The Good Doctor (6 page)

To what degree was my father truly bucking the trend in medicine that increasingly favored population-based data over clinical intuition? In her 2013 book on Sister Kenny, the famous polio nurse of the 1930s and 1940s, the historian Naomi Rogers argues that Kenny actually constructed an alternative pathophysiological model of the disease based on her personal bedside observations. That is, she rejected the then-current scientific explanations for how polio crippled patients, feeling that the mechanism responsible was the muscle spasms she observed, as opposed to nerve damage. Kenny’s novel treatment strategy for polio, which involved mobilizing paralyzed muscles as early as possible, followed directly from her unorthodox perspective. Seeing, in other words, was believing. I encountered this epistemological conundrum when researching breast cancer: certain patients insisted that their cancers were caused by toxic exposures and others assured me that screening mammograms had saved their lives even though controlled-study data indicated that both scenarios were unlikely.

Firmly grounded in scientific medicine, my father did not hold radical beliefs. But he practiced what the sociologist Charles L. Bosk called, in his 1979 book on surgical training, “clinical individualism.” My dad believed that his observations and research constituted a type of clinical reality that was lost when physicians considered only the characteristics of a given disease among large populations of patients. More provocatively, he thought that doctors could use their clinical acumen, experience, and even empathy to reach conclusions about how specific illnesses acted or were likely to act in specific patients. Without scientific proof, of course, these claims could always be contested. But for my father and those trained in a similar manner, such insights needed to be considered at patients’ bedsides.

Regardless of their beliefs about how medical knowledge was best generated, my dad’s colleagues largely appreciated his insights and were glad to have a meticulous, experienced, and compassionate physician looking over their shoulders. But he was not universally beloved. My father had extremely high standards and little tolerance for those who he believed were lazy or incompetent. If a patient needed antibiotics emergently and was not getting them, according to Robert Bonomo, my dad would yell, “You need to do this now!” until it happened. In one instance, my father learned that a senior surgeon was planning to follow his usual routine and give a penicillin compound to a patient who was already on the operating table. Believing that the patient had a penicillin allergy, my father went to the operating room and demanded that the patient be given a different antibiotic. The situation was tense but Phil Lerner ultimately prevailed. In his early years as a consultant, my father weighed carefully “the pros and cons of stepping on toes.” Later in his career, he often directly confronted certain colleagues, which probably contributed to an informal nickname that he acquired over the years: the Madman of the Mount Sinai.

My father justified such conduct by an intense devotion to his patients, which emanated from his upbringing and training and was, for him, the heart of medical practice. He went the extra mile not only to comfort his patients but also to demonstrate behaviors that he hoped other doctors might emulate. Of course, my dad’s ability to sit down with patients, spend time with them, and answer their questions was enhanced by his job as a consultant in the postwar, pre–managed-care era. Paul Beeson had advocated the same humanistic approach. So did fictional television doctor Marcus Welby, who was on the air from 1969 to 1976.

A representative case was that of a twenty-eight-year-old woman admitted for severe intestinal bleeding and several related complications whom my father described as “emotionally-shocked,” “terribly sick,” and “frightened.” Even though she turned out not to have an infection, my dad was the one who calmed her down during a “fantastic screaming spell” that he suspected was due to the “frightening stillness” of the regular ward once she had left the “hustle and bustle” of intensive care. Appreciating his kindness, the woman relied on him both during and after her hospital stay. “A very rewarding experience,” he later wrote, “but really outside my primary area of interest.” So, too, perhaps, was the time that he spent a half hour speaking with a woman with a severe bone infection who had become upset when one of her other physicians had made a lighthearted remark about her condition. Another patient my father bonded intensely with was a young man who showed “considerable fortitude and maturity” while battling ultimately incurable endocarditis. Although my dad strove to maintain a strictly “professional relationship” with his patients, he admitted that he had developed a “genuine affection” for this man.

One of my father’s more interesting encounters involved a patient who wrote to him to protest what he believed was an excessive fee for a ten-minute consultation. My dad wrote him back and explained that the consult had also involved discussions with the man’s doctors and nurses as well as a review of his chart and X-rays. The patient was evidently impressed because he paid the entire bill and added in an extra five dollars for the time it had taken my father to write a reply. This gesture was perhaps the 1970s equivalent of paying the doctor with a chicken. The five dollars was, of course, returned. This encounter was quintessential Phil Lerner: he went the extra mile to explain and demonstrate his philosophy of doctoring, and he gained a patient and a friend in the process.

My father was hardly the only intensely engaged physician at the Mount Sinai. Much more so than today’s practitioners, doctors of my dad’s generation viewed the medical decisions they made as almost personal—and defended them with ardor. My father was even known to get into fights with his brother, Allan, himself a passionate patient advocate. Once, when my dad noticed a house officer watching him and his brother argue with each other about a particular case, my father turned to the resident, rolled his eyes, and asked, “See what I have to put up with?” On another occasion, my father walked into the medical intensive care unit to find a surgeon and a gastroenterologist who disagreed about a patient’s care actually
physically
fighting with each other. In this case, my dad served as a peacemaker, helping to pull the two men apart. Recalling what he regarded as the Mount Sinai’s heyday, he later wrote that he “could bring any of my patients or anyone of my family into this hospital with the absolute assurance that the finest medical care was available in a stimulating, friendly and warm environment where everyone took pride in their work and was rewarded with the satisfaction of a job well done, even when the patient ran into problems, and even when death was the final chapter.”

My father’s concern for his patients was only enhanced by the fact that so many of them had a personal connection to him. Having lived most of his life in Cleveland and its suburbs, he knew many Jewish families. Of course, he also had personal connections to many non-Jewish patients, who were often former classmates, friends, and colleagues. In the words of the historian David J. Rothman, “doctor and patient occupied the same social space,” promoting a shared relationship. Meanwhile, the poor and minority patients my dad met for the first time at the Mount Sinai—including many he would then follow for years—got the same royal treatment. Just as my father’s choice of profession was in part out of gratitude that he’d grown up an ocean away from the Holocaust, his devotion to these ward or service patients, as they were called, was his way of acknowledging his good luck in the face of so many ongoing catastrophes around the globe. His goal was to “take extra pains with the service patients, to be certain they are reassured and confident in your care, and come to believe that you really care about him or her as an individual.” One way he did this was to take advantage of his flexible schedule. “It’s so simple,” he wrote, “to make an extra visit in the afternoon for these special cases, come back to report a new lab test result, review an X-ray [or] reassure that the scheduled test is necessary, important and will lead to some conclusive information.” Illness, he underscored, was “frightening.” When I read these words many years later as a professor, I had to smile. It was the exact sort of advice that I gave to students and residents when teaching them about the history of medicine and the doctor-patient relationship. My dad had acted this way as a matter of course.

Another group of my father’s patients consisted of doctors, nurses, other hospital employees, and their relatives. There may be no higher compliment for a physician than to be asked to care for a colleague’s loved ones, and my dad was definitely a “doctor’s doctor.” The 1970s was still an era of professional courtesy, and my father generally waived or reduced his fees when treating coworkers or their family members. This concept of the medical profession as a sort of guild that looked out for its members was a comforting one and may even have contributed to my decision to become a doctor. I remember seeing a few of my dad’s peers for sundry medical issues and feeling as if I was in good hands.

Whether he was caring for a friend, a relative, or a stranger, my father’s clinical interactions were always dominated by a paternalistic philosophy. It made sense to him that, since physicians trained for decades, spent long hours in the hospital, and devoted themselves to the care of both the poor and the wealthy, they should call the shots, and patients should acquiesce. Doctor knew best, whether he—and it was usually a he in those days—was renowned Harvard surgeon Francis Moore, polio vaccine inventor Jonas Salk, or heart transplant pioneer Christiaan Barnard. Practicing any other way was an abrogation of one’s duty. Physicians of my father’s era saw their paternalism as not only altruistic, but therapeutic: it was widely believed that if patients followed doctors’
orders
(and that is what therapies and other interventions were called), they were more likely to recover. Sometimes in serious illness, New York infectious diseases specialist Walsh McDermott said, the physician himself was the treatment.

Perhaps the best example of how paternalism dominated medicine was the fact that physicians in the postwar era routinely lied to cancer patients about their diagnoses. Doctors jumped through all sorts of hoops to try to convince their patients—many of whom were dying of their disease—that they had merely a tumor or an inflammation. Surgery and radiation therapy, the patients were told, were given “to be on the safe side.” When Columbia nephrologist Jay I. Meltzer joined a group practice of more senior physicians, he soon realized that “the best doctors were,” paradoxically, “the best liars.” He demurred, preferring to find out from patients in advance what they would or would not like to know about their diagnoses. Meltzer told me a story about paternalism involving his former Columbia colleague and devoted physician Randolph Bailey. After learning of the famous 1964 surgeon general’s report delineating the dangers of cigarettes, Bailey had told Meltzer that he planned to keep smoking so that his patients, who were unlikely to be able to stop themselves anyway, would not feel “frightened and helpless.”

Thanks to the large number of clinical advances in the postwar years—many of which came from experimental research—the medical profession at this time was gaining enormous prestige. The new antimicrobial agents had made formerly ubiquitous and scary diseases, like syphilis, tuberculosis, and bacterial pneumonia, far more manageable. The discovery and synthesis of insulin meant diabetes was very treatable. Salk’s vaccine had led to dramatically lower rates of polio, the dreaded summer plague. Meanwhile, the ability to bank blood made possible more aggressive operations for aneurysms, cancer, and other conditions. By the early 1960s, there were medications to treat high blood pressure, and dialysis machines to prolong the lives of patients with severe kidney disease. It was no longer enough to simply be a kindly and caring physician; the public also wanted doctors who were engaged with the latest laboratory research. “If They Can Operate, You’re Lucky” was the tagline for a cover story in the May 3, 1963, edition of
Time
magazine that detailed several innovative and aggressive new operations.

From a modern vantage point, it may seem curious that patients were so passive when dealing with such a serious topic as life-threatening illness. And there have always been patients who have questioned their doctors and disregarded their advice. But many sick people welcomed the opportunity to have highly trained professionals make all their decisions. One explanatory model for this behavior, introduced by Harvard University sociologist Talcott Parsons in 1951, was called the sick role. Relieved of their normal duties due to their illnesses, patients believed they had an obligation to do what was necessary to get well, specifically by cooperating in the therapeutic process. Thus, while Columbia professor Robert Loeb’s domineering personality bothered some patients, most revered him. After all, the man was in the hospital seven days a week and knew the names of all his patients, their family members, and even the hospital janitors. The same admiration was shown to breast surgeon Jerome Urban, who pioneered the super-radical mastectomy, a dramatic operation in which a woman’s breastbone and ribs were removed in an attempt to get rid of elusive cancer cells. Urban often slept on the couch in his office so he would be available to resume operating first thing in the morning. Long after such disfiguring surgery had been discredited, Urban’s patients remained quite certain his extraordinary efforts had saved their lives. Late at night, Columbia-Presbyterian surgeon Philip Wiedel pushed a small cart down the hospital’s corridor, quietly entering patients’ rooms and changing their dressings by himself. “A doctor must work 18 hours a day and seven days a week,” wrote one physician from this era. “If you cannot console yourself to this, get out of the profession.”

But by the early 1970s, the situation had begun to change. Over the previous decade, a series of research scandals revealed that some physicians had been willing to put fame and science above their concerns for patients. These violations occurred despite the fact that the Nuremberg Code—written in 1946 in response to the inhumane experiments carried out by Nazi physicians during the Holocaust—had explicitly mandated that all subjects must give informed consent before being enrolled in research. Yet in one case, a doctor studying the body’s immune response to cancer had actually injected cancer cells into the skin of chronically ill noncancer patients at a hospital in Brooklyn. These individuals, many of whom were, ironically, Holocaust survivors, were told only that they needed an injection. And what about the deliberate administration of active hepatitis virus into physically and mentally disabled children at the Willowbrook State School on Staten Island? The researchers argued that since there were frequent outbreaks of hepatitis at the institution, these children would get the disease anyway, and the study might lead to a preventive vaccine. But wasn’t this doing harm to a population that could not consent? The outrage reached a peak in 1972 when an Associated Press reporter revealed that in Tuskegee, Alabama, the US Public Health Service had observed poor southern African American men with syphilis for as long as forty years in order to study the “natural history” of the disease. The researchers had even continued the experiment—depriving the men of treatment—when a highly curative antibiotic, penicillin, became available in the 1940s. Many of the subjects died of syphilis as a result of this deception. That the men in the Tuskegee study were black and the doctors who conducted research at major medical centers were overwhelmingly white was especially objectionable in an era of civil rights protests.