before that, doctors saw themselves as leaders. The latter vision wins by weight alone. A person may be wrong, and so may several generations,
but humanity rarely makes mistakes.
Medicine has changed, although it is easier to see this now, thirty
years after most of the events in this book occurred, and when the change actually began. For older doctors, medicine did not change especially
fast, but gradually medical practice has become strange and unfamiliar to them. Many of them embrace the new ways unwillingly, clumsily, and
halfheartedly. In fact, in their hearts they do not accept the new system, and instead have contempt for it. Never surrendering fully, they only
pretend they have. Younger doctors never knew the old way. Still, some
of them have heard legends, and when they encounter the reality of medi-
cal practice rather than the charmed life they had imagined, they are
disappointed. They go from a time in their lives when they can neither
think about evil nor believe in its existence to their first years of practice, when they work against the system and grow cynical and frustrated. Day
after day goes by in battling against the obstinacy of some official or
repairing the blunders of a fool. They imagine nothing can be done; to
have an immense plan for health care would be useless, and even after
just a few years in practice they know it.
W H A T I S A D O C T O R ?
1 9 5
To cause people to be disgusted by their own work is a serious error
on the part of organized medicine. What could be more natural than
doctors liking what they do? But many of them don’t like it.
What bothers many doctors is the loss of their independence. They
dislike being employed, by whatever institution, although they do like
having their malpractice insurance paid for by an institution, as well as having an institution’s clerks do their billing. Lawyers have analogous
complaints. They like the security and convenience of employment, but
they resent their loss of autonomy. For both groups, there has been a
change. In the nineteenth century, law and medicine were typically re-
ferred to as the “free professions” because lawyers or doctors could set up shop anywhere and be their own bosses. Today, law and medicine remain
professions, but they are increasingly less free, with lawyers and doctors working as dependent, salaried employees.
Still, such griping will probably wane over the years. When I started
my training, most medical students aspired to be small businesspeople
and run their own shops, a mentality out of sync with employed work.
Today’s students seem less interested in being businesspeople.
Yet even if most doctors grow comfortable with being employed,
dependent employment raises the risk of medical catastrophe. Sometimes
doctors feel trapped between employers who demand one course of ac-
tion and patients who insist on another. They feel barred from choosing
what they think is the wisest course of action. The patient suffers.
The risk of catastrophe is so great that this author, who has always
supported private practice medicine, is tempted to choose national health insurance as the second option rather than the emerging model of dependent employment in the private sector. Although Medicare-for-all would
pay doctors less, doctors would keep much of their autonomy, at least in
theory. Compare this with the plight of an employed physician who re-
cently complained to me that she couldn’t even choose her own recep-
tionist. The company that employs her does the hiring and firing, and
when it hired someone who was nasty to her patients, causing many of
them to leave, there was nothing she could do. Then again, the benefits of Medicare-for-all are only theoretical. In reality, Medicare pays too little to allow most independent doctors’ offices to survive. In addition, Medicare’s regulators can be as intrusive as private-sector bosses—for exam-
ple, by fighting with physicians over what drug they can prescribe. Nei-
ther the second option nor the third fixes the problem.
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C H A P T E R 1 1
Doctors today find themselves in a difficult situation. Still, the blame
for their situation lies not with government or corporate America but with the doctors themselves. When doctors ceased to be leaders, they opened
themselves up to being employed, and not just because their technical
approach to medicine lent itself to an employment model. They also
refused to make the tough decisions about who would get care that
government and corporate America now make. If I were a corporate
executive confronting a physician whining about his or her loss of auton-
omy, I would yell right back at that physician:
“You know why corporate America took over medicine? It’s because
we provided a solution to the doctors’ spinelessness. Everyone knows
that unlimited high-quality medical care is a pipedream for now. Tough
decisions have to be made, gut-wrenching decisions. Decisions that may
cost some people their lives! And who’s going to make them? Who’s
going to say, ‘Sorry, you still want something from life, but you can’t
have it, because there’s not enough money’? Do you want government
making those decisions? Everyone’s afraid of government; even the poli-
ticians worry about getting too involved. Do you want ‘the people’ mak-
ing these decisions? Ah, yes, ‘the people,’ always the people. Why,
they’re the source of all this trouble, whipped up by those pie-in-the-sky activists, those seekers of truth, those fighters for justice, those representatives of the insulted and the injured who peddle ridiculous expectations about health care being a right, but who know nothing about how to run a
business. ‘The people’ are in no position to make these decisions. And so everyone hoped the doctors would make them—those wise, thoughtful
professionals, those learned men and women gifted with nuance and sub-
tlety. Everyone secretly hoped the doctors would make the hard deci-
sions, although no one said so in public, since the notion of health care as a universal right was still official ideology. But you know what the doctors did? They balked, the little cowards! We had counted on them to take the power, to be wise and judicious fathers, but they were too afraid!
They said, ‘We don’t have the stomach for this. Our forefathers may
have, but we’re different. Our consciences, our precious consciences . . .
why, we have to deal with patients face to face! Find a way to spread the burden of deciding, so that the consequences won’t fall on any one of us
individually.’ And in response to that pathetic, weak-kneed plea, corpo-
rate American’s health care bureaucracy was born: layers and layers of
utilization review specialists, insurance regulators, practitioners, secretar-
W H A T I S A D O C T O R ?
1 9 7
ies, and switchboard operators, all playing their role in gumming up the
process, keeping people from getting care, holding down costs, and each
one, along with the doctors taking for themselves a tiny slice of the blame for a patient’s death—not enough to keep anyone awake at night with a
bad conscience but enough to do what’s necessary to keep the system
solvent.”
This is the ugly truth. In an environment of sparse resources and high
demand, corporate America and government took over wh
en doctors ab-
dicated the position they held in days when health care was considered a
“privilege” rather than a “right.” As the final arbiters of who would get care, doctors once carried a heavy burden. By deciding to treat someone
based on ability to pay, doctors held the power of life and death. Doctors no longer play this leadership role, and they would not want it back if
offered to them. The public also prefers it this way. Doctors are human
beings, and for a human being to be complicit in a decision about re-
sources that causes another person’s death is called “murder.” Alterna-
tively, when an institution makes such decisions, the human element
disappears. Bad outcomes arise from the “system’s limitations.” Al-
though people compose a system, the public conveniently overlooks the
fact that a system is composed of people.
Today’s system no longer asks doctors to make decisions about re-
sources. Yet it still demands leadership from doctors, even employed
doctors, to prevent catastrophes. Such leadership requires protections for doctors. In theory, leaders shouldn’t need protections. Leaders are fearless. They stand firm. They do not put their pleasures above their responsibilities. But let’s be honest: most doctors aren’t leaders. They went into medicine to enjoy interesting work, make a good living, and do something worthwhile for humanity in the process. And so most doctors are
not fearless. To make the right decisions for patients, they need protection from fear. I suggest a tenure system for employed physicians, analogous
to what reigns in academia: after five years an employed physician enjoys more job security, so that he or she feels less afraid when making tough
decisions that benefit patients.
The doctor as leader is a vision and, for the time being, a fantasy. Yet
if I were asked what is the one thing missing from medicine today, caus-
ing doctors to hate their work and patients to complain about their care, I would say it is the disappearance of fantasy from medicine. The history of American medicine is worth separating into fact and dream. This book
1 9 8
C H A P T E R 1 1
focuses on fact. Yet there is something in the dream that still touches
patients and those who care for them, and remains worthwhile because it
resonates with them as much as fact does: the dream of people wholly
absorbed in a struggle to save a person’s life, fused within a collective group and yet still separate parts. It was the dream of my father and
grandfather’s eras, when doctors and their spouses, nurses, Catholic sis-
ters, and administrators each played their own special role in the drama, replete with special uniforms, giving the hospital the feel of a magic
country, and the experience of being sick almost an inexpressible charm.
Patients today cling to this legend and are loath to give it up. In their bewildered state they search in their imaginations for something to comfort them while ill, and they mix the realities of their caregivers with a little bit of fairy tale.
The dream brings to mind a symphony, where different instruments
that might otherwise play a separate melody come together to create a
perfectly harmonized hymn. Perhaps the music today is outdated, but it
was beautiful, and who doesn’t love beauty? A dying patient would rather
die in his sleep, but if he can’t, how much better to fall unconscious with that tender, beautiful music in his ears; how much better to die to that
music than to do so in a cacophonous modern facility staffed by anony-
mous “providers”?
If a terminally ill patient once dreamed of dying to that music, the
doctor, the nurse, the doctor’s spouse, and the Catholic sister once lived for it. Amid that great intangible melody, these caregivers not only fantasized about each other but also fantasized about themselves, as each had something special about them, each had something the others could admire but not share in. Perhaps that special ingredient was an unattainable ideal—a legend in dreams that could never become a legend in fact—but
through it, each person working in the hospital imagined his or her life
unrolling itself on a grand, almost mythical level. How proud to be the
doctor, the nurse, or the Catholic sister of legend! How proud to do things with ceremony, gravity, drama, and solemnity! How wonderful to fire
another’s imagination—and one’s own! How wonderful to be special,
honored, respected, and even worshipped! And how much better to be a
part of a magnificent symphony than to be a generic “provider” in a
modern facility, humming a stupid tune or, worse, creating a clamor
through discord, for what unique passions and excitement could a provid-
er possibly have with which to create music? The provider is like every-
W H A T I S A D O C T O R ?
1 9 9
one else. He or she dresses like all the other providers; he or she has the same strengths, the same worries, and the same weaknesses as the other
providers. The new order in health care may be efficient. It is certainly more advanced than in my father and grandfather’s time. But there are no
distinctive parts to the orchestra, and so there is no symphony. None of its music stirs the blood.
Change begins with doctors. Once they change, the rest of medicine
will fall into place and the music will begin again. Doctors must become
leaders.
NOTES
1. THE POLITICS OF A CATASTROPHE
1. Barron Lerner, “A Case That Shook Medicine,” Washington Post, No-vember 28, 2006.
2. IMPATIENCE AND THE URGE
TO BE MACHO
1. Roni Rabin, “You’re on the Clock: Doctors Rush Patients out the Door,”
USA Today, April 20, 2014.
3. THE TRAP OF OVERSPECIALIZATION
1. George Weisz, Divide and Conquer: A Comparative History of Medical Specialization (New York: Oxford University Press, 2005), 138–39, 145, 197, 231, 249.
2. “2014 Survey of America’s Physicians: Practice Patterns and Perspec-
tives,” The Physicians Foundation, September 16, 2014, accessed April 1, 2016, http://www.physiciansfoundation.org/news/survey-of-20000-us-physicians-shows-80-of-doctors-are-over-extended-or-at.
2 0 1
2 0 2
N O T E S
4. WHEN NO ONE IS IN COMMAND
1. Bachelor of Science in Nursing and Master of Science in Nursing.
2. Dilation (of the cervix) and curettage (scraping) of the uterus.
5. WHEN PATIENTS BECOME CONSUMERS
1. Kristine Crane, “Should You ‘Friend’ Your Doctor?” U.S. News and
World Report, May 22, 2014.
2. In my own practice, I once had a mother panic when her child coughed
and sputtered while going under anesthesia. The mother refused to leave the room, requiring the nurses to attend to her, which delayed us in our efforts to help her child.
3. Donald Berwick, “Stepping into Power, Shedding Your White Coat”
(graduation speech at Yale Medical School commencement ceremony, May 24,
2010).
4. Dorothy Wertz et al., “Has Patient Autonomy Gone Too Far?” American Journal of Bioethics 2, no. 4 (2002): 1–25.
5. Donald Berwick, “What ‘Patient-Centered’ Should Mean: Confessions of
an Extremist,” Health Affairs 28, no. 4 (July/August 2009): w555–w565.
6. A TALE OF TWO OFFICES
1. Now Medstar Washington Hospital Center.
2. For further discussion of these schools, see Ronald W. Dworkin, “Re-
imagining the Doctor,” National Affairs 18 (Winter 2014): 63–77.
&nb
sp; 3. See Melnick Medical Museum, “1930 Doctor’s Office,” accessed April
16, 2016, https://melnickmedicalmuseum.com/exhibits/doctors-and-dentists-
offices/.
4. Now the Armed Forces Retirement Home.
7. WHEN DOCTORS LOSE CONTROL OF THEIR OWN
PERSONALITIES
1. Sanford Brown, Getting into Medical School (New York: Barron’s Educational Series, 1997), 7.
N O T E S
2 0 3
2. Kenneth Ludmerer, “Instilling Professionalism in Medical Education,”
JAMA 282, no. 9 (1999): 881.
3. See Initiative to Transform Medical Education, the final report of the 2007 conference of the American Medical Association, accessed April 10, 2016, http://med2.uc.edu/Libraries/Medical_Education_Documents/AMA_ITME_
Project.sflb.ashx.
4. See Report of the Council on Medical Education, American Medical Association, accessed April 16, 2016, http://www.ama-assn.org/assets/meeting/
2011a/tab-ref-comm-c-addendum.pdf.
5. Veritas Prep, “Medical Schools Value Personal Qualities of Applicants,”
U.S. News and World Report, January 16, 2012.
6. Brian Joondeph, “Politically Correct Medical Schools,” Washington Examiner, June 18, 2015.
7. William Whyte, The Organization Man (New York: Anchor Books,
1957), 134.
8. WHEN DOCTORS LOSE CONTROL
OF THEIR OWN RULES
1. Richard Baumgarten, “Spinal Anesthesia Research: Let’s Not Be Hasty,”
in “Letters to the Editor” Section, Anesthesia and Analgesia 105, no. 6 (December 2007): 1862.
2. See, for example, Atul Gawande, The Checklist Manifesto (New York: Metropolitan Books, 2009), and Peter Pronovost and Eric Vohr, Safe Patients, Smart Hospitals (New York: Hudson Street Press, 2010).
3. In a placenta previa, the placenta covers the opening of the birth canal and risks rupture during delivery.
9. THE PROBLEM OF GOING PART-TIME AND WHEN TO RETIRE
1. AMGA/Cejka Search 2011 Physician Retention Survey, cited in Dike
Drummond, “Part Time Doctor: Physician Schedule Flexibility and the New
Normal,” The Happy MD (blog), accessed April 16, 2016, http://www.
Medical Catastrophe Page 28
