Medical Catastrophe

by Ronald W Dworkin

  This book is a journey of self-discovery. Over time I learned what a

  doctor is. But to this day, I have never really learned how to cope with

  patient death or to communicate a death to a family member. I consider it a failure on my part. That I have yet to be tested is no proof against this deficiency. It is not events or successes that produce good doctors, but

  rather a state of mind that can endow events with its own quality; a good

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  doctor must possess a particular state of mind rather than trust to the

  recurrence of luck to keep its absence from being exposed.

  My father had this necessary state of mind. Suffering usually passes

  through a doctor. He learns to ignore it so that he can work. But some-

  times it catches on something inside and strongly affects him. My father

  was like that. He was quiet and sullen whenever a patient he liked and

  had been taking care of for years died. At such moments he preferred to

  be left alone in his study. While he eventually moved on, the deaths over time got to him, sometimes in odd ways. I think his obsession with tennis or travel, for example, came in part from the urge to seize hold of his life and not to put things on hold, given how life can vanish so quickly into

  thin air. Still, no matter where he went or what he did, he seemed to carry death on his back. Behind his happiness, somewhere, always lurked a

  haunting, undefined anxiety, of which he was never entirely free. Even at his happiest moments, there was a tinge of doubting sadness, as though he thought his happiness was not really justified. Living means remembering. My father told a lot of people they were dying. He told a lot of family members that their loved ones were dying. He saw a lot of death. That, to him, was part of being a doctor.

  This grim acceptance of the facts of life is vital to the doctor’s state of mind. A doctor must be able to witness death, to handle death, and to

  accept death. Even if death happens under his watch, he must be able to

  say, “Perhaps I acted unwisely; I might have been wrong, but I did my

  best,” and then go back to work. I do not think I could do that. Indeed,

  when catastrophe looms in the operating room, I work feverishly to save

  my patient, not just for my patient’s sake but also for my own. If a patient died by my own hand, I would be crushed. I’d probably quit medicine. I

  lack this vital ingredient of the good doctor. I lack a mature outlook on death.

  This mature outlook is not the unique possession of the doctor, by the

  way. Why some people have it while others do not has always mystified

  me. As a teenager, while working as a hospital orderly, I saw my first

  dead body. It bothered me tremendously. One of the janitors saw this.

  Although largely uneducated, he gave me wiser counsel than anything I

  learned later on in medical school. He said, “Everyone is afraid of dead

  people. Only, if you work in a hospital, you have to tell yourself not to be afraid. And you can’t act afraid. Sort of like giving yourself orders. And

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  that’s all that matters.” Then he added, “But you’re still afraid.” He had the right outlook.

  There is nothing constant in the world of medicine but sorrow. Death

  doesn’t stop. No, death never stops for doctors, even for doctors who

  know what being a doctor means. It just haunts their souls and appears

  without invitation and absorbs their joys, their little human joys. Such is the construction of the world.

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  WHAT IS A DOCTOR?

  A doctor is neither a scientist nor a technician nor a benefactor nor a jobholder. A doctor is a fighter. A doctor has spine. A doctor doesn’t fear being called bad names. A doctor is flexible but sticks to his or her guns when necessary. A doctor is an authentic individual. A doctor has imagination and a sense of other people’s lives. A doctor knows how to use the minds of others. A doctor commands, but also smoothes over controversies, motivates reluctant subordinates, and knows the limits of those subordinates. A doctor is not an elitist; he or she knows that even stupid

  people must have their say. A doctor has a passion for his or her profes-

  sion, but recognizes the importance of other worlds beyond his or her

  profession. The doctor calmly assimilates other worlds, not just to broad-en his or her consciousness but also to clear his or her mind. The doctor knows how to put the medical profession aside and take it up again. What

  is a doctor?

  A doctor is a leader. These are the qualities of a leader.

  A doctor’s mind has successive coatings—science, technique, com-

  passion, and instinct. A doctor is made of all these coatings. But at bottom he or she must be a leader. A sound doctor has his or her foundation

  deep in this inner coating. The rest are just the pediments and columns

  that rise up into the bright regions of the mind. If they form the only

  coatings, catastrophe looms. A scientist obsesses about rules; a technician obsesses about the craft of medicine; the benefactor obsesses about pleasing the patient; the jobholder obsesses about time off. Each gives rise to its own genre of medical catastrophe.

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  Without a doctor in command, the whole of medicine lacks an essen-

  tial core, in the absence of which catastrophes occur. This is my argu-

  ment. The catastrophes themselves are political in origin. Politics is about relationships, but at root it is about how people see their place in the

  world. Today, many doctors are unsure of their place because they do not

  know what a doctor is. Competing models vie for their attention, but each has a downside. The public hates the cold scientist; the doctor as technician is too easily emulated by non-MDs; the doctor as benefactor can

  barely make a living; the doctor as gentleman seems too elitist in a democratic age. There are even worse downsides—for patients—as each of

  these models carries with it the risk of catastrophe.

  The confusion that doctors feel about their identities inevitably

  spawns real politics. The most important quality in a leader is that of

  being acknowledged as such. Today, doctors are not so acknowledged.

  Patients want to control medicine. So, too, do hospital administrators,

  bureaucrats, nurses, and insurance executives. With doctors confused

  about who they are, no one seems to be in control, and others want to step in and take control. Fighting ensues, putting the patient at risk. True,

  doctors still have power and say, but not enough to quell the fighting. The situation in medicine today is analogous to a country split by factions,

  where the dominant group represents only a little over half the voters. If the other groups feel anything like hatred for the leading group, the situation is dangerous. This is medicine today. Patient care proceeds in doubt and disagreement, as doctors lack the confidence of the other parties.

  The doctors’ confusion has spawned not only politics but also ideolo-

  gy. Patient activists push “rights” and “patient-centered care.” Nurse activists push “team medicine.” Administrators push “quality of care” and

  “accountable care.” All these aspirational ideas have a noble purpose. But when taken to the extreme they raise the risk of catastrophe. Whenever

  people are required to act together, there must be a chief. By pushing

  doctors aside, these ideologies throw medical decision making into disar-

  ray. That disarray is often more the fault of the ideology’s practitioners than the ideology itself, which should not surprise. Although reform
>
  movements are often necessary, the reformers themselves can be unat-

  tractive, obnoxious, fanatical people. Doctors complain about these peo-

  ple. And yet their very existence stems from the doctors’ own identity

  confusion. Doctors have only themselves to blame for their coming into

  being.

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  Much attention has been paid in the last decade to catastrophes and

  near catastrophes in medicine. The bulk of that attention has been focused on physician error and how to correct for it. Drs. Atul Gawande and Peter Pronovost push checklists, time-outs, and protocols to address the problem. These modalities have real value. But at some point more protocols

  yield less return. They reach for the high-hanging fruit; they try to make an already rare medical catastrophe even more rare. They even turn

  counterproductive as medical personnel focus more on complying with

  the new protocols than on caring for patients.

  Yet my purpose is not to belittle these important reforms but to call

  attention to an altogether different source of trouble. A doctor’s judgment is often swayed by other side considerations that have nothing to do with medicine. It is not just error or forgetfulness that causes catastrophes but also politics. Many doctors today fear their colleagues; they fear their

  employers; they worry about crossing the nurses; they worry about antag-

  onizing their patients; they even fear themselves. All this can cause catastrophe. Today, a parallel world of catastrophes rooted in politics sits

  alongside a world of catastrophe rooted in error.

  The fix begins with the medical profession itself. The American Asso-

  ciation of Medical Colleges predicts a shortage of a million doctors in the United States by 2025, with a third of that shortage in primary care. 1 To lessen that shortage, more medical schools are being built. The shortage

  is based on current models of doctoring—for example, the doctor as

  scientist, or technician, or caregiver. But if medical schools were to produce leaders, then the shortage would evaporate, as other professionals

  would take over the doctors’ traditional roles, necessitating fewer doctors.

  For example, the doctor-as-technician model has doctors performing

  most procedures and writing most prescriptions, and fighting nurses and

  other professionals to keep it that way. This notion once made sense.

  Decades ago, nurses were unevenly trained. Many drugs on formulary

  had a low therapeutic index, meaning the difference between a drug’s

  therapeutic dose and its toxic dose was small, demanding a physician’s

  education and experience to be prescribed safely. This is not the case

  today. Nurses are better trained. They must meet higher education stan-

  dards. Drugs on formulary are much safer. Nurses and other professionals

  also have technology to help them, whether in the form of computers to

  assist in diagnosis and treatment or machines to help them safely perform small procedures. Moreover, when they do these procedures over and

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  over again, they get good at them—even better than some doctors. Nurses

  and other non-MD professionals function well as highly skilled techni-

  cians.

  None of this should threaten doctors who see themselves as leaders,

  for this is what doctors must become. Being technicians is no longer how

  doctors add value. Doctors add value through supervising, governing, and

  coordinating, whether in the care of a single patient or a large demograph-ic group. They legitimate a patient plan and give it binding force, not just for the obvious reason that they give the orders but also because their

  broad consciousness is a unique source of power. In the future, when a

  conflict arises between parties in a patient’s care or during a medical

  crisis, doctors will be presumed to have all the facts, to be supplied with the best available intelligence of all kinds, and to have the diplomatic

  skills needed to get all the parties on the same track. This will make

  doctors the real arbiters among the many well-thought-out therapeutic

  options presented to them by nurses, computers, and robots.

  Such a system requires fewer doctors, especially in primary care,

  where much of the physician shortage is expected. The days of doctors

  fighting nurses over every inch of turf must end. Doctors must cede more

  of their turf. Health care costs alone demand this. True, this plan works less well in surgery than in medicine. Surgery, by definition, is procedure focused, and the tight connection between a surgeon’s advanced cogni-tive skills and his or her procedural skills forestalls a serious off-loading of technical tasks onto nurses and computers. Indeed, a fundamental divide once existed between medicine and surgery, one that waned during

  the twentieth century, but one that will likely return for the next few

  decades—at least until robots become as proficient as computers. When

  that happens, non-MDs armed with robots may be as useful as non-MDs

  armed with computers. Still, the doctors’ leadership role will remain vital.

  This change should excite doctors, not scare them. The natural tenden-

  cy of technicians is to do more of the same, which is dull. Doctors who

  are leaders will move beyond such thinking. Instead, they will have an

  overall view of everything that is going on in the patient care setting.

  Even if they have relatively less power over day-to-day patient matters,

  doctors will be thought to have the best knowledge of the entire situation.

  People will tend to believe in them. They will enjoy more respect. Their

  days will grow less monotonous. It is a work of art to lead people, and as the routine technical side of doctoring is offloaded, doctors will enjoy a

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  higher share of interesting work. For nurses and other non-MDs, work

  will expand to include technical and decision-making responsibilities that have largely been denied to them. For the health care system as a whole,

  fewer doctors will be needed as nurses and other non-MD professionals,

  computers, and robots fill roles that doctors vacate.

  This plan will also reduce the risk of medical catastrophe. Catastrophe

  arises from disorder and conflict as doctors, nurses, administrators, regulators, and patients fight one another. They fight because, at root, they don’t know where they stand. They don’t know who has the right to

  command and who must obey. They rebel in their hearts against what

  they perceive to be an unjust usurpation of their own prerogatives. A

  secret internal warfare pervades the entire field, with patients suffering most of all. By transforming doctors into leaders, the other players in

  medicine, including patients, will enjoy stable turf they can control, giving them a sense of dignity and the feeling of productive activity. The

  result will be a safer system for patients, analogous to what prevailed in my father and grandfather’s era, when all the players in medicine lived

  together in order and peace.

  Some doctors will disagree with this plan. They want to resurrect the

  old, for which they pine. They want to put the pieces back together and

  re-create the vision of doctoring that prevailed during much of the twentieth century—part scientist, part technician, part benefactor, and part gentleman. However, this dream is not only impossible and undesirable but

  also misplaced. That vision itself was the product of erroneous thinking, made p
ossible by a sudden explosion in scientific knowledge during the

  second half of the nineteenth century, and the subsequent doctors’

  monopoly on that knowledge during the first half of the twentieth centu-

  ry. It was a short moment in history, when doctors were scientists and

  technicians first. In the millennium before, most doctors added value to

  medicine not as scientists or technicians or benefactors but as leaders.

  Medical historian Nancy Siraisi’s account of the physician Bartholo-

  meus managing the care of Peter the Venerable in the twelfth century

  provides an example. 2 Although a layman, Peter was confident in his medical knowledge. During a bout of flu-like symptoms he accepted the

  advice of local caregivers and postponed his routine bloodletting, since

  they told him he risked losing his voice if he underwent the procedure. A few months later, he went ahead with the bloodletting, thinking his caregivers wrong. Still, his flu-like symptoms persisted. And he lost his voice.

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  His caregivers then recommended hot and moist remedies. But the well-

  educated Peter disagreed. According to his reading, hot and dry remedies

  were called for. Frustrated with his care, he wrote to Bartholomeus, who, with artful diplomacy, managed the ticklish situation. Bartholomeus generally agreed with the local caregivers but tactfully avoided directly

  contradicting Peter, so as not to antagonize any of the parties involved.

  He also used his extra knowledge to dress up the routine therapies pre-

  scribed by the local caregivers and lend them weight, at least in Peter’s mind. By today’s standards, Bartholomeus was a poor scientist and technician; yet he was the consummate leader, resolving a conflict between a

  headstrong patient and the caregivers the patient had lost faith in, while steering the patient toward what professional medicine at the time believed to be right course.

  For eighty years, American doctors saw themselves as a mixture of

  scientist, technician, benefactor, and gentleman. For two thousand years