Drs. W, X, Y, and Z
Mr. Erwin, a fifty-two-year-old man, was admitted to the hospital because of a spot found on a routine chest X-ray taken by his private physician. Once he was in the hospital, the X-rays were repeated. The spot was there, no doubt about it, in the upper left lobe of his lung.
Mr. Erwin was told that he should have surgery, and he agreed. But when it came to signing the forms, he asked for time to think it over. The next day, he was again advised to have surgery, and again he agreed, only to back out at the last moment. A week passed in this way.
Mr. Erwin never asked what was in his lung that required surgery. He never asked anything at all. And nobody volunteered to tell him. For one thing, the X-ray image was anomalous; it appeared to be some sort of tumor, but it didn’t present a classical picture. Mr. Erwin was extremely nervous, and the house staff chose to wait.
On the other hand, a week was a week. It became difficult to justify keeping someone in an expensive bed, but the house staff didn’t want to discharge Mr. Erwin because they felt he’d never confront his illness once he left the hospital. So there was an impasse. Mr. Erwin still didn’t ask about the operation. And still no one told him.
Finally, at the end of the week, Dr. W, a surgeon from a nearby hospital, came to conduct visiting rounds. Dr. W, a former athlete, was a big blustery man who performed surgery with drama and verve. The house staff presented him with the case of the reluctant Mr. Erwin. Dr. W was outraged at the way the staff had coddled this man, and insisted on seeing him at once.
Dr. W walked into the man’s room and said, “Mr. Erwin, I’m Dr. W; you have cancer and I’m going to take it out!”
Mr. Erwin burst into tears, and agreed to surgery.
The following day, the operation was performed. A granulomatous lesion was removed. In the center of the lesion was found some stringy material identified by the pathologists as beef. Apparently Mr. Erwin had, at some earlier time, inhaled a bit of meat while eating. The beef had lodged in his lung, and had been overgrown with a protective coating of tissue.
When Mr. Erwin awoke, he was told the good news by the delighted house staff. Mr. Erwin remained glum. He still cried frequently. As the days went on, he said he knew the house staff was lying to him, that he had cancer; Dr. W had told him so. The residents assured him that Dr. W was wrong, that there was no cancer. They showed him the pathology reports. They offered to let him see his chart. Mr. Erwin believed none of it.
Two days later, Mr. Erwin crawled out the narrow window of his room, and jumped to his death.
Dr. X performed surgery on the leg of a thirty-five-year-old woman. His intention was to tie off the femoral vein. Immediately after surgery, the woman complained of severe pain in the leg, which was noted to be blue and cold, with little pulse. Twenty-four hours after surgery, when there was no improvement in her condition, it was realized that Dr. X had mistakenly tied off the femoral artery, not the vein. The woman’s leg would now have to be amputated at the hip.
Dr. X was an elderly Jewish refugee from Nazi Germany. He was known to have made such errors before, and his surgical privileges had been revoked at a suburban hospital. The question was whether Dr. X would now lose his privileges at this hospital as well.
Two things interested me. The first was that nobody told the woman anything was amiss. In those days, before the flood of malpractice litigation, a woman who had been grossly mistreated by a physician known to be negligent was not being told anything by the other doctors around her. The woman was relatively young, and the mother of two; with one leg amputated, she was now going to have a very different life.
The second thing was that there was discussion about whether Dr. X would lose his surgical privileges, as if the question were in doubt. (In fact, the hospital did not revoke his privileges entirely. He was merely forbidden to operate alone any longer.)
Dr. Y was discussing the case of a traveling salesman who had been admitted for gall-bladder surgery. The salesman was a chronic alcoholic, and the staff was afraid that he would go into the DTs while in the hospital, which would complicate his treatment and might even kill him. It was decided that he should be allowed beer while in the hospital; every day the salesman got a case of beer delivered to his bedside.
I asked whether Dr. Y was troubled by the fact that this alcoholic patient was also a traveling salesman. Presumably, once his medical condition was resolved, he would be back on the road, drinking and driving. Did the hospital, knowing the man was an alcoholic, have any greater responsibility to the man, his employers, or the wider society of drivers?
“Well, this is a very difficult problem,” Dr. Y said. “For instance, I recently performed an insurance exam on an airline pilot who was a chronic alcoholic.”
What did you do in that case? I asked.
Dr. Y shrugged. “I certified him,” he said. “What else could I do? I couldn’t take away his livelihood.”
Dr. Z was a seventy-eight-year-old physician who entered the hospital in a near coma, in end-stage cardiac and renal failure. His son was also a physician, but not on the staff of the hospital, so he could only visit like any other relative, and he had nothing to say about his father’s care. He did, however, state that he wanted his father to die peacefully.
The old man was on the critical list for nearly a week. He had a cardiac arrest one night, but he was resuscitated. His son came in the next day and asked, with a certain delicacy, why the staff had resuscitated the old man. Nobody answered him.
Later that day, old Dr. Z suffered sudden massive congestive heart failure. The hospital staff was making rounds; they all rushed to his bedside. In a moment he was entirely surrounded by white-jacketed interns and residents, working on the old man, sticking needles and tubes into his body.
In the midst of all this, he somehow emerged from his coma, sat bolt upright in bed, and shouted clearly and distinctly, “I refuse this therapy! I refuse this therapy!”
The residents pushed him back down. He got the therapy anyway. I turned to the attending physician, and asked how such a thing was possible. This man was, after all, a physician, and he was unquestionably dying—if not today, then tomorrow or the next day. Why had the house staff contradicted his wishes, and those of his family? Why was he not being allowed to die?
There was no good answer.
Dr. Z finally died on the weekend, when hospital staffing was light.
Incidents such as these troubled me throughout my clinical years. Everyone around me seemed to shrug them off, and to go on about their business, but I was unable to do that. My concerns in these areas eventually became one of the major reasons why I decided to quit medicine.
Quitting Medicine
Back in my first year, shortly after I cut open a human head with a hacksaw, I decided to quit medical school. I went to Dr. Lorenzo, the dean of students, and said I wanted to quit, that medicine wasn’t for me.
“Okay,” he said. “Go see Tom Corman. After that, if you still feel the same, you can quit.”
At this time it was the policy of the Harvard Medical School that you had to talk to a shrink before you quit. Dr. Corman was the shrink. He was well known among the students. A lot of us had been to see him.
Dr. Corman was short, intense, and direct. “What’s your problem?”
“I want to quit medical school.”
“Why?”
“I hate it.”
“So?”
This confused me. I explained that I had been at the school for three months, I had given it a try, but I just didn’t like it, I didn’t like what I was studying, I didn’t like the experience, I didn’t really like my classmates. I didn’t like anything about it.
“So?”
I asked him to explain.
“Why did you come to medical school?” he said.
“I want to be a doctor.”
“Meaning what?”
“I want to help people.”
“And how many patients have you seen so far??
??
“Almost none.”
“So you’re not doing what you came here to do. You came here to help people and instead you sit in classes all day, right?”
“Right.”
“I can understand that you hate it,” he said. “Most of your classmates hate it. That doesn’t mean anything.”
I thought it did mean something. It meant that I hated it.
“The first two years of medical school don’t have anything to do with being a doctor, which is what you want to be. I think you owe it to yourself to wait until next year, when you start seeing patients in a clinical setting.”
I said that was too long to wait. I wanted to quit now.
“All right,” he said, “But consider the academic realities. It’s not advisable to quit in the middle of an academic year. It doesn’t look good on your record when you apply to graduate school in some other field. You’d be better off finishing this year, and then quitting.”
That was true enough. So, in the end, Dr. Corman talked me out of quitting. And after the first year, I felt a little better about medicine. I thought I’d give the second year a try.
The second year was even worse. I was back in Dr. Gorman’s office.
“I want to quit.”
“Still don’t like it?”
“I hate it.”
“What do you hate?”
“The classes.” And I did. For such a famous medical school, the quality of instruction was a disgrace. It was so bad that the students had recently rebelled, and demanded the right to tape the lectures, and to assign one student to each lecture to go over the tape and make decent mimeographed notes for the class. The faculty was up in arms about this, but the students were adamant, and won in the end.
To listen to one of those lectures, again and again, trying to put the speaker’s points into some kind of logical order, consulting the textbooks to explain what he forgot to explain, was a startling demonstration of how poor the lectures really were.
I had taught a lecture course at Cambridge University, so I’d had the experience of preparing and delivering lectures. I knew how long it took—in my case, ten to twenty hours to prepare an hour’s lecture. I knew how it felt to give a lecture when you were fully prepared; how it felt to be almost prepared; how it felt to be poorly prepared; and how it felt to wing it.
The Harvard lecturers were mostly winging it. One man after another would stand up with a fistful of last year’s lecture notes, including a few scribbled changes in the margins, and start to talk. The fact that a few instructors, like Don Fawcett and Bernard Davis, were superb only threw the inept majority into sharper relief.
“And are you seeing any patients?”
“Yes.” We were doing some introductory clinical work.
“How is that?”
“I like that.”
“Well, the classes you dislike will stop in a few months, and then you’ll just be seeing patients. So is it correct to quit now?”
He talked me out of it.
Pretty soon another year had gone by. I was in my third year, doing full-time clinical rotations, more or less living at the hospital. By then I’d concluded I wanted to be either a surgeon or a psychiatrist. But when I did my three-month surgical rotation, I found myself surprisingly bored. I liked the pragmatism of surgeons, I liked their active stance toward the world, I liked the crises and pressures, and I liked telling people what to do. All that appealed to me. But I noticed that surgeons were interested in each case in a way I was not. To a good surgeon, every gall bladder presented new features of interest. But as far as I was concerned, if you’d seen one gall bladder, you’d seen them all.
So I suspected I was not destined to be a surgeon.
This left psychiatry, but I’d had a disturbing experience with a female patient; I’d been uncomfortable as a therapist. And, worse, as I worked in the clinic, seeing as many patients as possible, I began to feel that psychiatry was not a powerful field. I didn’t think psychiatry could really help people much. On the one hand, I had seen severely ill, institutionalized people with dramatic mental disease. But psychiatry didn’t seem able to do much for them, and certainly couldn’t effect cures. And, on the other hand, there were lots of well-to-do people who didn’t strike me as sick but, rather, as self-indulgent. For them, psychiatry appeared to offer a glorified kind of hand-holding that I didn’t admire. And I wasn’t at all sure that it did them any good, either.
So I was disillusioned with both surgery and psychiatry.
Back to Dr. Corman.
“Well,” he said, “you haven’t finished your clinical rotations. How do you know you won’t like pediatrics, orthopedics, or internal medicine?”
“I’m pretty sure I won’t.”
“This far along, don’t you owe it to yourself to find out?”
He talked me into staying again.
When I was finally convinced that no clinical specialty appealed to me, I had completed three and a half years of a four-year program. And then it really didn’t make sense to quit.
I went back to Dr. Corman and said I was going to get my degree, and then quit. He sighed. “I thought you would quit in the end,” he said. “Your fantasies are too strong.”
In this he was correct. I was supporting myself in school by writing thrillers, and my imaginative tendencies were overpowering. I often listened to patients, thinking, How can I use this in a book? And sometimes when I heard the symptoms of their disease, I’d think, It’s obviously anemia, but can I imagine a new disease that would present with these same symptoms?
Of course, when you go to a doctor, you don’t want him to view you as a book chapter, and you don’t want him making up fictional diseases to explain your case of anemia. I was clear on that. I understood that I was not behaving like a doctor that I would want to consult. So I thought I ought to quit.
There were other problems, too. Much of medicine, as it was practiced in those days, I simply didn’t agree with. I didn’t agree that abortion on demand should be illegal. I didn’t agree that patients had no rights and should shut up and do whatever the doctors told them to do. I didn’t agree that, if a procedure presented a hazard, the patient shouldn’t be worried with the facts. I didn’t agree that terminally ill people should have treatment forced upon them, even if they wished to die in peace. I didn’t agree that, when malpractice occurred, doctors should cover it up.
Beyond these broad issues of ethics, I didn’t agree with the style of the new physician-scientist, so popular at that time. I didn’t think of people as a sack of biochemical reactions that had somehow gone awry. I thought people were complex creatures who sometimes manifested their problems in biochemical terms. But I thought it wiser to deal primarily with the people, not to deal primarily with the biochemistry. And while there was much lip service given to my view, in practice nobody did anything but treat the enzyme levels. Again and again, I met patients who had been in the hospital for weeks and who had obvious problems that nobody had ever noticed—because they didn’t show up in the lab tests. It made you suspect that the doctors weren’t really looking at their patients. Not as people.
And the trend toward the physician-scientist had brought to the medical school a kind of student with whom I had little in common. My classmates tended to think that literature, music, and art were irrelevant distractions. They held these “cultural” matters in the same intellectual contempt that a physicist holds astrology. Everything outside medicine was just a waste of time.
In those days Harvard had built a new medical library. One day a pale, ethereal-looking man wandered in and looked around. It took me a moment to realize it was Louis Kahn, who was one of my heroes. I was very excited and reported the news at lunch: “Louis Kahn was in the library today!”
“Who?”
“Louis Kahn.”
Frowns. “The new professor of medicine?”
“No, the architect.”
“Oh …” And the conversation turned away.
r /> Louis Kahn was not only a famous architect, he was arguably the most influential medical architect in the world, as a result of the building he had done at the University of Pennsylvania some years before. Harvard was putting up a lot of new hospital buildings at this time, and there was much discussion of their merits and faults. How could you have informed discussions if you had never heard of Louis Kahn?
This single-mindedness led to some bizarre medical episodes. Once I heard a group of residents plan the surgical treatment of a middle-aged businessman. The best thing for his intestinal problems, they agreed, was to schedule five separate surgical procedures. The first would clean up his bowel. The second would cut a hole in his stomach so he could defecate into a bag. The third would do something else. The fourth would repair the hole in his stomach and reconnect his intestines. The fifth would do something else again. All together, the man would be out of the hospital, good as new, in nine months.
The alternative was a two-stage procedure that would require only three weeks and no colostomy bag, but it was obviously inferior to the five-stage treatment.
I suggested that the man might not agree to the five-stage treatment. Everyone listened to this view with astonishment. Why on earth wouldn’t he agree?
I said perhaps the man didn’t want to spend nine months of his life in a hospital, undergoing one operation after another. I suggested that a busy corporate executive was worried about many things besides his health. He was worried about his family, about his income, about his rank in the company. A nine-month hiatus from daily life was going to give him a lot of problems.
I also said that to live with a colostomy bag was a major body alteration and it would not be lightly accepted by anyone, even temporarily.
No, no, they said. When we explain it to him, he’ll certainly agree to the five-stage treatment.
Of course the man didn’t agree to it. He wanted the fastest possible treatment, and he thought their elaborate plan was crazy. He reacted to the idea of a colostomy bag with horror. The residents came away shaking their heads: What can you do with somebody who doesn’t care about his health?