celed out my book smarts and extended educational experience, making
for a rough parity between us. In fact, this judgment is sometimes reasonable. The doctor, no matter what stage he or she is at, must have the tact, openness, and confidence to decide.
In this case, I refused to budge. The nurse anesthetist stormed off. In
the distance I saw her huddle with the three other nurses. A howl of scorn arose from the small assembly. I knew they were talking about me.
I began to feel uneasy. After all, I was new at the hospital. And it was
four against one. When they walked toward me I felt that my nurse
anesthetist had unleashed an angry mob.
They crowded around me. One nurse declared, “This is silly. We
could be waiting an hour for that rep to call.” A second nurse demanded,
“What makes you think you can just shut everything down?” The other
two nurses nodded their heads in agreement.
I knew why the nurses were pushing me. Just as some doctors are
impatient and want to go home, so are some nurses. The case was sched-
uled to start at 3 PM. The nurses ended their shifts at 4 PM. If the case start was delayed and the anesthetic induction and surgical prep were still going on at 4 PM, the nurses would have to stay longer to finish those
activities before a new team could relieve them. They didn’t want to stay.
They wanted to leave exactly at 4 PM.
The assembly exerted a strange mental force on me. It started to hyp-
notize me, upset my equilibrium; there was no obvious reason for me to
submit to it, and yet I could only keep from submitting to it by offering tremendous inward resistance. A doctor fighting another doctor is a low-intensity battle compared to a doctor fighting a nurse. A doctor may incur
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the wrath of another doctor, but he or she will see that other doctor only sporadically, making any workplace tension intermittent. In addition, the fight remains at the level of two combatants. But a doctor and a nurse see each other every day. When they fight, the resulting tension becomes
constant and unremitting. Word of the fight soon gets around, and some-
times other nurses join the battle to defend their colleague. Their collective derision can transform the doctor’s life into a living hell—a hell
perpetrated in countless ways, often small and insidious, and turning the doctor into a paranoid nervous wreck. At every turn he thinks the nurses
are out to get him. A nurse delays his case—they’re after me (even if the nurse didn’t do it intentionally). A nurse fails to carry out his order—
they’re after me (even if the nurse forgot the order). A nurse pretends not to hear him—they’re after me (even if the nurse really didn’t hear the
doctor). The doctor grows so unsettled that he or she can barely make it
through the day.
I kept up a bold front. I calmly told the nurses that we had to wait until we gathered all the necessary information. But I also knew well enough
how many times before I had yielded in like circumstances, and experi-
ence indicated that the future would resemble the past.
The nurses badgered me until my innate predisposition to hedge led
me to say that we would wait ten more minutes, and that if we hadn’t
heard back from either the patient’s cardiologist or the pacemaker compa-
ny rep by then, they could bring the patient into the operating room.
After ten minutes there was still no call. The nurses started to bring the patient into the room, but my courage had returned. I said no. The exchange grew more heated. “But you said—” declared a broken-hearted
nurse, in a tone of reproach. “I’m sorry, but that’s how it has to be,” I replied. She kept pushing. In the end I snapped at her and called her a
“silly goose.” The nurse fell silent, went to make a phone call, and then sat down to wait.
Within three minutes, BSN, MSN was down in the holding area,
standing directly in front of me and looking very angry. She was a large
and imposing person, wearing a long white lab coat.
“Young man, did you call one of my nurses a ‘goose’?” she blared.
My little assembly of nurses gathered round. Feelings of detestation
and horror mingled with satisfaction. This was what was wanted, it
seemed. It felt as though they wanted to make me feel like a boor, rather than the knowledgeable professional I was. If I were a respected doctor,
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they would have to contend with me. But I had used the hated g-word.
The role of archfiend in this grim drama now belonged to me. And if
BSN, MSN could produce in such a spectacular manner evidence of
boorishness in me, some of which didn’t even need proving (given what I
had said), then clearly it followed that this assembly of nurses should
reject all my recommendations in regard to the patient, who should be
brought into the operating room forthwith.
There was a stir of anxiety. The assembly sensed this was the big
moment: this was the moment when I would either seize the leading role
or be put in my place for good.
Still smarting over my nurse having told me a few days before to go
suck an egg, I refused to cave.
“Did I call the nurse a goose? I’m not sure. Maybe I just said she was
something like a goose,” I replied with heavy sarcasm.
“Now you listen here—” BSN, MSN said before stopping herself and
proceeding in a more pedantic tone of voice. “Now listen, young man, our
job is to take care of patients. We’re a team. Do you understand? We all
want what’s best for the patient. To work as a team we must treat each
other with respect.”
I told the chief nurse that I understood her concerns, but I also ex-
plained my concerns regarding the pacemaker and the pushback I’d been
getting from her nurses.
BSN, MSN winked at the nurses, feeling herself to be on firmer foot-
ing. “Waiting so long for this rep to call does seem unreasonable. I think we should at least start the case,” she declared with confidence. It was
now five against one.
“Well, I think differently. And I’m the doctor, so I’m in charge,” I
replied firmly.
“In charge of me?” she asked, her suspicions flaming up again.
“In this situation I am,” I said.
BSN, MSN stood still for a few moments in silence. “I’m not subordi-
nate to you, young man,” she harshly interjected.
“Then who are you subordinate to?” I asked.
“I am subordinate to the hospital president and to the board. You’re in
a department. I run a department. We’re equal. Don’t forget that,” she
answered angrily.
A phone call from the pacemaker company representative interrupted
the standoff. The rep said the patient’s pacemaker was a standard one, not
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a sequential one. It did not have to be reprogrammed after magnet place-
ment. The battery was fresh. The nurses felt vindicated. My concerns had
been for nothing, although we could not have known this before the
phone call. But the nurses didn’t see it that way. They already had a claim on me for my name-calling; now, to their minds, their judgment on medical matters had proved superior to mine.
BSN, MSN joined in the triumph, smiling even while her eyes still
blazed furiously.
Pointing her forefinger at the syringe in my shirt pocket, she said, “That’s an unlabeled syringe, doctor. You know the rules. All
syringes must be labeled.” She was determined to drive the point home
that we were on equal footing, that each of us could take turns ordering
the other, that she was watching me carefully and was prepared for any
eventuality, and that it would be unwise for me to come into conflict with her again.
The nurses brought the patient into the operating room. I started the
case by myself, my nurse anesthetist having left for the day. I placed the monitors on the patient and gave her some intravenous sedation. Two
operating room nurses hoisted the patient’s legs into stirrups. Both were new to the case. During the hand-off the departing nurses had spent
longer than usual telling the new nurses about the patient—and the reason for our delay. The four nurses had whispered quietly to each other, with
one of them glancing in my direction every few seconds. Although we
had entered the operating room on my terms, I knew I had not regained
my old position, as if there had never been a quarrel.
The gynecologist started the D and C. When I asked one of the nurses
if she could get me some warm blankets to put across the patient’s chest, she promptly did so. Then she left the room to start another case across
the hall. I noticed that the bag of saline connected to the patient’s intravenous was almost empty. Because I had to hold the sleeping patient’s chin
to assist her breathing, I asked the remaining nurse to grab a fresh bag
from the cabinet for me. The nurse acted as if she could neither see nor
hear me. I dropped the patient’s chin and got the bag myself.
I understood everything. It was the struggle between doctor and
nurse—who would dominate whom? Nothing was fixed, everything was
fluid and precarious, the outcome of the struggle unclear. I hoped that my
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decision to get the saline on my own, to be the bigger person, would
appease the nurse’s pride enough to smooth things over. I was wrong.
Every time I asked her for help, she would project an air of disinterest or sometimes pretend not to hear; when she did pay attention, she looked at
me derisively. Still, I carefully avoided pushing things into a state of open conflict, for I knew that when a doctor fights a nurse, the loss is great, while the gain is dubious.
Toward the end of the case, my semiconscious patient began to experi-
ence pain. I gave her additional intravenous sedation, but she continued to moan. I didn’t want to put her completely to sleep, with a breathing tube, because her anatomy suggested she would be a difficult intubation. Putting her to sleep without a breathing tube, however, risked aspiration,
because of her diabetes. It was a difficult situation, and an embarrassing one for an anesthesiologist, whose job is to eliminate pain. The prudent
course, I decided, was to continue with small doses of intravenous seda-
tion, including a drug called Versed, which causes antegrade amnesia
(meaning a patient fails to consolidate into memory events going for-
ward). Although the patient might still express pain, unconsciousness
would prevent her from being aware of her pain, while Versed would
keep her from remembering her pain.
Nevertheless, a moaning patient looks bad. The nurse came over and
demanded that I put the patient to sleep. I tried to explain to her my
thinking while simultaneously watching the monitors and injecting more
drugs. She stared at me angrily. When the patient moaned again, the nurse repeated her demand, looking at me as if I were an unfeeling brute. The
duel had to end. “Listen, when I want your opinion, I’ll ask for it,” I
snapped. Then I looked away.
The gynecologist decided that uterine bleeding failed to explain the
patient’s anemia. There was no reason to proceed to laparoscopy. Then he
performed one more pelvic exam. He suddenly exclaimed that he felt an
ovarian mass in the patient for the first time. He wanted to move forward with laparoscopy after all. I was surprised—and a little suspicious. I
asked him why he had suddenly detected a mass now. He replied that
anesthesia often allows for a more accurate exam, as it relaxes a patient’s muscles. Seemed reasonable. Still, in the back of my mind I wondered if
he had just wanted an excuse to perform a laparoscopy, to gain practice,
as laparoscopy was a relatively new procedure in those days. I asked him
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6 3
what he was hoping to find. He quietly replied, “We’re just going to take a little look around.”
I intubated the patient after some struggle. A technician came in to
assist the surgeon. He was a young man with no more than a high school
education. But he knew how to work the laparoscope better than any
doctor did, as he had been trained to assist physicians on this particular surgery, and only this surgery.
The gynecologist fumbled with the laparoscopic equipment, failing to
pierce the patient’s abdominal wall with the needle that fills the abdominal cavity with air. He pushed too little because he feared that pushing too hard might cause the needle to puncture a major blood vessel. The technician did it for him. Once the gynecologist was inside the cavity, he moved the organs around with a long stick, causing some bleeding that short
bursts of cautery stemmed. I stood ready to apply the magnet to the
pacemaker, but it wasn’t needed.
The gynecologist inspected the ovary that he thought had a mass. He
wasn’t sure if there was a mass, and he hesitated over what to do. He
looked at the technician, who sensed his opinion was desired. The techni-
cian said he had seen similar situations before. Those surgeons who had
dissected down further often regretted it, he noted. He recommended
coming out of the abdomen and doing a more complete workup with
noninvasive radiography. The technician then remained silent for a min-
ute, and the gynecologist remained silent also. But the latter’s eyes were as active as ever. He looked at the monitor that held a picture of the
patient’s ovary; then he allowed his eyes to settle on the surgical site. He seemed uneasy. Finally, he decided to take the technician’s advice and
end the surgery.
It was an odd moment. This young man had appeared unexpectedly,
from out of the blue, and determined the direction of the case. He was
practicing medicine. There was nothing of the doctor about him—neither
the surgeon’s knowledge of anatomy nor my knowledge of physiology.
He was an instrument. He carried out the will of others. But because he
had performed the same activity over and over again, he had gone from
being an instrument to being someone able to help, advise, and decide on
a particular case. If that is the definition of a doctor, then he had become a doctor.
The reader may think I am devaluing what this young man had to
offer. In fact, it’s just the opposite. He had added real value. As an
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accomplished technician, he may even represent the future of medicine.
Instead, my doubts are about the doctors. If a technician with vast experience doing a particular procedure can outperform a doctor doing that
procedure, then what value does the doctor add? What important contri-
bution does the doctor make? What is dis
tinctive about being a doctor?
Perhaps nothing, I thought to myself as I wheeled the patient back to the recovery room.
Several days later, I drove downtown to a hotel for a medical confer-
ence on “team medicine.” Attendance was compulsory for doctors,
nurses, and surgical staff from the region’s major hospitals, with multiple sections convening on different dates to accommodate people’s schedules. The conference’s purpose was to move doctors and nurses, now
called “providers,” toward a more democratic approach to decision mak-
ing. In the future, at least in the ideal, nurses would offer advice and
input, doctors would listen carefully, and the health care “team” would
make decisions instead of doctors acting unilaterally.
When I walked into the large conference room, I saw faces that I
recognized, looking bored or sullen. Unlike most medical meetings,
where people go to enjoy themselves, to meet friends, and to be simulta-
neously instructed and entertained, this meeting was strictly business. On the podium sat three nurses whom I did not recognize, along with BSN,
MSN. I took a seat in the back.
One of the nurses went up to the lectern and spoke generally about the
meeting’s purpose. She talked about the importance of helping the patient and working together to do so. She said we should treat our patients the
way we would want our family members to be treated. Her words seemed
unnecessary, as no one in the room—doctor, nurse, or technician—
thought otherwise. The whole speech conveyed a sense of emptiness and
thinness. Afterward a few people clapped.
Our first activity was designed to “break down barriers,” but its real
purpose was to destroy the traditional chain of command. Doctors,
nurses, and orderlies were randomly divided into groups, each group
containing a sampling of all three. A group’s job was to grab some Legos
from a large bin in the center of the room, return to home base, and build a tower with them. The group that built the highest tower at the end of
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