A Story of Friendship and Addiction
I rarely re-read books. But The Tennis Partner, an autobiographical work by Abraham Verghese, MD, is an exception. My current engagement on the Advisory Board of a substance use disorder (SUD) stigma reduction grant brought the book back to mind — many years after my initial reading. The book has several thought-provoking threads, and SUD stigma among healthcare providers is one of the more subtle of them.
In short, as a new attending internal medicine physician at Texas Tech University in El Paso, Texas, Verghese strikes up a relationship, centered around playing tennis, with a fourth-year medical student, David Smith. David had briefly been a tennis professional. The evolving complexity of this relationship provides powerful tension in this book. One key dynamic emerges when David discloses that he is in recovery from cocaine use disorder. David has just returned to medical school after an extended leave of absence during which he was treated for his SUD and started a 12-Step recovery program with close monitoring by the medical school requiring random drug testing. During the 18-month period that the book covers, David returns to cocaine use twice.
Four stigma-related themes emerge in the book.
First, the medical school practices a non-stigmatizing approach to David’s struggles. How? By word and practice, they address his struggles as the symptoms of a serious medical condition. Their response following each episode of cocaine use is to suspend training and mandate treatment. In other words, as they would with any other chronic illness that has negative consequences for the student’s well-being and optimal learning, and which impacts professional behavior and patient safety, they treated David, rather than punish him. This would be enlightened today, let alone in the early 1990s when these events took place.
Second, the book lays bare the self-deception that so many of us comfort ourselves and judge others with. We are not immune. The clear fact is that David’s great intelligence, his winsome personality, advanced education, medical training, access to professional treatment, engagement in self-help, plus support from enlightened and caring mentors – none of these, could insulate him or free him from his disorder. The uncomfortable lesson for us is that the advantages that enabled us to become health professionals and the additional privileges we enjoy as members of a professional elite do not insulate us from substance use disorders and the mayhem they engender in their wake. Yes, they may positively influence the trajectory of a nascent SUD, but they do not grant immunity.
Third, we see Dr. Verghese’s very typical reaction to David’s struggles. In part, this is a consequence of the complexity of the relationship. He is not just an attending physician in David’s training program, but a deep friend – surrogate family. Dr. Verghese, at times, personalizes David’s behavior, including his return to cocaine use, as if David was doing this to him – Abraham – rather than to David. His professional judgment is also clouded, as he fails, as David’s supervisor, to report a new episode of cocaine use to medical school leadership. Known colloquially as “enabling,” he (briefly) shielded David from the consequences of his illness. The cornerstone to behavior change is the understanding that behavior is shaped by its consequences. To the extent that consequences are minimized, their role in motivating behavior change is diminished.
Fourth and finally, we see Dr. Verghese’s deep compassion. He was one of the early HIV practitioners, practicing at a time before there were any treatments. He captures this in his 1995 book, In My Own Country, which describes his HIV practice in Johnson City and the Tri-Cities area in Eastern Tennessee. In The Tennis Partner, we see the same open, non-stigmatizing approach to those he treats for complications of SUD, some of them repeatedly.
The starting point for any personal change is to gain awareness that we need to change. None of us decide to think, talk, and act in stigmatizing ways. It’s simply “in the water.” We are all prone to categorize people into “us” and “them.” We often build defenses against things (people, information, beliefs) that are personally threatening. One of the most significant steps any of us can take is to replace the question, “Do I stigmatize those with SUD?” with “How and when do I stigmatize those with SUD?” The beginning of change starts with awareness.
Though I am fascinated by knowledge, I am even more fascinated by wisdom.
-Abraham Verghese