The Good Doctor (12 page)

Although I insisted on merging history and medicine as an undergraduate, I remained remarkably uninformed about the combination. Penn’s history department housed two of the country’s preeminent historians of medicine, Charles Rosenberg and Rosemary Stevens, but it never occurred to me to take their classes. The union of my interests finally came about due to chance and good luck. As a senior history major, I needed to write an honors thesis. My professor, Walter Licht, a labor historian, proposed that, as a future doctor, I consider a medical topic. I said okay but had no ideas at all. Licht suggested that I visit the university’s archives and see if the staff there might help.

So it was that I first realized the truth of the phrase “The archivist is the historian’s best friend.” Archives director Francis Dallett told me about a missionary medical school begun by Penn in China in 1905, the story of which had never been told. There were lots of relevant primary materials both at Penn and at other universities. I was off to the races. I loved doing the research, going through aged and fragile documents in reading rooms and taking notes on what turned out to be thousands of small note cards. I needed an adviser, and so it was that I finally met Charles Rosenberg, who claimed to know little about the topic but was of course an enormous help.

Meanwhile, I was applying to medical school. If my father had become a doctor in part as a way to give back to his industrious and frugal working-class parents and relatives who had made so many sacrifices for him, my decision stemmed from being raised in a comfortable liberal upper-middle-class home with two parents who explicitly modeled ethical behavior: my father, the compassionate and devoted physician, and my mother, a remarkably selfless person whose bout with and recovery from breast cancer led her to become an inveterate volunteer for the American Cancer Society—eventually even winning an award as Cleveland’s top volunteer of the year. That is, I pursued medicine not as a way to acknowledge my good fortune or surmount personal odds but rather as a way to do good for others. As someone with an interest in history and the humanities, I added an intellectual component to my career: scrutiny of the very profession that I had chosen to join. My father had entered medicine wide-eyed, but I entered it with my eyes open to the complicated and controversial issues that came with the territory.

I suppose that the topic of my honors thesis did arise during some of my medical school interviews, but at the time, I was planning to become a doctor, not a historian. Having compiled an impressive academic record, I was invited for a large number of interviews. First up was—no surprise—Case Western Reserve School of Medicine, my father’s alma mater and employer. My father had not suggested that I attend college in Cleveland, but medical school was a different story. So I had applied to Case’s medical school, even though we both knew I would probably not wind up there. We arranged for me to have the interview at the end of August 1981, just before I left Cleveland to return to Philadelphia for my senior year.

I can only begin to imagine how proud my father was that day when we entered the office of Jack Caughey, the iconoclastic (then emeritus) admissions director who had accepted my father to the same school twenty-five years earlier and who had played a major role in curricular reform. The interview was, of course, a formality. There was no chance that Professor Phillip Lerner’s son, who had compiled an excellent record and was—perfect for Case—a history major, would not be offered admission. My father and I also paid a visit to the University of Michigan Medical School. I was amused, years later, to read in my father’s journals that he had been “infuriated” that my only interviewer there had been a medical student, an issue that had not even occurred to me.

Another early interview took place at the Columbia College of Physicians and Surgeons in October 1981, during (as I recall) the school’s first week of interviews. I liked the idea of going to New York City for medical school, and Columbia was certainly prestigious. But before the meeting, I walked around the rather dreary Washington Heights neighborhood in which the school was situated, and it was not love at first sight.

An interesting event, however, occurred during my interview. Like other medical school interviewees, I had gotten advice about how to answer some of the questions I would probably be asked on the circuit. So I was prepared to explain why I had applied to medical school, why I had majored in history, what I planned to do during medical school (laboratory research, I dubiously claimed!), and what I might eventually choose as a specialty. But I was caught completely off guard by one of the questions asked by my interviewer, a faculty psychiatrist.

“What,” he asked, “was the most difficult thing you have ever experienced in your life?” I paused for a moment, thinking about my answer. But there was little question what it would be: my mother’s breast cancer. I wish I could remember exactly what I said but I do recall the words and feelings pouring out of me. The fact was that, although my family had often discussed the cancer, there had been no
real
conversations of the sort that my father was having with himself in his journal. So it was that I first openly expressed my fears that my mother was going to die in an interview room at Columbia. The discussion also helped crystallize in my mind why I had chosen to apply to medical school: to help sick patients like my mother.

The interviewer must have realized that he had not received a cookie-cutter answer. Within a couple of weeks, a fat envelope arrived in my college mailbox offering me admission to Columbia. But I was not done interviewing. I made a lot of other trips, including one to Harvard Medical School. My father had insisted that I look up his old mentor Louis Weinstein, who I had not seen since we moved from Boston to Cleveland fifteen years earlier. We had a nice chat in his large, cluttered office at Harvard’s Brigham and Women’s Hospital, where he had moved after leaving Tufts. I remember being impressed with his vast knowledge, just as my dad had been during their chance encounter in 1960. So I decided to mention to my tour guide, a Harvard medical student, that I had met with the venerable professor. His reply was not what I expected. “Weinstein.” He sighed. “He just goes on and on about those old diseases like tuberculosis.” I felt a little embarrassed at having mentioned Weinstein, but I later took solace in the fact that as the student and I were speaking, the tuberculosis bacterium was quietly planning a major resurgence.

By early 1982, I had completed my interviews. Once I heard back from all the schools, I considered my options. Columbia, I decided, was the place where I would become a doctor.

On the one hand, it is amazing that my father did not move me into medical school in August 1982. After all, having his son become a doctor was something he had dreamed about for years. I remember any number of fathers (and mothers) carrying boxes into Columbia’s Bard Hall, the residence for most first-year P&S (shorthand for Columbia College of Physicians and Surgeons) students. On the other hand, his absence was utterly explicable. He was tending to his uncle Mickey, his father’s youngest brother, who was dying of cancer. My dad visited him daily, providing advice about pain relief, answering medical questions, and simply sitting with him for long periods. Certainly no one would have begrudged my father’s going to New York for a few days—even if Mickey had died while he was away. After all, something momentous was occurring, and Mickey surely had other doctors. But he stayed and, indeed, was at the bedside when Mickey quietly died, the same day that I departed. For reasons I cannot remember, my mother stayed in Cleveland as well.

This is a somewhat painful anecdote for me to revisit, as, once again, it seems, my father had put being a doctor over being a parent. But I do not recall being very upset at the time. I knew that my dad was extremely proud of me. And, on the precipice of entering medical school, I surely was inspired by his profound devotion to his dying uncle. So I drove to New York with Toby Nygaard, a neurologist who had done an internal medicine residency in Cleveland at the Mount Sinai and become friendly with my parents. Even though Mickey died later that day, my father was thinking about me. “So tonight Barron is in New York,” he wrote, “on the threshold.”

My move from high school to college was relatively easy, but the transition to medical school was more difficult. I really enjoyed orientation week, but as soon as classes began, things got very serious very quickly. I remember many of my classmates heading to the library the first evening after classes, something even I had not done in college. And one of our anatomy professors began his first lecture by telling us that if we had not already begun memorizing anatomical structures, we were behind. Meanwhile, as a former history major, I was feeling a little overwhelmed. At least half the class, it seemed, had taken biochemistry—one of our introductory courses—in college. Some of my fellow students had even taken histology, the study of cells and tissues. I did not even know what the word meant.

It was a little unseemly for me to complain about all of this. Just because I had worked so hard in college and now apparently needed a little break did not mean that my classmates felt the same way. But, in my defense, the classwork was particularly tedious, mostly just dry talks about molecules, chemical reactions, and body parts. Compared to these presentations, my father’s lectures had been downright exciting.

It was clear why many of the lectures were so uninspiring. Many of the first-year faculty members were basic-science researchers, much more comfortable behind a microscope than in front of a hundred and fifty medical students. Only in later years did I realize that many of these individuals had been giants in their respective fields. Biochemist Elvin A. Kabat, for example, had made some of the most important discoveries about how the body produces the antibodies that attack invading bacteria. Hematologist Elliott Osserman knew more than anyone about two rare diseases involving abnormal proteins: multiple myeloma and amyloidosis. These professors were probably too modest to emphasize their own achievements, but some historical perspective would have made things more interesting—at least for me. I could not resist telling the microbiologist Harold S. Ginsberg, a pioneer in the study of adenoviruses, a bit of his own history: he had taught my father microbiology at Western Reserve University in the 1950s, and now, in the 1980s, he was teaching it to me.

I did have one confidante during my early days at P&S: Evelyn Attia, a classmate who had also been a history major in college and was feeling similarly deluged. The composition of medical schools had changed substantially from my father’s era, with its overwhelming predominance of white men. Evelyn was one of about forty women in my class of a hundred and fifty students, and, within a decade, Columbia and most other medical schools would attain a ratio close to fifty-fifty. We also had about twenty minority students. Although I had, in some ways, benefited from being a white male, I appreciated the changes, which brought a diversity of opinions and experiences to the laboratory and the wards. In fact, on several occasions when these women and minority students witnessed behaviors that they believed to be sexist or racist, they confronted the rest of the class. Sad to say, several faculty members held outdated views about gender and race, which they blithely broadcast. We students at times did the same. As a liberal person who had trained in the humanities, I considered myself fairly enlightened, but I was forced to confront some of my own prejudices.

Soon after my arrival at P&S, in a situation that mirrored my father’s unexpected and fortunate introduction to Louis Weinstein and the field of infectious diseases, I encountered someone who would become one of my mentors. It occurred in a class called Society and Medicine, which was being offered to P&S medical students for the first time. The lecturer, David J. Rothman, introduced himself as a United States historian from the main campus of Columbia University who had been asked to move to the medical center to study and teach about a new set of ethical issues being raised by technological advances, patient activism, and a spate of recent research scandals.

Most of my classmates did not especially like the course, seeing it as peripheral to becoming a doctor. But I ate up the Society and Medicine syllabus, which introduced me to a series of seminal controversies that defined the field of bioethics in its early years. For example, there was the 1961 article published in the
Journal of the American Medical Association
reporting that 90 percent of physicians preferred not to tell cancer patients their true diagnoses. This attitude stemmed not from any scientific research but the doctors’ “emotion-laden
a priori
personal judgments” that patients needed to be protected from bad news. There was the story of the God Squad, a committee of laypeople in Seattle in 1962 who were asked to decide which patients with chronic kidney failure would receive lifesaving hemodialysis from the limited number of available machines. Those left undialyzed would die. When the committee used social-worth criteria, favoring individuals who had families and went to church, the public objected strongly. Another important event was a report published in 1968 by the Harvard Medical School Ad Hoc Committee on Brain Death. This group of thirteen men—mostly physicians—argued that patients who had beating hearts but no electrical activity in the brain should be declared dead, an entirely new concept. Critics, however, argued that this definition of brain death was primarily a mechanism for increasing the number of available transplant organs. While this was a worthwhile cause, they believed, it had the potential to take advantage of dying patients and their vulnerable families.

A substantial amount of class time was spent on Willowbrook, Tuskegee, and the other research scandals of the 1960s and 1970s in which the principle of informed consent had been repeatedly violated. And there was the well-known 1975 Karen Ann Quinlan case, in which a young woman, after ingesting an unknown quantity of pills and alcohol, had become irreversibly comatose. When her parents asked that their daughter be removed from the ventilator that was keeping her alive, the Catholic hospital refused. Eventually, the New Jersey Supreme Court sided with the family, and its ruling helped codify the notion that gravely ill patients had the “right to die.” Ironically, when the ventilator was turned off, Quinlan, unexpectedly, lived—still in a coma—for nine more years.