The Good Doctor (20 page)

There were two other propitious aspects to my new job. First, the Arnold P. Gold Foundation, an organization begun by a Columbia pediatric neurologist and his wife and devoted to promoting humanism in medicine, was looking to fund a young professor at P&S. I was fortunate enough to win the professorship and thus began a very fruitful interaction with Arnold and Sandra Gold and their friends Russell and Angelica Berrie. Among numerous other innovations, the Gold Foundation conceived of the idea of the now ubiquitous white-coat ceremony, during which incoming medical students are cloaked with white coats for the first time, take the oath of Hippocrates, and are introduced to humanistic medicine. Second, although David Rothman continued to teach some bioethics, there were numerous opportunities for me to expand the curriculum for both medical students and house officers.

One of the first programs I initiated was the ethics and professionalism lunches for third-year medical students doing their rotations in internal medicine. These sessions drew explicitly on cases and situations that they were encountering during their clinical rotations. I had experienced many of them myself. So we discussed the right of medical students to learn procedures on patients and whether students were obligated to tell these patients they were just learning. I asked them about being grilled by more senior physicians on rounds or in the operating room, a practice dubbed
pimping
, which some educators had criticized. I mentioned that, as a student, I enjoyed getting asked about famous surgeons but realized that perpetually putting students on the spot could approach harassment. I also encouraged the students to speak up when they witnessed unethical behavior, particularly when it involved patients—exactly what I had not done when I was in their shoes.

Many of the scenarios I raised explicitly contrasted the old paternalism model with the new emphasis on patient autonomy. For example, adult children of cancer patients at times requested that the doctors not tell their parents the actual diagnosis, trying to emulate the benevolent deception that was so common in the 1950s and 1960s. But, I explained, recent studies had overwhelmingly showed that people want to know they have cancer, even if it is terminal. The students and I discussed ways to broach the issue with patients before their families attempted to intervene. Another good example involved the issue of doing an HIV test on a reluctant patient if a medical student or other hospital employee had been stuck with a needle while drawing blood from him or her. When I was a house officer, if that happened and the patient refused testing, we quietly drew an extra tube of blood and whisked it to the laboratory, unlabeled, to find out if the person was HIV-positive. But as of in the 1990s, New York State law—on the basis of autonomy—had declared the patient’s refusal of such testing to be inviolate. As a result, needlestick victims actually went on a complicated mixture of anti-HIV medications prophylactically until they were sure they were safe. Understandably, many students were outraged. This was, I admitted, patients’ rights at its most vigorous and problematic.

Two topics I always covered were DNR orders and medical futility. Although I always taught the current legal and ethical norms, I liked to pepper my presentations with some of my own cases that challenged standard assumptions. For example, we discussed slow codes, halfhearted resuscitation efforts that had been very common when I was a medical student and resident but had subsequently become much rarer due to the objections of bioethicists. In one case, I had actually seen medications injected into the mattress instead of the patient, so determined was the supervising physician to let the extremely end-stage patient die in peace. It was not that this doctor was opposed to patient autonomy, I told the students, but he believed that the patient’s family members had no idea what it meant when they told the medical staff to do everything for the patient. It was here that I might tell the story of the twice-foiled resuscitation of the arthritis patient, saving until the end the detail that the physician in question was my father. I would joke that all doctors are closet paternalists (or, in the case of women physicians, closet maternalists). My father, of course, was out of the closet.

In addition to running these lunches, I also helped organize a Gold Foundation lunch series for the Department of Medicine interns and, with the help of Columbia nephrologist Jay Meltzer and the local Vidda and Rudin Foundations, a medical-ethics fellowship for third-year residents. In all of these venues, issues that my father encountered regularly came up: What was the best way to break bad news to a patient? How should physicians deal with difficult patients? Was it ever appropriate to mislead patients in order to provide hope or get them to cooperate? Should doctors give medical advice to family and friends? Should pharmaceutical representatives, like those who had pitched their products to my dad, be allowed to take medical students and residents out to lunch, or did that compromise the objectivity of young physicians? And, finally, should medical errors be concealed or revealed?

My father had struggled with this last issue as a consultant called into cases in which earlier medical care had been questionable. He had entertained the idea of disclosing such information to patients and family members but, as far as I could tell, had largely kept quiet. Most bioethicists, steeped in the philosophy of patients’ rights and the importance of “doing unto others as you would have others do to you,” increasingly advocated truth-telling in such situations. Not only did patients deserve this information, but some studies suggested that such admissions actually
lowered
the chances of a lawsuit. And after the Institute of Medicine reported that up to one hundred thousand patients died each year as a result of medical mistakes, this topic could no longer be brushed under the rug.

Of course, it was much easier to promote widespread discussion of errors around a conference table than it was to carry out the actual disclosure in the clinic or the hospital. But I tried to do so whenever I could. In one instance, I had left on a Thursday night for a long weekend after seeing a patient in clinic who had a fever and abdominal pain. I ordered blood tests for her but did not check them because I had gotten her a follow-up appointment with a surgeon on Friday morning and I assumed the surgeon would look at the laboratory work. The surgeon saw the patient and gave her oral antibiotics to take at home, but she did not check the test results, which were extremely abnormal and mandated admission to the hospital. The next day, the patient experienced worsening abdominal pain and came to the emergency room, where doctors diagnosed a ruptured abscess. She had successful emergency surgery but an extremely rocky postoperative course, almost dying on one occasion.

At some point, I called the surgeon. I suggested that we had both made an error and needed to tell the patient. We agreed to speak with her separately. I told the patient exactly what had happened, that I had made a mistake in assuming her blood tests would be checked and that I was sorry. She was surprised when she learned the details but appreciated what I had said. I then asked her if she would be willing to tell her story to students studying the topic of medical errors. She said yes, and over the years, she joined me several times. I emphasized to the students that this type of disclosure was quite a new phenomenon. It was difficult and was a skill that needed to be learned from experts and more senior colleagues, but it was the right thing to do.

I also reminded both students and residents that, although I taught them about the doctor-patient relationship, I had learned a lot from other physicians who were especially adept and empathic when it came to patient care. In fact, some of these teachers had been more junior physicians. In one memorable instance, we were gathered around the bedside of a severely ill patient. The patient’s wife, who was standing with us, happened to notice a pin on the white coat of the senior resident.

“My husband belongs to that same organization,” she informed the resident.

Without missing a beat, the resident removed her pin and affixed it to the patient’s hospital gown. The gesture was so spontaneous and so warm that the woman began to cry. I was proud of the resident, and I tucked the memory into my back pocket.

One topic that I particularly liked to discuss was physician prestige. Should being an excellent doctor, especially one who makes less money and works longer hours than peers in other fields, allow someone to feel a sense of entitlement? Each year I showed the entering class of medical students a clip from the Hollywood film
The Doctor
, in which William Hurt plays a talented, but arrogant, surgeon. In one scene, Hurt’s character impatiently gestures for the hospital chaplain to leave a patient’s bedside. “Do some doctors actually think of themselves as more important than God?” I would ask the students. I also told them about a senior Columbia surgeon who had thrown a tantrum and severely injured his foot when a security guard would not let him enter the hospital without his ID tag, which he had left at home. The doctor had been called in at night to perform emergency surgery, and there he was, stuck in the hospital lobby. Who had been out of line here? And what about me? I liked to assign an essay I had written for the
New York Times
in which I sheepishly admitted to having jumped the queue in front of other hospital employees in order to get a flu shot more quickly.

These were issues that students and residents thought about, especially since they were the beneficiaries of Sidney Zion’s campaign to reduce work hours. Was it still possible to be a great doctor if you worked fewer than eighty hours a week and never more than twenty-four hours at one time? What should you do if your patients were unstable but you were told to leave the hospital and hand over care to someone who did not know them as well? Was it truly possible to bond with patients given such restrictions? Did it matter that new doctors in training—in contrast to my father and myself—would never witness the evolution of a patient’s illness over the crucial first thirty-six hours? Did being a great doctor entail constant devotion to one’s patients and one’s craft, or was it better to have outside interests and spend substantial time with one’s family?

Teaching such provocative topics was great fun. It was also pretty easy for me. I was well versed in the relevant scientific, historical, and lay literature on these subjects and had plenty of personal anecdotes to tell.

It was not until I immersed myself in my father’s journals, however, that I really understood how dramatically the practice of medicine had evolved over only a few decades. As a historian, I knew that such change was inevitable and that much progress had occurred. I also remained comfortable criticizing many of the decisions made by my father’s generation of physicians. But situating myself in the middle of my dad’s cases exposed me to an intoxicating type of medical practice that surprised me in the force of its appeal and eventually led me to revisit some very basic assumptions.

CHAPTER SIX

Treating the Whole Patient

As someone who was involved in promoting humanism in medicine and the doctor-patient relationship, I was well aware of several mantras: medicine had become too reliant on technology; doctors saw patients not as people but as specific diseases; physicians in training had become the equivalent of shift workers. Truth be told, I had heard the famous 1925 admonition by Harvard Medical School professor Francis Weld Peabody—“For the secret of the care of the patient is in caring for the patient”—so many times that it sounded almost hackneyed.

It was thus especially helpful for me to immerse myself in my father’s accounts of some of his most challenging cases. Here was someone who had trained in an era when devotion to clinical knowledge and patient care was intrinsic to both medical education and practice. And my father, due to his upbringing, personality, choice of specialty, and job flexibility, had become an especially fervid patient advocate. I found that reviewing his cases, without really knowing what specifically had made him such an outstanding physician, was a huge eye-opener for me—even though I was also a physician as well as a humanist.

The patients I encountered in my dad’s consultation files from the 1960s and 1970s, some of whom I mentioned in the second chapter, gave me insights into a type of clinical practice I had never really experienced. Exploration of some of his later cases—from the early 1980s to the mid-1990s, around the time that he prevented the initiation of CPR—provided even more intense revelations. The cases varied in certain ways. For example, as time went on, my father had to pay more attention to changing ethical norms that placed patients and families in charge of clinical decision making. But the cases all shared one characteristic: my father’s intense engagement in both his patients’ illnesses and lives. The more I read, the more I felt that the difference between my dad’s medicine and mine was almost epistemological. I cared for patients and treated their diseases but did not know them as he did. What was the value of his superior knowledge? And what, if anything, did it entitle him to do as a patient’s physician?

That several of his patients in the 1980s and 1990s had AIDS was particularly fitting. My father had entered infectious diseases during its early, heroic phase, just a few years after his mentors had been forced to watch young, vibrant patients dying of untreatable infections. Now, with the advent of AIDS, the same thing was happening. As my father approached his late fifties, he encountered perhaps the most challenging patients of his career. They tested both his scientific acumen and his skills at interacting with patients and families. When I opened one of his journals, a photograph of one of his AIDS patients, a gift from the man’s parents after their son died, fell out.

I certainly knew one case that I would find in my dad’s journals, perhaps his most memorable patient. Laura (not her real name) was a married woman in her twenties with two children who developed an extremely complicated and ill-defined disorder of her bone marrow and immune system in the mid-1970s. My father had become involved because she originally came to the hospital with the diagnosis of infectious mononucleosis (which turned out to be incorrect). Eventually, there would be many actual infections for him to treat. But he stayed involved—and essentially became Laura’s primary doctor—because he bonded with her as a friend. Although I understood very little about her medical condition, and I heard about her less after I went to college, her ups and downs were well known to my mother, my sister, and me. Certainly, my father was always in a better mood when she was doing well.