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When I was a student and then a resident, my deepest concern was to become competent.
It’s not only the stakes but also the complexity of performance in medicine that makes it so interesting and, at the same time, so unsettling.
Why medicine is interesting
The Department of Defense announced that it would rely on improved financial incentives to attract more medical professionals. But the strategy did not succeed. The pay had never been competitive, and joined with the near certainty of leaving one’s family for duty overseas and the dangerous nature of the work, it was not enough to encourage interest in entering military service. By the middle of 2005, the wars in Iraq and Afghanistan had stretched longer than American involvement in World War II—or in any war without a draft. In the absence of a draft, it has been extremely difficult for the
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Problem with military deployment
propriety and trust. No one seems to have discovered the ideal approach. An Iraqi surgeon told me about the customs of physical examination in his home country. He said he feels no hesitation about examining female patients completely when necessary, but because a doctor and a patient of opposite sex cannot be alone together without eyebrows being raised, a family member will always accompany them for the exam. Women do not remove their clothes or change into a gown. Instead, only a small portion of the body is uncovered at any one time. A nurse, he said, is rarely asked to chaperone: if the
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mLe and fmLe doctors
chaperone of the appropriate gender must be offered to all patients who undergo an “intimate examination” (that is, involving the breasts, genitalia, or rectum), irrespective of the gender of the patient or of the doctor. A chaperone must be present when a male physician performs an intimate examination of a female patient.
intimate examination and the need of a chaperone
The Federation of State Medical Boards has spelled out that touching a patient’s breasts or genitals for a purpose other than medical care is a sexual violation and a disciplinable offense. So are oral contact with a patient, encouraging a patient to masturbate in one’s presence, and providing services in exchange for sexual favors. Sexual impropriety—which involves no touching but is no less proscribed—includes asking a patient for a date, criticizing a patient’s sexual orientation, making sexual comments about the patient’s body or clothing, and initiating discussion of one’s own sexual
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inappropriate work related baheviour
Some of these cases have involved such outrageous acts as having intercourse with patients during pelvic exams. The vast majority of cases involved male physicians and female patients, and virtually all occurred without a chaperone present.
intercourse during examination -,-
Inappropriate patient behavior might be averted, too. A 1994 study found that 72 percent of female medical students and 29 percent of male medical students experienced at least one instance of patient-initiated sexual behavior.
patient at fault
My father, a urologist, has thought carefully about how to avert such uncertainties. From the start, he told me, he felt the fragility of his standing as an outsider, an Indian immigrant practicing in our small southern Ohio town. In the absence of guidelines to reassure patients that what he does as a urologist is routine, he made painstaking efforts to avoid any question. The process begins before the examination. He always arrives in a tie and white coat. He is courtly. Although he often knows patients socially and doesn’t hesitate to speak with them about private matters (the subjects can
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doctor protocol
IT IS UNSETTLING to find how little it takes to defeat success in medicine. You come as a professional equipped with expertise and technology. You do not imagine that a mere matter of etiquette could foil you. But the social dimension turns out to be as essential as the scientific—matters of how casual you should be, how formal, how reticent, how forthright.
social as important as scientific
silent Victorian melodrama.” So do male physicians make women more comfortable with intimate examinations by involving a chaperone or not? My bet is that bringing an aide in helps more than it hurts. But we don’t know; the study has never been done. And that itself is evidence of how much we’ve underestimated the importance and difficulty of human interactions in medicine.
human interactions in medicine
She said that she had a friend who had been given a diagnosis of cancer erroneously and undergone unnecessary surgery. Reed pressed, though, and by the end of their discussion she allowed him to remove the visible tumor that remained on her thigh, only a half-inch excision, for a second biopsy. He, in turn, agreed to have another pathologist look at all the tissue and provide a second opinion. To Reed’s surprise, the new tissue specimen was found to contain no sign of cancer. And when the second pathologist, Dr. Wallace Clark, an eminent authority on melanoma, examined the first specimen he
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wrong case of diagnosis
MALPRACTICE SUITS ARE a feared, often infuriating, and common event in a doctor’s life. (I have not faced a bona fide malpractice suit yet, but I know to expect one.) The average doctor in a high-risk practice like surgery or obstetrics is sued about once every six years. Seventy percent of the time, the suit is either dropped by the plaintiff or won by the doctor in court. But the cost of defense is high, and when doctors lose, the average jury verdict is half a million dollars.
doctor malpractice suits
When it became apparent that I was just a first-week medical student and hadn’t been treating the woman, the court disallowed the case. The lawyer then sued me for half a million dollars, alleging that I’d run his client over with a bike. I didn’t have a bike, but it took a year and a half—and fifteen thousand dollars in legal fees—to prove it.
legal battles so stupid
The dermatologist sat straight-backed and still in the witness chair as Lang fired questions at him. He tried not to get flustered. A friend of mine, a pediatric plastic surgeon who had had a malpractice suit go to trial, told me the instructions that his lawyer had given him for his court appearances: Don’t wear anything flashy or expensive. Don’t smile or joke or frown. Don’t appear angry or uncomfortable, but don’t appear overconfident or dismissive, either.
how to ppear at court hearings
Even when he enrolled in night classes at Southern New England School of Law, a few blocks from his office, she didn’t think anything of it. He was, as she put it, “forever going to school.” One year, he took English literature classes at a local college. Another year, he took classes in Judaism. He took pilot lessons and before long was entering airplane aerobatics competitions.
fore er at schol
But what if I have a good record among surgeons, with generally excellent outcomes and conscientious care? That wouldn’t matter, he said. The only thing that matters is what I did in the case in question. It’s like driving a car, he explained—I could have a perfect driving record, but if one day I run a red light and hit a child, then I am negligent, he said.
pst record speakfor nothing in bd medicine and bad drivin
But what if they aren’t responsive—what if they seem to be worrying more about a lawsuit than about the patient—or what if their explanations don’t sound quite right? People often call an attorney just to get help in finding out what happened. “Most people aren’t sure what they’re coming to me for,” Vernon Glenn, the South Carolina trial attorney, told me.
why law suits occur
Peter’s chest continued to harbor residual cancer. He was given a new chemotherapy regimen, which so weakened his immune system that he almost died of a viral lung infection. He was in the hospital for weeks and was finally forced to take a leave from school. The virus left him short of breath whenever he did anything more strenuous than climb half a flight of stairs, and with burning nerve pain in his feet. His marriage slowly disintegrated; a disaster can either draw people together or pull them apart, and this one pulled Peter and his wife apart.
family leaves when disazter strikes
This is our situation in medicine, and litigation has proved to be a singularly unsatisfactory solution. It is expensive, drawn out, and painfully adversarial. It helps very few people. Ninety-eight percent of American families that are hurt by medical errors don’t sue. They are unable to find lawyers who think they would make good plaintiffs, or they are simply too daunted.
how many american families sue
An expert panel has enumerated the known injuries from vaccines, and, if you have one, the fund provides compensation for medical and other expenses. If you’re not satisfied, you can sue in court. But few have. Since 1988, the program has paid out a total of $1.5 billion to injured patients. Because these costs are predictable and evenly distributed, vaccine manufacturers have not only returned to the market but produced new vaccines, including ones against hepatitis, chicken pox, and cervical cancer. The program also makes the data on manufacturers public—who got sued and for what—whereas
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the vaccine fund
To become a doctor, you spend so much time in the tunnels of preparation—head down, trying not to screw up, just going from one day to the next—that it is a shock to find yourself at the other end, with someone shaking your hand and offering you a job. But the day comes. Mine came as I was finishing my eighth and final year as a resident in surgery. I had got a second interview for a surgical staff position at the hospital in Boston where I had trained. It was a great job—I’d be able to do general surgery, but I’d also get to specialize in surgery for certain tumors that interested me.
how doctors spend a lifetime in training
Yes, I said, a little startled. The position, he explained, came with a guaranteed salary for three years. After that, I would be on my own: I’d make what I brought in from my patients and would pay my own expenses. So, he went on, how much should they pay me?
guaranteed salry for three years
During our hundred-hour-a-week, just-over-minimum-wage residencies, we all take a self-righteous pleasure in hinting to people about how hard we work and how little we earn. Settled into practice a few years later, doctors clam up. Since
how hard we work and how little we earn
Everything’s in there, with a dollar amount attached. For those who have Medicare, the government insurance program for the elderly—its payments are near the middle of the range—an office visit for a new patient with a “low complexity” problem (service No. 99203) pays $77.29. A visit for a “high complexity” problem (service No. 99205) pays $151.92. Setting a dislocated shoulder (service No. 23650) pays $275.70. Removing a bunion: $492.35. Removing an appendix: $621.31. Removing a lung: $1,662.34. The best-paid service on the list? Surgical reconstruction for a baby born without a diaphragm:
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services a doctor can charge for
year. But then I’d have to spend thirty-one thousand dollars a year on malpractice insurance and eighty thousand dollars a year to rent office and clinic space. I’d have to buy computers and other office equipment and hire a secretary and a medical assistant or a nurse. The department of surgery deducts 19.5 percent for its overhead. Then there are the patients who don’t have insurance and can’t afford to pay—15 percent of Americans are uninsured, and like many other doctors, I believe we’re obligated to care for such patients insofar as we can. Furthermore, even when patients are insured,
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when some patients dont have onsurance
Doctors quickly learn that how much they make has little to do with how good they are. It largely depends on how they handle the business side of their practice. Many doctors expect patients to deal with insurance problems. But that’s a recipe for not getting paid. If the doctor sends in a bill and the insurer rejects payment, unless the matter is resolved within ninety days, insurers will pay nothing. Pass the bill on to the patient and many will not pay either. So, to be successful, she said, you have to take on many of the insurance troubles yourself.
how doctors manage business side
Parillo’s recommendations are pretty straightforward. Physicians must computerize their billing systems, she said. They must carefully review the bills they send out and the payments that insurers send back. They must hire office personnel to deal with the insurance companies. A well-run office can get the insurer’s rejection rate down from 30 percent to, say, 15 percent. That’s how a doctor earns money, she told me. It’s a war with insurance, every step of the way.
how doctots make money by fighting with insurance agents
professor, has done a number of studies on the work life of physicians. He and his colleagues found that working hours for physicians are indeed longer than for other professions. (The typical general surgeon works sixty-three hours per week.) He also found that, if you view the expense of going to college and professional school as an investment, the payoff is somewhat poorer in medicine than in some other professions. Tracking the fortunes of graduates of medical schools, law schools, and business schools with comparable entering grade-point averages, he calculated that the annual rate of
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annual rate of return for education
Yet it seems churlish to complain. Here are the facts. In 2003, the median income for primary care physicians was $156,902. For general surgeons, like me, it was $264,375. In certain specialties, the income can be a good deal higher. Busy orthopedic surgeons, cardiologists, pain specialists, oncologists, neurosurgeons, hand surgeons, and radiologists frequently earn more than half a million dollars a year. Maybe lawyers and businessmen can do better. But then most biochemists, architects, math professors earn less. In the end, are we working for the profits or for the patients? We can count
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how much a doctor earns annually
I had to catch my breath for a moment. He’d made more than a million dollars every year for at least the past decade. I wondered how it was possible, or acceptable, to earn so much for doing general surgery. He was perfectly aware of the reaction. (As was his hospital, which did not want his or its name to appear in print on the subject.) “I think doctors shortchange themselves,” he said. “Doctors are working for fees that are similar to or below those of plumbers or electricians”—people who, he noted, don’t require a decade of school and training. He doesn’t see why doctors should let
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if you want to see the doctor trained for ten years then you pay cash period
the most common operations in general surgery—insurers will pay surgeons about seven hundred dollars. He asks for eighty-five hundred dollars. For a gastric fun-doplication, an operation to stop severe reflux of stomach acid, insurers pay eleven hundred dollars. He charges twelve thousand dollars. He has had no shortage of patients.
bad writing gawande
Dr. B did not really want to get involved. He was in his forties then. He’d gone to a top-tier medical school. He’d protested the Vietnam War in the 1960s. “I’ve gone from a radical hippie to a middle-class American over the years,” he said. “I wasn’t on any bandwagons anymore.” But his patient said the team needed a physician only to pronounce death.
radical hippie to middle class indian
Thomas is now in a long-term care facility. He was brought to my office recently, by ambulance, on a stretcher. He was gaining strength, the rehabilitation doctors told me, but in the office he had difficulty just lifting his head off the pillow. I covered his tracheostomy so he could talk. He asked me when he would be able to stand again, to go home. I didn’t know, I told him, and he began to cry.
he began to cry with his ailing health he was helpless
Many talk about the border between what we can do and what we can’t as if it were a bright line drawn across the hospital bed. Analysts often note how ridiculous it is that we spend more than a quarter of public health care dollars on the last six months of life. Perhaps we could spare this fruitless spending—if only we knew when people’s last six months would
last six months most expensive healthcRe spending
The seemingly easiest and most sensible rule for a doctor to follow is: Always Fight. Always look for what more you could do. I am sympathetic to this rule. It gives us our best chance of avoiding the worst error of all—giving up on someone we could have helped.
dont give up on someone you could help
But as we talked, Jeanne also told me of doctors she thought had stopped pushing too soon. So I asked what she felt the best doctors did. She thought for a while before answering. Good doctors, she finally said, understand one key thing: “This is not about them. It’s about the patient.” The good doctors didn’t always get the answers right, she said.
not about you it is about student
In 1817, for example, Princess Charlotte of Wales, King George IV’s twenty-one-year-old daughter, spent four days in labor. Her nine-pound boy was in a sideways position with a head too large for Charlotte’s pelvis. Only after the fiftieth hour of active labor did he finally emerge—stillborn. Six hours later, Charlotte herself died, from hemorrhagic shock. As she was George’s only child, the throne passed to his brother instead of her, then to his niece—which is how Victoria became queen.
story of princess charlotte
(The name “Cesarean” section may have arisen from the tale that Caesar was born of his mother, Aurelia, by an abdominal delivery, but historians regard the story as a myth, since Aurelia lived long after his birth.)
history of caeserian
The story of the forceps is both extraordinary and disturbing, because it is the story of a lifesaving idea that was kept secret for more than century. The instrument was developed by Peter Chamberlen (1575–1628), the first of a long line of French Huguenots who delivered babies in London. It looked like a pair of big metal salad tongs, with two blades shaped to fit snugly around a baby’s head and handles that locked together with a single screw in the middle. It let doctors more or less yank stuck babies out and, carefully applied, was the first technique that could save both the baby and the
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story of forceps
But in 1933 the New York Academy of Medicine published a shocking study of 2,041 maternal deaths in childbirth in New York City. At least two-thirds, the investigators found, were preventable. There had been no improvement in death rates for mothers in the preceding two decades; death rates for newborns had actually increased. Hospital care brought no advantages; mothers were better off delivering at home. The investigators were appalled to find that many physicians simply didn’t know what they were doing: they missed clear signs of hemorrhagic shock and other treatable conditions, violated
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nothing has really changed after all study
Having these standards reduced maternal deaths substantially. In the mid-1930s, delivering a child had been the single most dangerous event in a woman’s life: one in 150 pregnancies ended in the death of the mother. By the 1950s, owing in part to the tighter standards and in part to the discovery of penicillin and other antibiotics, the risk of death for a mother had fallen more than 90 percent,
probem of childbirth
birth on a scale from zero to ten. An infant got two points if it was pink all over, two for crying, two for taking good, vigorous breaths, two for moving all four limbs, and two if its heart rate was over a hundred. Ten points meant a child born in perfect condition. Four points or less meant a blue, limp baby.
apgar score for newborn babiesbabies
THERE'S A PARADOX here. Ask most research physicians how a profession can advance, and they will tell you about the model of “evidence-based medicine”—the idea that nothing ought to be introduced into practice unless it has been properly tested and proved effective by research centers, preferably through a double blind, randomized controlled trial.
nothing in medical practice without evidence based resear h
tension on the forceps, you should have some sense that there is movement,” he said. Too much force and skin can tear, the skull can fracture, a fatal brain hemorrhage may result. “Some residents had a real feel for it,” Bowes said. “Others didn’t.”
good doctors have a feel
“Then one day I realized, ‘You know what? This is a stupid thing to think. You have a totally gorgeous little child and it’s time to pay a little more attention to your totally gorgeous little child.’ Somehow she let me put all my regrets behind me.”
did i fail as a mother or screw that did i give birth to a beautiful baby
For patients with pneumonia, how often does my hospital get them the correct antibiotic, and on the whole how do they do? How do our results compare with those of other hospitals? Gathering this kind of data can be difficult.
which school performs better
Yet here was Matthews saying that he and his colleagues could stop the disease from doing serious harm for years. “How long [our patients] will live remains to be seen, but I expect most of them to come to my funeral,” he told one conference of physicians.
success is still prolonged death success is still a later dropout
He began his speech with a gripping story about a 1949 Montana forest fire that engulfed a parachute brigade of firefighters. Panicking, they ran, trying to make it up a 76 percent grade and over a crest to safety. But their commander, a man named Wag Dodge, saw that their plan wasn’t going to work. So he stopped, took out some matches, and set the tall dry grass ahead of him on fire. The new blaze caught and rapidly spread up the slope. He stepped into the middle of the burned-out area it left behind, lay down, and called out to his crew to join him. He had invented, on the spot, what came to
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think yet in disaster
He began his speech with a gripping story about a 1949 Montana forest fire that engulfed a parachute brigade of firefighters. Panicking, they ran, trying to make it up a 76 percent grade and over a crest to safety. But their commander, a man named Wag Dodge, saw that their plan wasn’t going to work. So he stopped, took out some matches, and set the tall dry grass ahead of him on fire. The new blaze caught and rapidly spread up the slope. He stepped into the middle of the burned-out area it left behind, lay down, and called out to his crew to join him. He had invented, on the spot, what came to
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two ways to improve
