Medical Catastrophe

by Ronald W Dworkin

  injected the anesthetic—all in less than a minute. Because it was an

  emergency I used lidocaine, a drug with short duration but quick onset.

  The obstetrician cut. A healthy baby emerged from the patient’s abdomen

  one minute later.

  We were home free. Then the obstetrician ran into some bleeding that

  kept the case from finishing. Thirty minutes later, the patient moaned in pain. Since lidocaine should last forty minutes, I decided anxiety was

  probably exacerbating her pain, and that she still had some anesthesia

  left. The obstetrician said he needed twenty more minutes. I gave the

  woman some intravenous sedation to calm her down, but there was a limit

  to how much I could give her. She had eaten a full meal two hours before.

  If she went to sleep without a breathing tube in place, she might vomit

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  and aspirate her stomach contents, which could kill her. To go to sleep,

  she would require an endotracheal tube—but that risked a bout of angioe-

  dema.

  Her moaning grew worse. In the most stupid American way, I tried

  telling her that we would only be ten more minutes. I spoke English

  slowly. I spoke English loudly. It had no effect. She cried and screamed. I reached for the Pentothal and muscle relaxant and prepared to induce

  general anesthesia.

  Suddenly, Dr. F walked in. I informed him of the situation. I asked

  him to inject the drugs so I could intubate. He motioned me to put the

  drugs away. Then he took off his mask and stared directly into the pa-

  tient’s eyes. He spoke words that I did not understand.

  “Kam hitch um hot ho! ” he said to her, harshly, as if giving her an order.

  The woman quieted down and stared back at him.

  “Uh-h-h do kee ha ai-raku! ” Dr. F declared forcefully.

  Transfixed, the woman kept staring at Dr. F. Then she quietly replied,

  “Ah so.”

  Dr. F continued. “Ne ha so tu,” he said. In a tone that made him sound very wise, he followed up with “Des ka nu so ha.”

  The woman kept staring at Dr. F, her eyes sparkling with amazement.

  “Ah so,” she said again.

  Their dialogue continued for several more minutes, with the woman

  replying “Ah so” each time. She was now quiet and calm.

  The obstetrician raced to finish the surgery. He placed the last suture

  ten minutes later. As the drapes came down, both he and I thanked Dr. F

  profusely for his help.

  I went to visit the patient during my postoperative rounds the follow-

  ing day. A translator was present. I asked her if she remembered me.

  Through the translator she said, “Yes.” I asked her if she had any after-

  effects from the spinal anesthetic. She said, “No.”

  Then she asked me, “Who was that funny man in the operating room?”

  “The man speaking with you? That was Dr. F,” I replied.

  “He was a funny man. He spoke words I didn’t understand,” she said.

  “What?” I said, a little startled. “He was speaking to you in Japanese,

  wasn’t he?”

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  The woman continued, “He must have been speaking a foreign lan-

  guage. But I felt I could understand him. I thought he was telling me that I was all right, and that everything would be all right.”

  Speechless, I simply nodded my head and left.

  I saw Dr. F later that day. I told him what the woman had said.

  “You weren’t speaking Japanese to her, were you?” I asked him.

  Dr. F smiled and said nothing.

  “You don’t speak Japanese, do you?” I asked, desperate for some kind

  of explanation.

  Still smiling, he patted me on the shoulder, winked playfully, and

  walked on.

  His weirdness had averted a potential catastrophe.

  Life pushed Dr. F and me onto separate paths. Years later, I heard

  about the troubles he had toward the end of his career when he became an

  employed physician.

  The first salvo came when he told a nurse who had changed her

  hairstyle that she looked “sexy.” The nurse, who was angry with Dr. F for other reasons, complained. The company chastised Dr. F, who was truly

  confused, as he thought he was paying the woman a compliment. The

  company told him to behave. But now Dr. F was unsure what it meant to

  behave. Unfamiliar with the new rules governing corporate America, he

  was like a man who moves around without the use of his senses, beset by

  traps. He talked less at work. He also avoided social events, such as

  Christmas parties, as these were now considered extensions of the work-

  place, making them sources of risk.

  Although Dr. F self-censored, his unique style nevertheless peeped

  through. One day, a technician asked him over the phone to silence a beep on an anesthesia machine. Dr. F was busy at the time, so he told the

  technician to press a certain button. The technician told Dr. F that he had to do it. Harried, but still in good humor, Dr. F replied, “Okay, but you know, it’s not rocket science.” The technician complained, accusing Dr. F

  of fostering a “hostile work environment.” On another occasion, a nurse

  put a small intravenous in a patient going for surgery that would poten-

  tially have high blood loss. When Dr. F saw it he humorously corrected

  the nurse with the patient nearby, saying, “You couldn’t suck enough

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  water through that straw to survive in the desert.” While Dr. F placed a

  larger intravenous, the nurse complained to Dr. F’s superior, saying Dr. F

  shouldn’t have corrected her in front of the patient. The complaint made

  its way up through the ranks of officialdom. Again, Dr. F found himself

  in trouble. In the end, he decided to retire early. The company was happy to see him go.

  Doctors reading this book may laugh at Dr. F. Part of me laughs at

  Dr. F. But such laughter is a sad indication of what doctors have become.

  Doctors laugh because they know that in order to avoid trouble these days one has to be exquisitely sensitive to other people’s feelings. No careless quips. If one is foolish enough to be weird, one should at least take good care not to display that weirdness in front of others. The smart person

  today follows the rules and displays outward obedience to them, even if

  he or she has nothing but contempt for them. The main thing is order and

  system. Now is not the time of the weird people. It is the time of the

  flexible people, the people who know how to bend at the right moment. It

  is the time of the company people who shave off their idiosyncrasies to fit in and belong. That’s how a doctor today avoids trouble. From that perspective, Dr. F was a fool.

  My parents trained me to be a company man. They instilled in me

  mental radar that let me discern what other people were thinking so that I could tailor my behavior accordingly. As a child, whenever I asked my

  mother what I should do in a particular situation, she would invariably

  reply, “Well, what are all the other kids doing?” In solid 1950s fashion I learned the importance of being liked and fitting in. Later, when I became a doctor, I decided this education had been unnecessary, since doctors,

  unlike company men, had the freedom to be
themselves, including the

  freedom to be weird. But as doctors increasingly become employees, that

  education has proved valuable after all.

  The problem for patients is that good company people do not neces-

  sarily make good doctors. They do not necessarily prevent catastrophes.

  A doctor’s weirdness has nothing to do with his or her ability to practice medicine well.

  I have known several outstanding doctors in my career who were

  oddballs.

  I knew a German-born anesthesiologist who specialized in putting

  children to sleep. Built like a medium-sized bear, he would sit children on his lap to anesthetize them, while his muscular legs would squeeze their

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  spindly legs to prevent them from kicking. High-minded and stubborn,

  distrustful of others, angry at the world, and without an ounce of coziness, he took his woes and burdens with him wherever he went. Few people

  liked him; many children feared him. “Do you have any bra-thers?” he

  would ask a child in a thick German accent, his painful way of trying to

  be pleasant. “Do you like spa-ghet-ti?” he would ask in a guttural tone.

  Sometimes the child would wail and struggle, prompting him to tighten

  his hold on the child and declare, “Ach, you little brat!” Yet he was an outstanding doctor. He saved lives.

  I knew an anesthesiologist from Latin America with a bad temper. He

  would flare up like gunpowder in the face of any patronizing reference to his origins and rarely controlled himself in time. Most of his anger was

  real, although some of it was slightly calculated, like a dog’s snarl, a way of telling an offender not to go there or to leave things alone. Once begun, his tantrums stopped only when they ran out of fuel; he yelled, he berated, and on one occasion he put his fist through a wall and broke a bone.

  Curiously, despite the habit of distrust and constant vigilance that had

  insinuated itself into his personality, he was at heart a kind individual.

  Watching children suffer especially pained him. He was a complex char-

  acter. He was also an outstanding doctor. He saved lives.

  I knew an anesthesiologist from the Midwest. Straight-laced and re-

  served, he had the aura of the scoutmaster about him. He was incredibly

  thorough during his patient intakes. Sometimes he would interview

  healthy patients for almost an hour before giving them anesthesia, prob-

  ing for a history of even minor ailments, such as sexually transmitted

  diseases, looking at patients with parental severity, speaking to them in icy tones, and driving some of them crazy. But even at his most distant,

  he was engrossed in his patients, studying them with all-knowing eyes,

  while to his colleagues he was cold and sober beyond need simply be-

  cause he was complete and didn’t require their society. He didn’t spend

  time thinking about what other people thought of him. Yet he was an

  outstanding doctor. He saved lives.

  These anesthesiologists would have difficulty finding employment to-

  day. There are few institutional laws that I can point to as the reason for their difficulty; it all belongs in the category of unwritten laws of behavior. Their personalities would make them socially undesirable. They

  would make bad company people. Nevertheless, they were good doctors.

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  Many American doctors today are good company people. They all

  come from the same incubator; they’re marked with different-colored

  inks, but there’s essentially no difference. Their behavior is in exact

  conformity with existing prescriptions. No rough edges. At work they

  talk like NPR; their words rarely contain a single living emotion. At best, they are people who avoid revealing the whole of their thought; they are

  different from how they are in real life; they are a people constrained and held in check. Other doctors are company people to their very bones.

  They say what is expected of them; they are inconspicuous; they weigh

  their words carefully even while joking; they know the importance of

  being politically correct; they will never start revolutions; they will never hurl challenges or level accusations against their bosses; they are easy to move with carrots and sticks; they are easy to intimidate with threats to their employment. Because they are paid well they are simultaneously

  self-satisfied and scared. In sum, they are completely harmless people.

  Corporate America is not to blame for the rise of the company culture

  in medicine. Corporate America is what it is. Since the 1950s, it has

  preferred to employ company people. The result has been great success.

  From cars to toothpaste, corporate America produces vital products at

  low cost. Yet taking care of patients is different from making cars or

  toothpaste. More risk is involved, and the company personality is not

  only irrelevant to the defraying of that risk but also a distraction from the core elements needed to do so.

  The medical profession is to blame for the rise of the company culture

  in medicine. That culture filled a void that opened up when the medical

  profession no longer knew what a doctor should be.

  First, the doctor-as-technician model that replaced the old vision of

  what a doctor should be enabled the corporate takeover of medicine.

  Before, when doctoring involved a complex set of qualities and attributes, and not just technical wizardry, the notion that business executives could

  “manage” doctors using fixed rules and procedures would have been

  inconceivable. It would have been like telling ministers to sermonize with one or two words, or telling painters to paint with one or two colors.

  Doctoring, like preaching and painting, was not merely a craft but also an art that required a broad grasp of humanity and subtle intelligence. But

  technicians are easy to manage. Their tools are predictable. Their think-

  ing is predictable. Their output is predictable. Business executives like to manage workers whose decision trees follow a few simple pathways.

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  When doctors became technicians they paved the way for business execu-

  tives to come in and manage them, too.

  Second, medical schools began to select for company people among

  their applicants. This represents a significant change from the past.

  In the 1930s and 1940s, when the company culture cemented itself in

  American corporate life, prospective job applicants took personality tests to show they were loyal, well-adjusted, able to get along with people, and politically correct (which in those days meant conservative). During this same period, medical schools focused almost exclusively on their applicants’ scientific aptitude. No personality tests were used to screen future doctors. In the 1950s, medical schools encouraged applicants to take

  classes in the humanities; yet this wasn’t personality screening so much

  as a cue to applicants to be both good scientists and well-rounded gentlemen. In the 1960s, as the technology race between the United States and

  the former Soviet Union heated up, medical schools reemphasized scien-

  tific aptitude. Indeed, many prospective medical students during this peri-od applied with the intention of being biomechanical engineers. 1 An applicant’s personality went largely unknown.

  During the 1990s, in the name of “professionalism,” medical schools

  began to screen for student attitudes. 2 This was not yet t
he company culture. On the contrary, the purpose of such screening was not to graduate company people but to avoid doing so. Medical schools feared doctors

  working under managed care might be more loyal to the companies they

  worked for than to their patients. Classes were held to teach students to put patients first.

  But the door was opened for more behavioral modeling. In 2005, the

  American Medical Association pushed a new initiative to give a medical

  school applicant’s personality more weight in the selection process. Phy-

  sicians had a sense that a doctor should be more than just a scientist or a technician, but they weren’t quite sure what a doctor should be. They

  settled on an applicant with excellent social radar, someone who excelled in getting along with others, who worked well within an organization, and who embraced popular cultural values. They wanted an applicant who

  would pay close attention to the signals he or she received from others,

  and who would adjust his or her behavior accordingly; a person who

  would be liked by others, and who would want and need to be liked; a

  person who would seek the approval of his or her peers, and who, when

  getting that approval, would desire more approval; a person who would

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  be at home anywhere and nowhere, and who was capable of a superficial

  intimacy with everyone. In other words, they wanted an applicant with a

  certain personality—the same personality sought by American companies

  in the 1950s. 3

  In 2010, the American Association of Medical Colleges joined the

  initiative, publishing a grab bag of virtues, such as compassion, the ability to function as part of a team, dependability, adaptability, altruism, high enthusiasm, and conscientiousness—again, the same traits that companies

  screened potential employees for in the 1950s. 4 More than half of U.S.

  medical schools now screen for one or more personality traits among

  their applicants. 5 The medical school entrance exam (or MCAT) was also adjusted to screen for the company personality. The personality exams of