The Good Doctor (13 page)

A variety of ethical issues were raised by these episodes, including truth-telling, rationing of scarce resources, informed consent, experimentation, and the rights of the dying. But they all shared a common thread: patients, or, in the case of research, human subjects, were actively excluded from clinical decision making and at times used as a means to an end. My father and other doctors of his generation justified such behavior as beneficent or helpful for the greater good, but the new bioethics found it entirely unacceptable.

After Rothman’s first lecture, Evelyn and I approached him and identified ourselves as college history majors. The two of us began to hang out at the Center for the Study of Society and Medicine, which Rothman was running. During the summer between the first and second year of medical school, Evelyn and I did research projects on the history of Presbyterian Hospital, spending most of our time at the archives on the Columbia main campus. It was terrific and very rejuvenating. So were other outside activities that I pursued during medical school. I finally put my ten years of clarinet lessons to use and played in the pit for several surprisingly good musicals performed by a P&S student theater group, the Bard Hall Players. And I became very active in a local organization that opposed American military policies in Central America and sent health supplies to the region. Pursuing these endeavors took time away from my studies but somehow seemed to provide balance and perspective to my nascent career in medicine.

Despite my early dissatisfaction with the curriculum, there were bright spots. In an innovative course called the Physician-Patient Relationship, patients were regularly invited to speak to our class. That it was taught by a general internist named Constance Park underscored the humanistic approach that women physicians could bring to medical education. To show our respect for the patients, we were expected to wear our white coats to these presentations. In one sense, these meetings were a throwback to traditional grand rounds, in which doctors gathered in an amphitheater in their starched white coats and neckties to hear interesting cases and, at times, meet the patients. But they were also a reaction to these earlier sessions in which patients were publicly examined but rarely asked to participate. The first PPR class was a huge eye-opener. The guest was a woman with diabetes who had used a labor-intensive insulin regimen to successfully carry and deliver a healthy baby, thereby countering the long-standing opinion of many medical experts that pregnancy was too risky for diabetic women. She spoke candidly and forcefully about her decisions and experiences. It was one of the few instances—aside from Rothman’s course—when we addressed the concept of an empowered patient. Actually meeting one was even better.

Fortunately, classes during my second year were considerably more interesting. Rather than learning simply how the healthy body worked, we were learning pathophysiology—how the body malfunctioned in the case of an enormous range of diseases. Two professors from the division of infectious diseases, Harold C. Neu and Glenda J. Garvey, gave some of the most interesting lectures and often won Best Teacher awards. Neu knew my father very well, and I made sure to go and introduce myself. He apparently said something to Garvey, because when I met her, she was, well, thrilled. “Your dad is the endocarditis Lerner,” she immediately announced. Garvey, who ran the all-important internal medicine clerkship for third-year P&S medical students, was one of the most respected woman physicians at the medical center. She would eventually become a good friend and the most important figure in my medical training.

By the summer of 1984, my classmates and I were pretty burned out. We had spent two years memorizing enormous amounts of material and taking test after test. P&S finally put us on the wards for a physical-diagnosis course, in which we interviewed and examined patients. This was my first experience seeing great cases, patients with disorders that had been identified as particularly interesting and thus were ideal for eager medical students to see. I was in a group of five students; we were supervised by one of the veteran internists at the medical center, a man I will call Dr. Jones. Jones was a 1943 graduate of P&S and probably in his mid- to late sixties.

My recollections of this course, plus the first two clinical rotations of my third year, are enhanced by a brief journal that I kept from May to August of 1984. I had largely forgotten about this effort and did not reread the entries until 2012, when I was working on this book. As one might imagine, there were stories in the journals that I remembered and others that I had long since forgotten. On the whole, however, it helps to explain why I chose my subsequent career path.

Although I loved being on the wards, meeting actual patients, and seeing actual pathology, I almost immediately felt uncomfortable with the physical-diagnosis course. Some type of permission was probably obtained for our visits, but it was hard to believe that the patients really knew what they were getting themselves into. Typically, one or two of us would interview and examine the patient. Later on, we would present our findings to Jones and the rest of the group. Then we would all go back to see the patient. Jones would typically ask a few more questions and then watch as the rest of the students performed an examination. Then we would talk about what we had found, all the while standing around the patient’s bed. “The patients,” I wrote, “were hardly people to me.” I don’t recall translating our highly medicalized discussions into comprehensible terms for them nor asking if they had any questions. We generally just thanked the patient, hopefully covered him or her up, and left the room.

Some of this was generational. Physicians of Jones’s era were generally comfortable with seeing ward patients as what was called teaching material, patients available to help educate doctors in training in exchange for essentially free care at a major medical center. And this wasn’t necessarily all bad. Jones and his patrician contemporaries, many with upscale private practices in midtown Manhattan, oozed confidence, sagacity, and, at times, a lot more empathy than we younger folks. W. Proctor Harvey, a skilled Georgetown University cardiologist who practiced in this era, liked to emphasize the importance of shaking patients’ hands and, if necessary, even plumping up their pillows. One of my favorite stories, told by the physician-writer Abigail Zuger in the
New York Times
, described the time that she and her rumpled fellow residents decided to annoy their supervising Park Avenue attending by bringing him to meet a belligerent patient who was refusing to leave the hospital. His white coat, Zuger wrote, “was from another era: snowy thick 100 percent cotton fastened with braided cotton toggles.” “Hello dear,” the doctor said to the patient, and he cradled her hand in both of his. “Ten minutes later,” Zuger remarked, “the two of them were sitting side by side on her bed, making animated plans for her discharge.”

Jones, however, was especially behind the times. He still called African Americans “colored.” Thus, it was hardly surprising that when we visited a black patient with abdominal pain, Jones’s first comments were about how much alcohol the patient had drunk and the fact that he was apparently a drug dealer. Even though I realized that a complete drug and alcohol history was crucial for all patients, regardless of their race, I was concerned that Presbyterian Hospital physicians were biasing their patient care due to what I termed
preconceived suppositions
. What I did not record was my response to these types of behaviors, which disturbed me and my fellow classmates. As I recall, we rolled our eyes but said nothing to either Jones or the patients. We were, unfortunately, too intimidated by the strict hierarchy in medicine, which discouraged any criticism of one’s superiors.

The problem of balancing the care of patients with students’ need to learn, which I labeled the
great third-year conflict
, was not limited to rounds with more senior physicians. During one physical-diagnosis session, an internal medicine resident took us on what I called classic medical rounds, whisking us from room to room to examine patients. It was an invaluable teaching experience: I felt my first enlarged liver and heard several different heart murmurs. But it had to have been a jarring experience for the patients. “It doesn’t matter if you are napping, about to undergo surgery, or whatever,” I wrote. “You will be exposed and examined whenever a mass of white coats congregates at your bedside.”

Two specific examples from my notes vividly demonstrate what happened when earnest, and generally polite, doctors had as their primary focus the need to learn. The resident introduced one patient, a young, deaf African American woman, as “Miss Smith, an intravenous drug abuser.” Even though that fact may have been true, it was surely a denigrating appellation. As we examined the patient, she writhed around in pain. The resident tried to soothe her, calling her “honey” and “sweetie,” but that was unlikely to help someone who was deaf. Of a second patient, a woman with schizophrenia and a swollen abdomen, I felt as if she “had no clue as to who we were or what was going on.” As we examined her, she kept trying to cover herself with the sheet. Even the resident was somewhat uncomfortable, remarking that he hated to treat patients as teaching material.

It is not as if P&S was oblivious to this type of issue, as shown by Rothman’s and Park’s courses. Plus, shortly before the physical-diagnosis course began, the school had offered my class an awareness seminar that discussed issues such as racism, sexism, and homophobia (although, unfortunately, only eighteen of the hundred and fifty students in my class attended). One of the exercises was for the white students to pretend they were minority students and vice versa. But it was one thing for students to discuss respect and equality in the classroom and quite another for them to speak up on the wards if they thought that a patient’s dignity was being violated. I confined my thoughts to paper.

Why did I find these issues—the ethics of a teaching hospital, the professional development of medical students, and the need to balance learning with caring—particularly compelling? I suspect that these interests stemmed from the values of my parents, my intellectual attraction to the humanities, and my early, intense exposure to my father’s brand of patient-centered medicine. As I would find out, the third and fourth years of medical school and then residency training raised an almost endless source of ethical and philosophical questions.

When I began my third-year clinical rotations in July 1984, I was thrown into the fire, doing obstetrics and gynecology at Harlem Hospital Center. If Presbyterian Hospital was the mecca, an Ivy League–run institution full of high-achieving physicians and fascinating cases referred from all over the country, Harlem, a public hospital, was the safety net for a largely poor African American neighborhood. The quality of the medical and nursing staffs was variable, but there were many extremely talented clinicians who had specifically chosen to work there.

Unfortunately, constant financial pressures meant that Harlem Hospital was always crowded and chaotic. Providing patient-centered care required lots of extra effort. Some staff members went out of their way to comfort and listen to patients, but many did not. The residents who staffed the labor and delivery suite, for example, would go from bed to bed saying, “Push, push, miss!” or “Kaka, kaka, senora.” I wrote at the time that the ob-gyn residents, most of whom were women and minorities themselves, did not seem to remember the patients’ names. I was also concerned that inadequate amounts of anesthetic were being given to the largely poor and minority patients who were giving birth—and that the particularly annoying patients were even being punished in this manner. My periodic complaints, I wrote, “receive various excuses.”

I also experienced another typical medical student dilemma: how to balance the need to learn invasive procedures with the care of patients. The ob-gyn residents at Harlem were good about giving students the chance to draw blood, place intravenous lines, and do other tasks—perhaps too good. I was definitely not the kind of student who could watch a procedure done once and then do it himself. It took me several tries to successfully draw my first blood glucose, even though my attempts were on pregnant women with particularly large veins. Apparently I was pretty hapless, as I later wrote that some of the patients laughed when I entered their rooms and started “fumbling around with my tubes and needles.” But I also wrote that they were remarkably tolerant, permitting me to “poke around their arms without complaining.”

Some students, particularly those who were very proficient or intended to become surgeons, had few qualms about learning on patients. The rest of us and some of the residents joked about our flubs and successes. But no one discussed the ethics of the situation. Did students, indeed, have a right to do these procedures? How many times was it acceptable to try before giving up? And were you obligated to tell patients that you were doing a particular procedure—possibly even something as invasive as a spinal tap—for the first or second time? Not surprisingly, I chose an ethics topic for a presentation I needed to do for the rotation: the treatment of severely disabled neonates. For decades, paternalistic physicians had quietly left such babies to die, not necessarily even telling parents they could possibly be saved, albeit with major physical and mental deficits. Such lives, these doctors believed, were not worth living. But in an era of patient autonomy, I explained to my classmates and colleagues, parents were being given the option to pursue aggressive treatment. I applauded this development, although as a medical student, I had admittedly not seen any such children.

When I returned to Columbia in the 1990s as a faculty member, I was fortunate enough to obtain funding to initiate an annual series of lunches with medical students in which we discussed these types of ethical and professional issues. To me, it made sense for the students to learn and think about such things
before
they encountered them as physicians. Perhaps they could do a better job than I had at highlighting instances in which they felt conflicted or patients were being treated with disrespect. Of course, my fellow medical students and I were not merely pests. William Osler, who had first brought students onto the wards in the 1890s, believed that those who spent ample time with patients could learn crucial information that others had missed. Indeed, we students had both the time and inclination to get to know our patients while the residents and attending physicians rushed from duty to duty. For example, I discovered that a patient who was about to give birth had a history of both syphilis and herpes, which was important because it meant that she should probably have a Caesarean section. In another instance, a patient in the family-planning clinic thanked me for putting her at ease and asked if I would continue to work there. It became clear to me that spending only a few extra minutes learning about my patients meant a huge amount to them—and even potentially benefited their care. Although I was learning this firsthand, it was also something that my father had taught me by example.