friend, “Chip,” who gets away with grievous criminal offenses simply because he is white. And in the scene described above, CK depicts a dentist who uses his “medical” expertise in order to take advantage of his patient. We all know that real Larry probably wouldn’t risk a financially and emotionally costly divorce simply because he wants to hold his wife responsible for a coffee stain. Similarly, it is very unlikely that real Dave has a friend named “Chip” who drives under the influence through red lights with the stereo blasting “We’re Not Gonna Take It!” without receiving so much as a slap on the wrist. Obviously, these routines wouldn’t be funny if they happened every day.
But, as Sigmund Freud stated sometime between thinking about his mother and hating his father, there is no such thing as a “harmless joke.” These distortions are created to first capture, then redirect, our collective attention to social occurrences we take for granted. David tends to have us question social norms and etiquette: “Why the hell do we care so much about a cup stain…why do we feel the need to ‘respect wood’?” Chappelle, on the other hand, tends to draw our focus to more profound — and extremely topical — social contradictions: “Why do we have to put up with racial profiling in law enforcement?” These jokes are supposed to make us laugh, but they should also make us squirm. David and Chappelle are experts at turning the mirror onto their audiences, and forcing them to reckon with the uncomfortable realities they would otherwise blissfully ignore.
Louis CK accomplishes the same incredible feat in his television show, but with an added twist. He turns the mirror onto his audience, and then angles it slightly to accommodate the reality of the health care professional in the same frame. This is why I consider CK to be our greatest contemporary comedian — he is not only capable of highlighting the absurdities of human reality, but he can additionally ponder what may happen when multiple realities clash. (And as a prospective medical professional, I love it when this reality clash plays out in a medical context.) The technique of comic distortion, perfected by Chappelle and David, came in mighty handy in the scene at the dentist’s office.
While almost every conversation with a medical professional is somewhat limited by an asymmetry of knowledge between patient and provider, this divide is often mitigated by the communication skills of the provider. However, in the “Louie” scene, this knowledge gap is accentuated by the actions of the incompetent dentist, who sedates CK and bifurcates their shared reality into two obviously distinct ones. CK’s unconscious reality drifts to the sands of Saudi Arabia, while the dentist’s is firmly entrenched inside the dentist’s office, where he is completely empowered to solve or disregard CK’s ailment. CK has absolutely zero control over the matter. From start to end, he does not understand the source of his tooth pain, and the dentist does nothing to abet this understanding. If anything, CK leaves the office in a state of even greater confusion.
Between this scene and Jennifer Aniston’s virtuoso performance in “Horrible Bosses,” one might have second thoughts about going under for a dental or medical procedure. And unfortunately, there are in fact terrible people who have taken advantage of patients in this setting. The last thing I’d ever want to do is diminish the psychological and physical harm suffered by patients at the hands of their providers. Neither was it CK’s intention, I believe, to make light of something as serious as sexual misconduct in the health care setting. Rather, he wanted to distort the inevitable asymmetry between the patient’s knowledge and the practitioner’s expertise, and this asymmetry happens to be maximally distorted when the patient is unconscious. The key point here is not the perverted distortion, but rather the ubiquitous existence of an asymmetry, a reality clash between patients and providers.
Often times, this asymmetry is benign. A patient may not understand a virus the same way the doctor understands the same virus, but the doctor can explain the infection in laymen’s terms and provide clear instructions for care. The patient leaves with treatment and a rudimentary understanding of his or her illness. Other times, however, this asymmetry is detrimental. In psychiatry, for instance, there has been a huge push to standardize diagnostic criteria (in the form of the DSM-IV) and create discrete “diagnostic categories” when the medical community is only just beginning to understand the biological basis of mental illness. As Harvard psychiatrist Dr. Steven Hyman so eloquently stated in his review “The Diagnosis of Mental Disorders: The Problem of Reification,” the modern zeal to find a “shared language…creates epistemic blunders that impede progress toward valid diagnoses.” Indeed, simply by adopting the confusing terminology of the larger medical community, the provider (in this case, psychiatrist) may not only deny the patient access to correct treatment, but may even deny the patient’s own experience with illness. That is what Hyman meant by “the problem of reification.”
Perhaps not coincidentally, Dr. Hyman adapted the rhetoric of outspoken 20th century medical pessimist Ivan Illich, who saw medicine in general as an enterprise of reification. According to Illich, doctors treated illness in ways patients could not understand, while patients experienced illness in ways that doctors do not care to understand. Louis CK distorts — and thereby draws our attention to — “reification” by imagining a scenario in which the provider wittingly disadvantages the patient, while Dr. Hyman references “reification” to point out that providers may even unwittingly disadvantage the patient.
As future doctors and patients, it is critical to remain cognizant of this gap between the provider’s expertise and the patient’s own experience. In fact, the term “knowledge asymmetry” may even be a counterproductive misnomer because it implies that the doctor’s knowledge supersedes the patient’s in the matters of diagnosis and treatment. Rather, if anything, I prefer the concept of “conflicting realities,” so beautifully embodied in Louie’s trip to the dentist. Patients have their own theories, ideas, feelings and experiences surrounding even a single illness. They have their own “reality.” Doctors, meanwhile, have a different set of values regarding illness, often times rooted in personal experience and evidence-based medicine. It is incumbent upon the doctor to try to understand the patient’s reality, if only to establish greater trust. At the very least, this sort of effort on the part of the doctor can only enhance the patient’s confidence that the doctor is listening to them. At the very most, the doctor’s willingness to reconcile his or her “reality” — a set of diagnostic and treatment classifications — with that of the patient’s can lead to profound improvements in patient health.
Recent criticisms of “evidence-based medicine” and the renaissance of more humanistic approaches together suggest that the medical profession is starting to acknowledge a place for the patient narrative in health care. To that end, I heavily recommend psychiatrist Peter Kramer’s New York Times piece “Why Doctors Need Stories” to anyone interested in patient-centric care. In the article, Kramer discusses how he relies on a combination of “clinical vignettes” (stories of patients who responded to anti-depressive treatment, for example) as well as scientific studies to inform his practice. Large-scale empirical studies tell us about the population effect of an intervention, Kramer suggests, but they alone cannot “remind us of the variety of human experience and enrich our judgment.”
Louis CK hilariously frames the problem of conflicting realities in a medical setting. Dr. Kramer offers a compelling solution: storytelling. Of course, the ability to tell the patient’s story requires the ability to truly listen to, and communicate with, the patient. And who knows, the patient might know the key to peacefully ending global terrorism!