I am not sure how I get there, but now and then I find myself facing a stone wall with a large gate. There is a woman sitting in a guardhouse the size of a telephone booth. I walk up to the gate and greet the woman. I start a conversation. Here is the first one.
JVS: I always thought the gate would be pearly, but it is just rusty iron.
Woman: The gate you refer to is further up the path, and it is not pearly; it is made of titanium—lightweight, shiny, and rustproof. This is the triage gate.
JVS: This gate is open so may I go on?
Woman: No, you may not. You are not dead yet and only the dead may go further.
JVS: I am here because I have some very important questions for St. Peter. He was known in his day as Simon Peter and I think we may be related; my father's name is Peter (from the Greek for stone) Simone. He must have passed through this gate almost 50 years ago.
Woman: Yes, he did. Nice man.
JVS: You saw him? Was he OK? Was he allowed past through the pearly— sorry—the titanium gates?
Woman: Everyone who passes through this gate is OK. And I can't say what happened to any of them after they pass through, but I wouldn't worry about him.
JVS: But I must ask these very important questions of St. Peter because he will be the last authority I see before "The Decision," and I do not know if he will let me through the titanium gate or point me to the sign, "All ye who enter here abandon all hope."
Woman: Maybe I can help you with your questions.
JVS: But these are detailed questions about the medical profession. I am a physician.
Woman: I know all about you, even about that incident in Kyoto.
Woman: My scanner identified your DNA as you walked up and my computer had your entire history in 6 milliseconds.
JVS: How can you "scan" my DNA; you didn't take a tissue sample. And I don't see a computer.
Woman: We have had non-invasive DNA scanners forever; they are entirely biological and small enough to be implanted in my eye. The computer is also biological and is in my brain. No cables to fool with and no stupid IT department required. Every staff member here has this equipment and we are all connected wirelessly.
JVS: That is astounding! You must have a gigantic memory.
Woman: You can't even imagine.
JVS: Well, OK. I guess I have no choice but to ask you the questions.
Woman: That's right, and you better get on with it. We need to finish before the evening rush.
JVS: Well, the first question is…wait a minute, do you know what I am going to say before I say it?
Woman: Yes, but go ahead; I enjoy the exercise.
JVS: I am worried about the state of the medical profession back home. We find ourselves in the middle of an econocentric society, one that often measures success by how much money and goods one accumulates. And we doctors end up focusing on financial issues and dealing with payers. I am ashamed to admit that, at times, money becomes a main focus of the practice overriding prudent medical judgment, sometimes consciously, sometimes not.
Woman: Your worries are justified. What have you done about it?
JVS: Me? Well, nothing. What can I do about it?
Woman: It is not my job to tell you what to do.
JVS: What about St. Peter? Can he tell me?
Woman: No. He answers to only one question—"Which way?" But there are others above who may respond to your questions and, as you know, we are all connected wirelessly. Who would you like me to ask and what is your question?
JVS: I'm thinking. OK, I would like to ask Sir William Osler the following question—Sir, you set very high standards for the practice of medicine. What can myself and my colleagues do to protect the noble values of our profession? I know we have lived in a different eras, but you must have dealt with this issue.
Woman: [After a pause, she speaks with a male voice.] Physicians in all eras have dealt with this issue. Doctors' behavior is subject to the bell curve of human nature, just like the population at large. A minority consists of idealists who are willing to forego personal gain and safety for the good of patients and the profession. At the other end is a minority essentially wedded to the business of medicine. For them, there is never enough income and, using self-serving rationale, they willingly sacrifice the good of patients and society for personal gain.
The remainder is the great middle that consists of individuals who have some features from both extremes, but lean more or less toward one extreme or the other. That is where hope lies, not with the idealistic saints, but with those on the "good" side of the great middle group. They are pragmatic but have mature, well-informed consciences that lean toward idealism and the option for the patient. And the group is large enough to be influential. They need to know they are not alone and they can make a difference. The better professional associations may be able to foster and support this group; but, unfortunately, membership organizations often pander to the lowest common denominator. They offer glitzy programs on or near the beach and pass out trinkets and shoulder bags, which some doctors collect. You and others of like mind have your work cut out for you.
JVS: Thank you, sir.
Woman: Satisfied? [In her own voice.]
JVS: Well, it was helpful, but somehow I expected something more specific.
Woman: You can ask someone else, but only one more; it's getting late.
JVS: Yes, the evening rush.
Woman: Well, we don't really have any evening since time does not exist here, but we try to use terms familiar to the souls coming through. Who would you like to question next?
JVS: I'm not sure; maybe William Carlos Williams. I admire him enormously both as a physician and a poet, but on the bell curve he may be too close to the border between the great middle and the idealists. He wrote about the practice of medicine:
"I have never had a money practice; it would have been impossible for me. But the actual calling on people, at all times and under all conditions, the coming to grips with the intimate conditions of their lives, when they were being born, when they were dying, watching them die, watching them get well when they were ill, has always absorbed me. I lost myself in the very properties of their minds: for the moment at least I actually became them, whoever they should be, so that when I detached myself from them at the end of a half-hour of intense concentration over some illness that was affecting them, it was as though I were re-awakening from a sleep. For the moment, I myself did not exist, nothing of myself affected me. As a consequence, I came back to myself, as from any other sleep, rested."
I think if I asked him that might be his answer. It is admirable, but so personal that it might be of little help to me.
Woman: How about Don Berwick?
JVS: But Berwick is alive.
Woman: So? He does live in your era.
JVS: Yes, I guess Osler was right. Medicine has had, and still has, heroes like Berwick as well as its scoundrels. I guess we must look within ourselves and our profession, as it is today, to find and encourage those who have studied and work at sustaining the more noble values of our profession. We must look to them for leadership and support. This has been a valuable experience; it has given me a lot to think about and ideas for some actions I might pursue. I guess I will head back. Thanks for your help.
Woman: You are welcome.