In July 1986, I began my third year of medical school. My classmates and I were excited to transition from the dry domains of biochemistry, histology, pathology, and the like to meaningful participation in the care of actual patients. We draped our stethoscopes about our necks; stuffed the pockets of our crisp, white coats with 10 pounds of handbooks, reflex hammers, otoscopes, and wishful thinking; and ventured out to the wards to help save lives.
I was assigned to the Veterans Affairs hospital internal medicine service. The Veterans Affairs hospital was considered one of the best places to train because students and residents were given great autonomy in managing cases. Attending physicians would come for rounds only once or twice a week. There was a chain of command to which we adhered, but the expert at its terminus was the resident covering the service, a person who a mere 1 or 2 years previously had himself been a medical student. One grows up fast under such circumstances.
A patient I will call “Mr. George” was admitted on my first day. He was a veteran of World War II and a “frequent flyer,” a term referring to patients admitted every few weeks to tune up their diabetes, detox from alcohol, deal with an escalation in their posttraumatic stress, or get a little rest and relaxation. Mr. George, whose life had disappointed him in almost every conceivable way, appeared to take true pleasure in one thing only: chain-smoking Camel cigarettes. Given that his admitting diagnosis was lung cancer and that his shortness of breath necessitated that oxygen be run through a mask by his face, Mr. George's hobby of smoking was frowned on by the staff, more for their own sakes (fearing a fire or explosion) than for his.
My intern dispatched me to do Mr. George's history and physical. I gathered my medical accoutrements and youthful enthusiasm and went to his room. I was startled when I laid eyes on him for the first time. I had been told that Mr. George would be found slumped in his wheelchair by the window, oxygen mask shoved to one side to make room for the cigarette dangling from his lips, and so he was. However, the thing that astonished me was the position of his head. It lay unusually low, as if it had been detached from his neck and bolted to his upper chest. I took my concerns to the intern.
“I think Mr. George's head is going to fall off,” I reported.
“I think Mr. George's head is going to fall off.”
“What are you talking about?”
“I'm talking about Mr. George's head, which is about to fall off.”
The intern scoffed at me. “Why don't you let me worry about Mr. George's head, OK? His head is not going to fall off. Just write up your H&P and let me worry about his head.”
I did as I was told, but I could not get the image of Mr. George's unusual head placement out of my own skull. Finally I decided to act. I called for a transporter to take him to radiology and filled out a paper requisition for a STAT cervical spine radiograph, signing it “Dr. Hirsch.”
A few minutes later I got a voice page: “Call Dr. Khan!”
Uh oh. Dr. Khan was Chair of the department of radiology.
He picked up the phone on the first ring. “Is this ‘Dr. Hirsch’?” he demanded. I could hear the derision in his voice. I prepared myself to be excoriated for impersonating a physician—poorly. At that moment I felt more remote from being a real doctor than I ever had in my life.
“Well? Are you Dr. Hirsch?”
“Y-y-yes,” I finally stammered.
“This man's head is going to fall off!” he declared. “He has a metastasis that has eaten away most of his fifth cervical vertebra. Get him in a neck brace and send him for radiation therapy right away.”
“Yes, sir!” I said, and that's what I did.
For the next 5 days I tried to persuade Mr. George, who wanted nothing more than to sit as comfortably as possible in his chair and enjoy his cigarettes, to quit smoking and to wear his neck brace. He pretended to comply but would light up his smokes and remove his brace, which he hated, as soon as I was out of his line of sight. He died minutes after the intern scribbled a do-not-resuscitate order in his chart.
This vignette from my medical youth is relevant to the current philosophy of patient-centered care. I find it helpful to conceptualize our medical systems as a universe of potentialities that might affect the patient who resides at its center. My role as a physician is to assure that testing and management decisions revolve around the best interests of the patient. With this model in mind, I believe I was right to pursue the correct diagnosis for what I perceived was Mr. George's benefit, even as the junior member of the team and even taking liberties with the rules to do so. In today's era of enhanced supervision by attending physicians (not to mention computerized order entry), for a medical student to do what I did is inconceivable. However, advocating for the patient remains an important duty of all medical care providers regardless of their station.
Our systems are clearly flawed in many respects, but one positive trend has been the evolution away from regarding physicians as unchallengeable authorities and toward a collaborative, safety-focused approach in which input from all members of the team is valued and everyone is empowered to advocate for the patient. Like many physicians, from time to time I have had to deal with the frustration of a strong-willed and opinionated member of the care team insisting on a view that differs from my own. Such a person can make it difficult for me, the team leader, to actuate my plans for the patient, but I would never trade him or her for someone who thoughtlessly carries out my orders. When anyone can stop the train, everyone is forced to ground their thoughts in data and sound reasoning rather than the far less reliable justification of authority. This tradeoff benefits patients.
On the other hand, although I made the correct diagnosis, it must be acknowledged that my intervention made no difference in the end. A dying man died just as he would have without my efforts. My misguided attempts to get Mr. George (the most important and only indispensable member of his medical team) to quit smoking represent more than naiveté. They reflect a lack of understanding of how to identify, place into context, and prioritize a patient's objectives in seeking treatment. I still believe in acting, and acting boldly, when action is called for. I also recognize the value of not acting under the right circumstances. Too often we allow action (ie, testing and treatment) to take the place of wisdom.
In his excellent book, Being Mortal: Medicine and What Matters in the End, Atul Gawande1 notes that we physicians are conditioned to rectify deviations from the perceived path of health. I believe that this is the proper attitude for a professional whose job is to fix, mend, and heal. However, in certain circumstances, of which the case of Mr. George is an extreme example, perhaps we have things backward. Perhaps it would be better to default to not acting and to require justification for any action we contemplate taking, using the tools at our disposal to educate and advise the patient as best we can. What follows should be guided by one question: What are the patient's objectives?
I have heard it said that good judgment comes from experience, and experience comes from bad judgment. That has certainly been the case during my career. If I have good judgment nowadays, a lot of it comes from understanding that the things patients need, more than the things I can do, are what really matter.