A 3-year-old asks her physician father about his job, and his inability to provide a succinct and accurate answer inspires a critical look at the profession of modern medicine.
In sorting through how patients, insurance companies, advertising agencies, filmmakers, and comedians misconstrue a doctor's role, Andrew Bomback, M.D., realizes that even doctors struggle to define their profession. As the author attempts to unravel how much of doctoring is role-playing, artifice, and bluffing, he examines the career of his father, a legendary pediatrician on the verge of retirement, and the health of his infant son, who is suffering from a vague assortment of gastrointestinal symptoms.
At turbans serious, comedic, analytical, and confessional, Doctor offers an unflinching look at what it means to be a physician today.
Object Lessons is published in partnership with an essay series in The Atlantic.
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THE FOURTH WALL
In medical school, during my surgery rotation, I was expected to report for service rounds at 5:00 a.m. All of the patients on the floors needed to be rounded on prior to the OR cases, which began at 7:00 a.m. Therefore, to pre-round on my patients, I arrived at the hospital at 4:00 a.m. I figured this was a good time to experiment with growing out my hair and not shaving. Midway through the rotation, a cardiothoracic surgeon suggested I get a haircut and shave. He did this in private; it was not a rebuke, rather a suggestion. He advised, "Your patients want you to look and talk like the doctors on television." He was tall and trim and had perfect hair and teeth. He spoke slowly with a regal South African accent.
For the most part, I've followed his advice to this day. Every once in a while, I break the fourth wall and let the patients know I am as frustrated and disappointed with the medical system as they are. Usually, this is when they see me on the phone with an insurance company or witness my struggle in trying to obtain their medical records from another hospital.
My father, who just turned seventy, intuitively plays the part of the iconic television doctor. He defines himself as a doctor. He's been a pediatrician for over forty years; many of his patients are the children of his former patients, and some now are even the grandchildren of his former patients. When kids dress up as a doctor for Halloween, my father is the kind of doctor they are simulating. Indeed, a number of children have specifically dressed up as Dr. Bomback for Halloween. A local magazine, which profiled him as the top pediatrician in the county, asked him to pose for the cover of that issue. He and one of his patients re-created a Norman Rockwell Saturday Evening Post cover, my father cast as the reliable family doctor about to give a shot into a boy's rear end.
It's a morbid but entirely true thought: my father's obituary will mention his doctoring in the first sentence. That first sentence of my father's obituary — after labelling him as a husband, father, and grandfather — will say he was a devoted pediatrician to tens of thousands of children. If asked for input, I will also suggest the phrase "master diagnostician" be used. My father did a fellowship in genetics but has never used that training in his practice. He's a general pediatrician, without a true subspecialty, although websites and magazines have given him a subspecialty distinction of "difficult diagnoses." The obituary should say, "When other pediatricians needed help, their first call was to Dr. Bomback." My father was Dr. House before Dr. House existed, except my father is kind, humble, and needs sixty seconds (and not an entire TV episode's worth of drama) to make the diagnosis.
The obituary won't mention his stutter — it would be an odd detail to include in an obituary, I concede — but it should. My father does not stutter the way people stutter in movies. He doesn't repeat a consonant over and over again. His stutter is more accurately labelled a block. He blocks on words. He can't get started. He produces the sound of someone trying to clear snot from his nose without the aid of a tissue. This happens every time he answers the phone. This happens even when he is the one placing the call. "Mmmmmpphhh. Mmmmppppphhh." A pause, then: "Hello." When he's on service, returning calls from patients (more accurately, the parents of patients) is a process. He starts his speech while dialing, hoping the block ends while the phone is ringing. He's worked with a speech therapist for years, practicing a way to essentially cough out a greeting when he calls his patients.
The doctors in movies and on television don't stutter. The best on-screen doctors see a patient, make a diagnosis immediately, and then calmly and fluently communicate their recommendations to the patients and/or their families. Think George Clooney in ER. Think Jerry Orbach in Dirty Dancing. Think Patrick Dempsey ("McDreamy") in Grey's Anatomy. My father knows exactly what will help the patient, knows exactly what he wants to say to the patient's parents, and then can fall into a block that looks like dry heaving. I've shadowed him in clinic and seen this happen. The parents wait for him to get out the words. They are patient, because they know his reputation; they've often traveled far distances and endured long wait times to listen to his expertise. These moments only bear the slightest embarrassment for them, but I know, because my father's told me, that these blocks are excruciating for him.
I haven't quite figured out my feelings about my father's inevitable, upcoming retirement from medicine. I should say that he hasn't decided to retire. He claims he doesn't want to retire. He just turned seventy and always pictured himself practicing into his eighties, but the moment of reckoning is fast approaching. He is virtually computer illiterate. He's lost with the electronic medical record. Two or three times a year, he asks me to help him complete an online training course required by the hospital. "I can't do this," he laments. Because his quick, illegible handwritten notes are now considered insufficient documentation, he's had to cut down his daily patient panel almost in half. He's never had to think about billing, about collecting, about the financial part of his practice. In contrast, his junior partners are de facto experts on medical economics. When the partners sold their practice this past year to a large, multi-specialty medical group buying up independent practices, my father was the only one not involved in the negotiations.
My father doesn't need to work from a financial standpoint, but he is struggling with the idea of life as a non-practicing physician. His only hobby is exercising at the gym, but he mostly goes to keep my mother company. On vacation, he brings medical journals as his pleasure reading. For as long as I can remember, the magazine rack in my parents' bathroom has been stuffed with my mother's New York magazines and his latest copy of Pediatric Infectious Diseases. A retired medical school librarian, whom I cared for in the hospital, asked me if I was related to my father after I introduced myself. She told me she used to hold tapes of medical textbooks for him at the circulation desk. I remember these tapes in his car. He listened to them driving to and from work. "Your father used to thank me so much for holding the tapes for him," the librarian said, "and I didn't have the heart to tell him that no one ever checked them out except him."
"I waste so much time on the computer," my father tells me repeatedly, with the subtext that he's spending less time with patients and their parents. He used to brag, when he'd come home at night, about how many children he'd seen that day, sometimes fifty, sometimes sixty. He used to take pride in how he could see four children in the time a junior colleague could see one. He will be miserable when he retires, because he has always taken tremendous satisfaction from his job, but he is miserable now, because that satisfaction is slowly being taken away from him. His doctoring skills — his ability to diagnose, treat, counsel, etc. — remain unparalleled, but he has no skill in navigating what doctors of my generation call "the system." This, I surmise, is because there was no system when he started practicing. He will be relieved when he no longer has to force his outstanding but antiquated method of medicine into the modern mold of being a doctor.
The irony, of course, is that this modern style of doctoring involves less speech and, therefore, fewer opportunities for stuttering. The modern doctor "talks" with computer notes. We don't have time for thirty minute discussions. We write our notes, and the medical records software generates a patient letter out of the note, replete with spell-check. If my father started medicine today, his stutter would be less of a handicap. Still, he'd rather struggle with his tongue than with a computer. He'd rather try to talk to patients than try to figure out which check boxes he needs to click. "It's not doctoring," he's said about electronic documentation.
The older generation of doctors — the ones my father's age — are much more confident in their abilities than my peers, and I don't think this is solely due to experience. They began their careers in an era when doctors were held in much higher esteem than they are now, and I think they bought into the collective philosophy of doctor knows best. In other words, they naturally — without any hesitation or forethought — act like on-screen doctors. My generation of doctors has doubts and realistic expectations. We were explicitly trained to avoid paternalism with our patients. It is exceedingly rare to find an ultra-cocky, young doctor in my hospital, although the type still appears on television shows and in films. He or she sticks out like a sore thumb and is roundly criticized as "overconfident," "reckless," or a "cowboy." Over-confident is a buzzword in our evaluations of the residents and fellows, a way to signal that this doctor is capable of hurting a patient.
Tom Cruise plays an overconfident doctor in Eyes Wide Shut. I saw this movie while in medical school, and I was intrigued by how Cruise's character flashes his medical license the way cops whip out their badges. His ability to prove he's a doctor gets him out of jams, gets him invited inside apartment buildings, gains trust from others, and makes him sexier to women. I've never seen any doctor do that — in life or in other movies — but for a while I carried my medical license in my wallet. On a plane once, a passenger was short of breath, and the flight attendants asked if there were any doctors on board who could assist. I volunteered and flashed my medical license to an unimpressed stewardess, who didn't even glance at the document.
Jordan Grumet, an internal medicine physician, performed an "autopsy" of the medical profession in a blog post entitled, "Are we witnessing the death of the modern-day physician?" Grumet eulogizes the dying profession: "While some physicians are committing suicide or becoming addicted to drugs, others are leaving in less-devastating but still consequential manners: early retirement and nonclinical career paths." He then searches for "intrinsic" and "extrinsic" causes of this death.
The extrinsic factors are the predictable complaints: higher costs of education, lower salaries, less respect in the community, mountains of paperwork in a system that favors compliance over competence. I am more interested in what he calls the intrinsic cause, which is essentially the practice of medicine itself not living up to the expectations of medical students and residents. "The highs are much less common, and the lows are part of our moment-to-moment experience," Grumet writes. "Unlike most sitcoms, our patients die frequently. Diseases rarely follow patterns and rules. We lose many more battles than we win." Because I grew up with a physician father, my idea of a doctor wasn't based on someone from television or in a movie. I should not feel betrayed by medicine, that the field promised one thing and then delivered something else. Except my father's doctoring, with the sole exception of his stutter, has always been as exalted as anything on screen.
A survey of patients asked what bothered them most in a doctor's appearance. Answer choices included earrings and long hair on men, nose rings and buzz cuts on women, tattoos, bad teeth, obesity, and body odor, but the winner (or loser, I should say) was sneakers. Patients did not want their doctors wearing sneakers. Doogie Howser, M.D. famously wore sneakers on the hospital wards, but what patient wants a teenager as a doctor?
A Google Images search for "doctor" reveals essentially the same picture: a doctor wearing a crisply ironed white coat with a stethoscope draped, scarf-like, around the neck. The only difference between the images is the actual doctor — man or woman; white or black or Asian. The stethoscope sits like a fashion accessory on all of them, ear pieces over one shoulder, chest piece over the other. I never saw doctors wear their stethoscopes like this until shows like ER and Scrubs.
The older doctors in my hospital, like my father, never wear their stethoscopes like this. They have the ear pieces meet at the back of the neck, like the clasps of a necklace. They project the notion they were just using the stethoscope and can use it again at a moment's notice. The "doctor" images that Google returns with the stethoscope worn in this fashion are almost exclusively cartoons, and the cartoon doctor is an old, white man, like my father.
My most obvious example of breaking the fourth wall is with my patient, Louise. She has a rare form of kidney disease, fibrillary glomerulonephritis, about which we know very little. And because we know so little about its etiology, we subsequently know even less about effective treatments. She presented with moderate kidney failure, and, in the first year of treating her, she advanced to severe kidney failure. We had tried the only therapy that had been shown in case reports to work for her disease: a monoclonal antibody called rituximab, although the rationale for why this drug would work for this specific disease was at best speculative. She broke down in my office. She was in near hysterics. Two medical students were shadowing me that day, and her crying was clearly making them uncomfortable. I handed Louise a box of tissues and told her we would re-dose the rituximab and a second round of therapy would help. I said, "You will get better," which was not an outright lie, because if her kidneys failed, she'd get a transplant, in which case she would technically get better. Louise stopped crying. "You really think so?" she said. "Yes," I said, in my most television-doctor certainty.
Later, when Louise left the office, the medical students asked me if I really thought she'd get better. "No," I said, "but she needs to have some hope right now." They laughed, but Louise did get better. After it was clear her recovery was going to be sustained, when she was stable and healthy and no longer suffering from kidney failure for over two years, I reminded Louise about that episode in my office, about her crying and my saying she would get better. She remembered it as clearly as I did. "I was bluffing," I confessed with an awkward smile, but also in a way a television doctor might say the line.
My father called me late on a Friday night. He was in a panic about an online training course required by the hospital. He couldn't get the course started. "The computer is saying something about cookies," he said timidly. "And it needs to know what version of Internet Explorer I'm using. How do I do this?" I answered, "Maybe you should retire."
"Just help me," my father said. "Please."
The exchange felt like something on television.CHAPTER 2
MY FAVORITE TYPES OF PATIENTS
My favorite types of patients (in descending order): once sick but now healthy and attributes his or her good health to my care; sick, seeing me for the first time, and optimistic that my recommendations will help; sick, following my recommendations, and understands that I am trying my best to help, but there is a limit to what medicine can do; sick, following my recommendations, and questions why he or she is not getting better; sick, not following my recommendations, but now will consider following my recommendations; sick, not following my recommendations, and has his or her own ideas on how to proceed based on what he or she has learned on the internet; healthy, never sick, never really needed to see me, and appreciative of that good health; healthy, never sick, never really needed to see me, but convinced that there is something wrong that I have yet to find.
There's a major disconnect between what patients expect of their doctors and what doctors are actually able to do. The other day I walked past a urologist, standing outside an operating room, talking to a patient's wife. I was able to hear the urologist tell the wife he'd removed a large kidney stone: the husband would be fine now as long as he drank plenty of fluids to prevent another stone. The urologist had a great head of silver hair and looked a lot like Richard Gere. His smile expressed pure contentment that he'd done the right thing. The wife was looking up at him with an equally content expression that she and her husband had gotten everything out of the doctor they'd wanted.
As I left them behind to finish up their conversation, I thought how this scene is so much the exception rather than the norm, yet it's the scene we doctors want to play, and the scene our patients want to play along with us, too. The next time I saw this Richard Gere-looking urologist, he was standing by an elevator, nervously running his hand through his magnificent silver hair, talking on his cell phone and telling someone he'd be there as fast as he could. The smile was gone.(Continues…)
Excerpted from "Doctor"
Copyright © 2019 Andrew Bomback.
Excerpted by permission of Bloomsbury Publishing Plc.
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Table of ContentsIntroduction
1. The Fourth Wall
2. My Favorite Types of Patients
3. I Have Good News and Bad News
4. You Get Better Because We Are Better
5. Doctors at Home
6. Texters and E-Mailers and Tweeters
7. What Are Their Names?
8. Highly Attentive Medicine
9. It's Complicated
10. And It Will Last Forever
11. The Business of Medicine
12. A Diagnosis (Something to Do)
13. Everything You Say Is Important to Me
14. Harp Lies
15. The Longer You Stay, the Longer You Stay
16. The Future Is Already Here
17. History and Physical
18. Don't Worry