The Good Doctor (27 page)

Another group of physicians that at times disappointed my dad were family physicians. At first glance, one might think this surprising, given the specialty’s emphasis on comprehensive care of patients and their families, but my father had encountered several such colleagues who he believed were lacking. In one instance, he found himself being the first doctor to address the emotional concerns of a patient with Crohn’s disease who was going to need surgery and an ileostomy (an opening in the abdomen for expelling intestinal waste). That a specialist, and not the woman’s family physician, was the one actually caring for the whole patient was unsatisfactory.

My father’s gripe with family physicians raised hackles within our own family. My wife’s dad, Sam Seibel, was a highly competent general practitioner on Long Island for decades. When he first met my dad, he was planning to take board examinations in family medicine, the specialty that had come to encompass the broad sort of medicine that he practiced. At that Sunday brunch, my dad could not resist saying how often he had to repair the damage that certain family physicians had caused. Sam, although not yet boarded in the field, was understandably a little defensive. The ensuing discussion, which grew heated for a while, led my sister to joke that the two doctors needed to go outside and settle matters with a duel.

I was embarrassed by both the vehemence of my father’s complaints and the particular venue in which he had chosen to make them known. Even if he did not mean to imply that he and his colleagues were superior to physicians in the specialty of my soon-to-be father-in-law, his comments struck me as haughty. In addition, he was painting with far too broad a brush, condemning entire groups of physicians for the sins of a few, something that he at least recognized he might be doing when writing in his journals. I asked him to tone it down when we were with Sam, which he agreed to do. But his profound disappointment with the efforts of certain physicians remained on his front burner. Like Robert Loeb and many other great professors, my dad simply could not stomach physicians who did not “give it their all” and thus cut corners on patient care.

Also in my father’s line of fire were “the increasing number of house officers who appear not to understand the rare privilege they have been given, to become physicians.” Of course, it was not all their fault. Thanks in large part to the Libby Zion case, training programs had finally begun to cut residents’ work hours. To some degree, I had benefited from this new approach. Not surprisingly, my father and many physicians from his generation were wary of what would become characterized as shift work. If 24/7 immersion in patient care was the gold standard, even an eighty-hour-maximum workweek—the first reduction that was widely implemented—seemed deleterious for both learning medicine and attending to patients. Young physicians increasingly wanted to “get home in time for whatever” and “not be burdened with concerns about what he/she left behind,” my father derisively wrote. “Someone else is covering—I don’t have to worry!”

But my dad was even angrier at the bureaucracy that had come to dominate medicine. Beginning in the 1980s and increasing over time, it was no longer adequate for physicians to examine patients and leave their findings and recommendations in the medical charts. Rather, it was necessary to leave certain types of notes, ones that did not necessarily convey useful medical information but contained details that satisfied regulatory agencies or ensured that the hospital got appropriately paid for its services. “My daily activities in the hospital are already swinging drastically in favor of documenting rather than doing,” my father wrote in 1992. “I am a cog in a large, impersonal juggernaut of activity, much of it wasteful.”

What especially irked him was the fact that the requests for greater documentation came from “non-professional data gatherers” and “management maniacs” who could call into question “the activities of a physician trying to care for an evolving biological process.” For example, Medicare was constantly changing its coding system, leading to errors and interfering with the reimbursements for my father’s consultations. He saw all of these changes as direct threats to both the authority of physicians and the art of medicine. Future doctors, he feared, would not use their own experience and judgment but would merely carry out diagnostic and treatment protocols designed by managers and insurers. My dad was too ill by 2007 to read Jerome Groopman’s book
How Doctors Think
, but he would have agreed with Groopman’s concern that reliance on generic patient profiles leads modern doctors to “ignore the individual characteristics of the patient.”

Related to the growing bureaucratization of medicine were changes in medical education. The notion of being a specialist in infectious diseases and yet not doing one’s own Gram stains was anathema to my father. One of his “Ten Commandments in Infectious Diseases,” which he distributed annually to his students, was “Thou shalt have no other Gods before the Gram stain.” Being directly involved in the process by which a particular infectious organism was identified was a “connection to the world of microbiology,” the best way for a specialist to make an accurate diagnosis and then recommend an effective therapy. Moreover, senior physicians had a duty to teach their junior colleagues and medical students how to do Gram stains, examine urine specimens under the microscope, and spin their patients’ blood in a centrifuge to check for anemia—as I had done during my medical school rotations and as a house officer.

But now this type of intimate knowledge was being threatened. As medical documentation became more formalized, with accreditations necessary for hospital laboratories and other facilities, the information obtained in makeshift resident labs could no longer be considered official. Cleveland’s University Hospital, the main teaching center for Case Western Reserve medical students, attempted to solve this problem by renaming them teaching labs, used to train students but not for patient care. Unfortunately, when asked by an inspector from the Joint Commission on Accreditation for Hospitals whether the information he was obtaining in the laboratory would be used in patient care, a Case medical student—telling the truth—said yes. The dean of the medical school closed the labs the next day.

It was a similar story in other teaching hospitals, including Columbia-Presbyterian. Not only medical students but all the physicians in the hospital became more and more dependent on information generated by other hospital staff members, such as laboratory technicians and radiologists. Reading a report on a piece of paper or a computer screen had replaced looking at actual specimens. This development was especially difficult for my father and his generation, who prided themselves on seeing everything with their own eyes, whether it was a deteriorating patient in the middle of the night or that patient’s phlegm, urine, or blood. Now the nurses paged whatever doctor was covering, and that doctor just read the reports in patient’s record. As late as 1995, my father was still teaching medical students how to do Gram stains, running what was probably one of the last such educational efforts in the country. That same year he learned that Mount Sinai Hospital was planning to move its
actual
microbiology laboratory off-campus, meaning that the few remaining doctors who still did their own smears or reviewed those prepared by the laboratory would not even be able to do that. Predictably, he termed this action “insanity.”

Other paperwork was “drowning” my father as well: “letters, memos, forms, claims, licenses, applications.” To order certain tests or examinations, one had to obtain permission or prior approval from insurance companies, which my father believed were “taking over the profession” by promoting “cookbook medicine.” Third-party payers, who did not begin to understand the complicated cases they were evaluating, were “passing judgment
from a distance
on proper medical care.” My father tried to get his secretary to handle these matters, but he often had to write letters or make phone calls. Given his frustration with the middlemen who he felt were interfering with the practice of medicine and raising costs, he wanted physicians themselves “to develop and monitor treatment guidelines for our new healthcare system.” My dad also became an advocate for a single-payer model and was disappointed at the failure of the Clinton administration to reform health care in 1994.

But my father did not just sit around and complain. Far from it. He was heavily involved in trying to help the Mount Sinai deal with all of the new requirements and was constantly giving what he termed “respected and even well-received” feedback to members of the hospital’s hierarchy. Toward the end of 1992, for example, the Mount Sinai computerized its laboratory system as a way to improve accountability and accuracy. But what resulted were enormous printouts of laboratory data, as much as two hundred pages per patient, which were dutifully inserted into the medical charts. Realizing that information generated in such a format was not only unwieldy but probably confusing, my father went to the pathologist who ran the laboratory system to alert him about the problem. The pathologist referred him to the hospital’s computer information specialist, who agreed to contact the company in charge of the project to correct the glitch. Apparently, my father had been the only person to register a complaint. The episode, he later wrote, “clearly illustrates a
total
, I mean absolutely, complete lack of quality-control supervision of the laboratory.”

Seeing the opportunity for meaningful change, my dad used this episode to urge the formation of a committee of physicians and staff members to computerize the storage and retrieval of patient data “in an organized and a visionary fashion.” But after one “very enthusiastic opening meeting,” my father learned that two of the most essential committee members, the computer specialist and the nursing administrator, were probably going to be let go, essentially dooming the committee. “To say that this is pulling out the rug from under me is no exaggeration,” he wrote.

And on it went, as Dr. Phillip Lerner and a small band of fellow physician-reformers tried to influence the inevitable transformations at the Mount Sinai. Their efforts were largely ineffective. At times, my father wondered why he was even bothering. “Why am I so stubbornly pursuing this when no one else seems concerned—at all concerned?” he asked himself after the incident with the excessive printouts. The answer, for him, was always the same. “The bottom line is patient care,” he wrote. “If it is being compromised by this inanity, I simply can’t abide it in any way, shape or form.” It was, as James Rahal had said, the lament of a committed physician.

It was this devotion to the patient, which he had first embraced so passionately at the Western Reserve School of Medicine in the 1950s, that led to my father’s unfortunate misstep at his thirty-fifth medical school reunion in 1993. After dinner, a number of his classmates stood up to speak, all discussing their careers, families, and adventures since the last reunion. A few spoke more substantively about health-care reform and other changes in medicine. But my father, probably assuming that he was preaching to the choir, launched into a tirade about how his professional life had been shattered. He did not write down his exact remarks that night but it is reasonable to assume they resembled what he had been recording in his journals: anger at the insurance companies, anger at his hospital’s administrators, and possibly even anger at certain clinical specialties, representatives of which may have been in the audience. When I first heard this story, I thought of the 1959 film
The Last Angry Man
, which I watched with my dad when I was a teenager. In the movie, Paul Muni plays a revered physician who devotes his life to caring for a poor, immigrant community but who gets unhinged by the business tactics of his younger competitors and the social changes in his neighborhood. At that point, my father had not yet soured on medicine, but I recall his fierce identification with the Muni character.

He did record in his journals the reaction of his fellow classmates to his reunion diatribe: “stony silence.” To make matters worse, when he sat down, my mother rightly upbraided him for not mentioning her at all when his other classmates had made a point of thanking their spouses. He deeply regretted his actions, especially snubbing my mother—“my oxygen, my anchor”—and realized how “preoccupied and disturbed this has all made me, influencing my behavior almost in an uncontrollable way.” He was “obsessed” with the topic and perhaps even “unstable.”

Having frequently heard my father’s gripes and having been told about the reunion debacle, I was not surprised by much of what I read in his journals from these years. But it was profoundly sad for me to see him questioning his own sanity, something that he did only privately. It was these entries that led me to think of my father’s old hero Ignaz Semmelweis, the physician who made the brilliant discovery about the transmission of puerperal fever via unwashed hands but who later grew fanatical about the subject and died in a mental institution. Fortunately, my dad’s condition—which he termed, at various times, an agitated depression, an anxiety disorder, or panic attacks—never reached that point. But the obsessive nature of the two quests was not dissimilar. After the reunion, my father pledged to “shed this yoke, as it is threatening to get out of hand and literally consume me.”

He never really did. Activities that once had generated pleasure, such as running the infectious diseases teaching committee for medical students, no longer made him happy. Curriculum changes at the medical school were “window dressing” that avoided the main problem: “Where have all the good teachers gone?” Even worse was that attendance for the committee, still given during the spring of the second year of medical school, had dropped dramatically as students increasingly chose instead to study for their upcoming national board examinations. In 1995, for example, only about forty students (one-quarter of the class) attended with some regularity, despite the fact that my father and his colleagues dutifully rewrote the syllabus every year and made sure to deliver interesting lectures. “Will have to explore other options for next year,” he concluded with resignation. Three years later, things were no better: “Few showed up for the sessions.”