never learned it, and even if they had learned it, they would have been
averse to using it, having long had a feeling of fastidiousness about conflicts over money and power. These doctors were educated, successful,
and polished; yet in some ways they had never really progressed beyond
childhood—they spoke fighting words, but they were incapable of
clenching their fingers into a fist and striking.
The third group included both American-born and foreign-born doc-
tors. Shrewd men, they felt all the pulses of life and understood politics.
They knew how to fight and how to hit hard, but they also knew when to
fight, especially those doctors from authoritarian countries who had
learned by experience. Had they been faced with such a crisis back home,
they would have carefully maneuvered themselves into positions of pow-
er over the doctors in the first and second groups, not through bluster, but rather through strategy and cunning. Like the other doctors in the room,
they hated managed care, having grown rich on traditional fee-for-service medicine. But they did not have the same self-satisfied arrogance about
being doctors as doctors in the second group. On the contrary, rather than feel contemptuous toward businessmen, they saw themselves as businessmen; whether to fight managed care was purely a financial calculation on
their part, and not a question of defending the medical profession’s so-
called honor. Since managed care appeared inevitable, some of these
doctors were actually thinking of giving into it, joining it—now, before it was too late—with the goal of running the whole thing in five years.
A doctor from the second group went up to the podium to speak. He
was tall, white, and elegantly dressed, in his late sixties, wearing a navy blue suit, a white cotton shirt, and an Ivy League tie. With his chest held high, he declared:
“We don’t want managed care. It only brings shoddy medicine. And
we won’t allow a bunch of businesspeople to take care of our patients, to
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C H A P T E R 6
make a mockery of the Hippocratic Oath, and to desecrate the sanctity of
the doctor-patient relationship.”
The hall broke into thunderclaps. Handsome despite his years, with his
hair a distinguished gray, his posture erect, and his face expressing determination and pride, the speaker looked like a leader. He went on:
“We have to stand together and fight, not negotiate. I’ll never sign a
managed care contract.” The audience clapped again. It did their hearts
good to look at him. He was an icon, not a doctor. Several shouts were
heard:
“To hell with managed care!”
“Keep things the way they are!”
The speaker continued, many in the audience staring at him in admira-
tion, even envy. He was elected to chair the committee responsible for
fighting managed care. Around eight o’ clock, the meeting broke up and
all the doctors left the room, many of them confident that their fate had passed into good hands, that this distinguished, elegantly dressed man
with the erect posture would destroy managed care and they could go
back to business as usual.
My father also seemed reassured, as he always had had a feeling of
fluttering respect for WASP physicians. But for some reason, while driv-
ing home, his confidence left him and he began to panic.
“My God,” he moaned, “how everything changes. I finally have my
office, and now this trouble comes along.” Then he yelled at me, “What’s
the name of that fancy college you want to go to?”
“Swarthmore,” I replied.
“Well, it’s too expensive. Who do you think you are? The Prince of
Wales?” he snapped. Then he returned to his own problems, and sighed,
“What’s the point of it all? Maybe nothing matters . . .”
He dropped me off at the old house. Gradually, my mind drifted back
to the image of the tall handsome physician with the noble bearing and
neatly combed gray hair, and I felt better, thinking maybe there was hope after all.
There was no hope. The tall physician with the gray hair could not
save my father or the medical profession. My father’s practice dwindled
over the next five years, until he was forced to abandon his office alto-
A T A L E O F T W O O F F I C E S
1 2 3
gether and sell its furnishings. Unable to work as a solo practitioner in the new managed care environment, he applied for full-time salaried positions but was unable to secure one despite his experience. His odd personality was likely a factor. After working here and there, he retired from
medicine early, which depressed him, as he loved being a doctor. His
back grew bent, as if a stone hung around his neck; he spent most of his
time in a chair. It was sad to see this man, who for decades had stood
ready at the drop of a hat to rush to a patient’s aid, and whose very nature of life had accustomed him to continual movement, end his days of motion in the enforced sitting of retirement, marking time in one spot. He
died in 2002 an unhappy man.
My mother suffered through the travails of being an ex-doctor’s wife.
“A dethroned queen,” she called herself. No more party invitations came.
Sometimes she would ask me to drive her past a doctor’s house on an
evening when a party was being held there. I would park the car on the
street and let her stare at the house and listen to the laughter coming from inside and remember how it all once was. As I pulled away, a strange
force would twist her neck and turn it back in the house’s direction. The low point came at a wedding reception when she was forced to sit at a
table in the back reserved for ex-doctors’ wives. All the “rejects,” she
moaned pathetically. A kind of mini-leper colony. Fortunately, she was
able to turn her misfortune into a career as a social worker, which she
excelled at.
My grandfather’s career as a physician began in failure and ended in
success. My father’s career began in success and ended in failure. The
pivot around which both men’s lives moved was the American ideal of
the doctor. My grandfather could not adapt to that ideal. My father em-
braced it at the moment it began to unravel.
In the 1970s and 1980s, the physician ideal was attacked from every
angle. As part scientist, the doctor was increasingly viewed as someone
cold and heartless, and more interested in slotting patients into treatment categories than in listening to them. As part technician, the doctor was
thought to be more interested in gadgetry than in people. Worse, gadgetry made medicine too expensive. Gadgetry was also something that non-MDs could master, making it easier for nurses and other health care
professionals to challenge physician control. As part gentleman, the doc-
tor was seen as protecting his monopoly against the intrusion of women
and minorities into the profession. As part benefactor, well, doctors
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C H A P T E R 6
seemed to be as money-hungry as everyone else, and posing as benefac-
tors simply made them look like hypocrites.
As the vision collapsed, professional medicine broke down again into
competing schools, each declaiming on behalf of the scientist, the technician, the gentleman, or the benefactor. It was a rehash of the same fight American doctors had a century before. I watched this drama play out as a resident
(described in this book’s first chapter).
The story of my grandfather and father bears directly on the problem
of medical catastrophes.
First, both my grandfather and my father were oddballs. Despite this,
they were still able to practice medicine. In the new order, as doctors
move from being independent practitioners to being dependent employ-
ees, on salary, they have less freedom to be oddballs. Oddball doctors
sometimes even have difficulty finding good jobs. The system today
prefers doctors who are good “company people,” even though good com-
pany people do not necessarily make safe doctors.
Second, the politics of medicine were once quite interesting, even
comical, because all the different players in medicine shared power. The
doctors, the doctors’ wives, the nurses, the Catholic sisters, the hospitals, and the insurance companies—each group had some power, but no group
held all the power. Along with the silliness, real heartwarming social
behavior flowed out of this way of life—for example, doctors sending
expensive Christmas gifts every year to other doctors, or doctors giving
the children of other doctors their first summer jobs. Some friendships
were true; others were anchored in self-interest, an exchange of favors.
But taken altogether, the silliness and the sweetness, the friendly gestures and the self-interested ones, humanized the practice of medicine.
Such charm and delicate sentiments waned when doctors became sala-
ried employees. So did any feeling of independence. Immaculately
dressed, clear-thinking businesspeople with all the facts before them took command. They spoke in geometric terms about human affairs, such as
“the organizational processes affecting the annual case load,” and so
forth. They called doctors “providers.” They threatened those providers
with dismissal if they judged their performance to be inadequate. Health
care itself became organized like a pyramid, with a corporate or hospital entity employing doctors and nurses, and enjoying the lion’s share of
power. While a pyramidal system is often successful administratively, it
poses risks to patients clinically.
A T A L E O F T W O O F F I C E S
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Third, both my father and my grandfather loved being doctors. To
them, doctoring was more than just a job. It was an object of affection
that they feared being torn away from. This attitude is less prevalent
today. Many physicians now do think of doctoring as a job. This decreases the risk of medical catastrophes in some ways but in other ways
raises it.
Each of these points will be discussed in the next three chapters.
7
WHEN DOCTORS LOSE CONTROL OF
THEIR OWN PERSONALITIES
Early in my career, I knew an anesthesiologist named Dr. F. In his mid-fifties, originally from somewhere in the Caucasus, he was short, stout,
and hairy, with a remarkable gift for making people feel warm and happy.
His casual, free-and-easy way came not from any political conviction but
from the simple fact that he liked people more than places, and places
more than ideas. He found everyone interesting, listened attentively to
their problems as if they were worthy of a memoir, and smiled sincerely.
His only defect from the perspective of conventional morality was that he ogled pretty women. People knew how he was, but they gave him a pass,
in part because he was so likeable but also because he was consistent; it was mostly change that caught people’s attention and made them nervous. Had Dr. F once been a choirboy who started ogling women only
recently, people would have complained. But his behavior was as it had
always been. With his reputation established quick and early, and having
been at the hospital for over twenty years, he and his antics were viewed as part of the normal backdrop of life.
One day, I walked into the operating room to give Dr. F a break. A
young woman lay on the operating table half asleep, her strong muscular
legs hanging in stirrups and slightly contracting against the force of gravity, her thin blue gown barely concealing her large bosom, which pro-
truded upward and outward. The gynecologist, a short, weedy, bald man
with a pencil neck, sat on a stool inches away from the patient’s bottom, 1 2 7
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C H A P T E R 7
his head framed by the patient’s legs, impatiently waiting to perform a D
and C.
“Ah, young man, a break for me? You’re a good fellow,” Dr. F ex-
pounded, a broad smile tugging at the corners of his mask. “But first let me put the EKG leads on,” he said, his eyes flickering sparks of lust.
“Is she asleep?” I asked him.
“Well, young man, that’s a good question,” he began, his large hairy
hand moving across the woman’s left breast, his fingers holding an EKG
pad and looking like the talons of a giant prehistoric bird. Dr. F paused for a moment to concentrate, and then continued:
“Even when a woman is anesthetized, she’ll protect herself down
there, you know? Give her enough Pentothal to close her eyelids and
she’ll still snap her legs together faster than a clam in danger when
touched. Give her some more Pentothal so that she barely breathes. Her
legs drop nice and loose in the stirrups. You think you’re all set, but
watch and see, she’ll knock those legs together the instant she’s touched.
Give her some more Pentothal. Make her stop breathing altogether. Why,
she still shuts her legs—even when she’s turning blue! She’ll die before
opening those legs. Lord in Heaven! You’ve got to inject enough Pento-
thal to drop her blood pressure before she’ll surrender her honor. Amaz-
ing, isn’t it? I call it God’s protective reflex. He gave it to all women, even the ugly ones—the Lord is just—to prevent men from taking advantage of them. It’s wisdom for life, my boy.”
While Dr. F lectured, the gynecologist applied a sharp instrument to
the patient’s bottom without telling anyone. Suddenly the woman’s heart
rate jumped. Before Dr. F or I could react, the woman, although uncon-
scious, wrapped her legs around the surgeon’s neck and squeezed. Unable
to free himself, he cried for help. The operating room nurse tried to pry the woman’s legs apart but failed. Things grew serious as the women’s
strong legs threatened to twist the surgeon’s head off its pedicle or choke off his air supply. Almost by instinct Dr. F injected a slug of Pentothal into the woman’s intravenous. Within ten seconds her legs relaxed and
the gynecologist escaped.
“Damn you, F!” cried the gynecologist.
“My boy, there you are! Just as I told you!” Dr. F joked, patting me on
the back. The nurse retreated to the back of the room, convulsing with
silent laughter.
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The gynecologist shook his head to check for injury and then dove
back into work, too embarrassed to look around the room.
That was Dr. F.
The next day, a drug rep served lunch for the anesthesia department.
Everyone knew it would be a good meal, as catered lunches were once a
way for drug companies to entice doctors to use their products. There was noticeable animation in the lounge when the rep walked in with four hot
> trays wrapped in tin foil. People nimbly jockeyed for position around the crowded table.
Dr. F ate three helpings. Afterward, fuddled by his heavy meal, he
quietly smiled. He had worked the previous night, and before lunch his
fatigue had been painfully apparent. Shakily had he made his way to the
lounge to eat, stumbling toward the door, moving in little spurts, as if
fighting a heavy wind. Now he sat contentedly in his chair, refreshed and cheerful. A post-call doctor needs so little. He has only to get a bit farther away from death and disease as usual, sit in a comfortable chair, eat a
good meal, and up it comes, the fast-ripening doctor’s happiness.
Dr. F’s next patient was waiting for him in the holding area. When he
rose to his feet he looked weary again, but joyfully so, almost giddy. He wandered over to see his patient, a massively obese woman scheduled for
weight-reduction surgery. His bloodshot eyes looked a bit crazed as he
interviewed her. I listened in while waiting for my own patient to arrive.
“I’ve tried so hard to lose weight,” the woman wept halfway through
the interview.
“I know, dear, I know,” Dr. F cosseted her without restraint, putting
his hairy hand on her arm and stroking it. “But after the surgery, you’ll look wonderful. You have such a lovely face. Why, when I saw you from
a distance I thought, ‘I don’t know what her name is, but she’s not just a woman, she’s beauty itself!’” he said with conviction, although his
speech was slightly drunken-sounding.
“Really?” she replied, somewhat embarrassed.
“Now there’s no reason to be modest,” Dr. F went on delightedly, his
wide smile crinkling the dark circles under his eyes. “Why, you’re like
whipped butter! In a few months every man will be trying to spread you
on slices of bread and eat them.”
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C H A P T E R 7
“But I’ll still be big,” she moaned.
“Not big. Strong! That’s very attractive. Why, when I was a young
man I dated a first-class wrestler, in the top grade. Now, I was strong, too, in those days. It was before I became a doctor. I could carry a rug on each shoulder anywhere I liked, but even so this woman would get around me,
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