"Complicating relationships"--the water that doctors breathe.

In a commencement speech delivered shortly before his death, the author David FosterWallace told a parable about two young fish. As they swam along they met an older fish swimming in the opposite direction, who nodded at them and asked, “How’s the water?” The younger fish swam on a bit, then looked at each other and shrugged, ‘What the hell is water?’” Wallace was challenging the graduates to consider their “default mode”––the autopilot that generates our biases and opinions before we consciously consider them. Most of the world relies on stored memory to make its decisions and take action, foregoing the failsafe of critical appraisal. The purpose of a liberal arts education, Wallace believed, was to open the storehouse windows and let in the rational light of day. And to remind us of the need to constantly air it out. For primary care physicians, relationships are the water we breathe. Earlier this year, Abigail Zuger, writing in the New York Times, cautioned doctors against becoming too close to their patients. She suggested that social connections with patients (as family, friends, coworkers, or constituents) could cloud objectivity and result in “too little medicine or too much, the care becoming instantly substandard.” “How many degrees of separation are needed between patient and doctor for effective medical care?” she asked. “The correct answer is ‘many,’ or even ‘as many as possible.’” She continued: “Medicine is filled with difficult decisions . . . These shoals are rocky enough without additional complicating relationships.” Competing pressures