Realities in the doctor's office

I had high hopes for the new resident I’d be seeing for my annual physical exam. His last name was the name of one of my favorite mixed drinks, so I had a premonition that the appointment would go swimmingly well. It might even be fun, I thought, like enjoying some solitude on the beach while sipping a cool beverage and marveling at the paper umbrella on the end of the toothpick.

In the exam room, however, Dr. Mixed Drink seemed nervous. He answered more than one of my questions with a vague factual statement about something loosely related to my query. At one point, I inadvertently rolled my eyes. Later when he delayed putting in the order for bloodwork, I wondered if he was being deliberately slow because he’d noticed my annoyance with him. Then again, my appointment was late in the day, so perhaps he was just exhausted. I left the office feeling a mixture of frustration and empathy for Dr. Mixed Drink.

That evening, I picked up Ronald W. Dworkin’s new book, Medical Catastrophe. Despite the dramatic title, most of the book’s content reflects something closer to the subtitle, Confessions of an Anesthesiologist. Indeed, it reads like a confession in the multivalent sense that Augustine used the term: it’s the story of one doctor’s search for vocational identity set alongside a critique (including plenty of self-critique) of the history, structures, and entanglements of modern medicine. Stories of “medical catastrophes,” most of them near-misses due to a combination of human error and complex relationships in the operating room, frame the narrative. But underneath those dramatic stories is a deeper, well-articulated vocational question: what does it mean to balance the traditional roles of the doctor—gentleman, technician, scientist, benefactor—with the leadership required of doctors in today’s world? These questions unfold with an escalating sense of urgency as the book proceeds. The author demonstrates how many medical catastrophes can be blamed on politics—not large-scale national politics so much as ground-level power struggles in the relationships between the many people who are involved in patient care.

A beautifully-written autobiographical chapter in the center of the book starkly contrasts Dworkin’s childhood perceptions of the medical profession (viewed through his experiences with his grandfather and father, both of whom were doctors) with the realities of a system that is now run by corporations and driven by fears of lawsuits. Some things haven’t changed, Dworkin notes, like the reality of confronting death. Reflecting on his father, he writes:

Even at his happiest moments, there was a tinge of doubting sadness, as though he thought his happiness was not really justified. Living means remembering. My father told a lot of people they were dying. He told a lot of family members that their loved ones were dying. He saw a lot of death. That, to him, was part of being a doctor.

Yet, the days of Catholic nuns cooking fresh meals for the Jewish doctors at their hospital while the doctors’ wives host luncheons to drum up business for their husbands are long gone.

Dworkin laments some of these changes but also attempts to move constructively past them. In the process, he critiques managed care, patient-centered models, team medicine, overspecialization, nurses and technicians who overstep their bounds, the intrusion of corporations and lawyers into medicine, overconfidence, lack of confidence, and many other realities. I’m guessing I would disagree with many of the author’s political views, which lurk under the surface. And I wish he’d used more gender-inclusive language rather than just apologizing for not using it in the opening author’s note.

But I’m glad to know that doctors are asking the kinds of questions this book poses. Dworkin may be extraordinary in the depth to which he ponders the role of politics in the vocation of medicine, since he’s also a political philosopher. (He wrote his doctoral dissertation on Augustine, it turns out, so the word confessions in the subtitle may be more than coincidental.) But if my doctors are asking similar questions even to a lesser extent than Dworkin does, I suspect they will end up being better leaders and safer physicians.

Reading this book also helped me reframe my own experience in the doctor’s office. Although Dr. Mixed Drink didn’t project the kind of presence I would expect from a doctor, Dworkin reminds me that neither does the fun imaginary doctor I’d hoped for before entering the exam room. The reality is that going to the doctor is nothing like enjoying a mixed drink. Medicine is difficult and the invisible factors weighing into doctors’ decisions, words, and actions are multiple. Knowing more about this complexity helps me be a better patient—one who might even help my doctors live into their vocations as leaders.