just above the knee, and by the shoulder, and she would flip me over and
pin me to the mattress. Oh, what a woman! Don’t worry. It was all done
with love. And if it hadn’t been for the war, I would have sat happily on a branch with her for the rest of my life. We would have been like love
birds. But she found a young lieutenant . . .”
A nurse interrupted their conversation and told them it was time to go
back to the operating room.
Whistling softly to himself, Dr. F helped wheel the woman back to the
operating room and within five minutes had her asleep. With fatigue
creeping back over him, and so much food in his stomach, he grew sleepy
himself. Feeling cold he went out into the hall to get two blankets from
the warmer. He wrapped one around his shoulders and the second around
his waist. Then he nodded off. Toward the end of the case, he woke up
and rushed to catch up on his charting. Absent-mindedly, thinking of
other things, he injected morphine into the intravenous—a drug the pa-
tient had a known allergy to. Within minutes the woman turned beet red,
her blood pressure dropped, and her lungs tightened. Dr. F grew startled
and called for help, but by the time I and another doctor had rushed in, he had injected adrenalin and remedied the situation.
In the recovery room the woman asked Dr. F why she was so red.
“I’m afraid you had an allergic reaction to the morphine,” he replied
sheepishly.
“Oh, I’m so sorry!” she countered. “I think I told you about that. I’m
allergic to morphine. I hope I didn’t cause you too much trouble. I’m so
sorry!”
Dr. F patted her hand and told her there was no need to apologize.
Afterward I whispered to him, “You give her a drug she’s allergic to and
she’s the one who apologizes?” Dr. F winked playfully and said nothing.
On one level, this story says something obvious about catastrophe
prevention: tired doctors are more likely to cause catastrophes than well-rested ones are, especially in anesthesiology. Dr. F should have gone
home that morning and not put that patient to sleep. Yet this story also
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says something important about doctor-patient relationships, and what it
means to be a doctor.
Patients will often accept a few mistakes from their doctors if their
doctors befriend them, as Dr. F befriended his. That’s because there’s
nothing more painful than ending a friendship. An injured patient eagerly sues his doctor if his doctor treats him like an insignificant nothing. He gets to turn the tables and treat his doctor with even greater contempt than he was treated. But when a doctor and a patient are friends, the patient
often wants to forget about his doctor’s mistakes and pretend that they
never happened. Because if they did happen, and the patient sues his
doctor, then he’ll have to call his doctor something other than “friend,”
and nothing is more painful than breaking with a friend. Lawyers will
advise the patient to reconsider, but he won’t. The patient feels his doctor is his own kind, a kindred spirit. “Yes, you’re right,” the patient will tell his lawyer. “I’m injured. But that’s just one side of my life . . . what you don’t see . . . there are other reasons.” And the patient forgives.
Yet being friends is not the same as being equals. This is a mistake
that doctors often make, especially today, as patients have more access to medical information, thereby narrowing the gap between what doctors
and patients know, while the health care system turns patients into consumers, or even colleagues, with both doctor and patient “working togeth-
er” to fight disease. Lawsuits are more likely in this environment. As
doctors try in every way to be democratic and treat their patients like
respected colleagues, patients almost start to imagine themselves real
doctors, with medical opinions that deserve to be taken seriously. When a doctor sees this happening, his or her democratic instinct is to think,
“Okay, I’m not proud. I don’t mind if my patient thinks he and I are on
the same level. We’ll both be doctors.” But later, if injured, the patient, who now imagines himself on a par with real doctors, thinks scornfully of his doctor, that he (the patient) earned the title of doctor by reading a few websites, while the doctor went to medical school and yet, despite his
extra education, still made a mistake. The patient sues almost on princi-
ple, to rid his profession of hacks.
Dr. F often befriended his patients, but he never treated them as
equals. At the same time, he never allowed his friendship with patients to cross over into true intimacy, in part because it was unprofessional, but also because it would have kept him from reacting properly during a
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crisis. Dr. F’s relationship with patients existed in its own space: he was both a friend and a master to his patients.
When patients go to doctors, they entrust the directing of their health
to professionals whose minds they regard as more powerful than their
own. Some patients are more deferential than others, and some patients
argue more than others, but all patients possess a master in their doctor.
They never cease to draw on doctors’ minds, and they do so with a
prejudice in their doctor’s favor. Yet patients also have a friend in their doctor. That doesn’t mean patients and doctors agree on all subjects.
Sometimes they may disagree entirely on important issues—as friends
do. But doctors and patients do share the same hopes and face the same
disappointments. What doctors and patients enjoy is friendship on a high
level, one that is free of jealousy because they share a common objective.
The doctor works hard for the patient. The patient, in turn, works hard at getting better. Satisfaction prevails because both are busy and there is
little time for ill feelings to develop. And yet, despite their friendship, the patient still recognizes the doctor as the moving spirit in the relationship.
For this dynamic to work, doctors must accept patients as they are in
the same way that friends accept their friends in everyday life. This is
why doctors must be more artists than craftspeople. Doctors and patients
do not live together, and therefore doctors lack the opportunity to ap-
praise their patients the way prospective friends appraise each other every day at the school lunch table or at the officers’ mess hall. Doctors must innovate to compensate for the lack of time they spend with patients.
Sometimes doctors must apply the methods of the philosopher and the
novelist to understand their patients en route to accepting them.
But patients must also accept their doctors. This is why Dr. F’s odd-
ball personality worked so well. A doctor’s intelligence and scientific
accuracy will not always gain his or her patient’s acceptance. On the
contrary, many patients fear the opinion of a mind that is too lucid. They prefer to be friends with someone less exacting. They prefer in their
doctors a few amiable weaknesses added to the high qualities. There is
something inhuman in absolute perfection that overwhelms the mind and
heart; it may command respect, but it keeps friendship at a distance
through discouragement and humiliation. Patients are often glad when a
great doc
tor reassures them of his or her humanity by possessing a few
peculiarities. And peculiarities Dr. F had aplenty.
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So did my father and grandfather. Both men were oddballs. My grand-
father’s weirdness hobbled him in private practice because he was weird
in a way that many patients disliked. That doesn’t devalue the importance of weirdness in doctors. Eventually my grandfather found an audience
that did appreciate him, at the Old Soldiers’ Home. He liked the old
soldiers and they liked him. As for my father, his patients warmed to his brand of weirdness. I hated his corny jokes, but his patients liked them.
He once asked me in front of a patient if I was “corn-fused” (a play on
“confused). I thought the play on words stupid, but his patient laughed
and laughed.
Friendship works through a hidden fraternity of spirit; the act of
friendship itself is an obscure ordering in which it is impossible to find a rule or law. This is why tutorials on the doctor-patient relationship are useless, or worse, downright irritating. They try to transform the miracle of friendship into an algorithm, to turn sentiment into a program, to
anchor the doctor-patient relationship in “effective methods” and
“achievable measurable goals.” Better to let doctors just be themselves
and for patients to select them on the basis of idiosyncrasies that harmonize with their own. It is why patients hate it when insurance companies
restrict what doctors they can go to. It’s not just that patients fear getting a lousy doctor; it’s also that they fear getting a doctor whom they are not in sync with, and who is not weird in the same way they are.
I watched carefully how Dr. F put patients at ease.
One day, while on obstetrics, he helped me get a patient ready for a
cesarean section. The woman was obese, which can complicate place-
ment of a spinal anesthetic. I methodically cleaned the woman’s back
with alcohol, sweeping the series of drenched swabs over her skin in ever widening circles. The woman bent her fat waist in a bow. Syringe in
hand, I warned her from behind that a small needle stick was coming.
“You’re going to feel a little prick,” I said.
Dr. F, who was facing the woman on the other side, whispered to her,
“A little prick? That’s how you got into this mess. Right?” He chuckled.
The woman outright laughed, her fat back jiggling with emotion. I passed
the larger spinal needle. No cerebrospinal fluid returned. I passed the
needle again and again, but there was no spinal space, no bone, no noth-
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ing. Dr. F distracted her with more lewd humor. The woman giggled with
each joke, giving me more time to poke around and find the right spot. A
few minutes later, I found it and injected the anesthetic.
We rolled the woman on her back. The nurses prepped her abdomen.
Despite our warnings, the woman kept reaching for her abdomen, threat-
ening the field’s sterility. In all her nervous excitement about having a baby, she kept forgetting to keep still. By now her husband was sitting
next to her; yet he had no more luck in calming her down than we did.
Finally we taped her arms down against the armboards to keep them from
moving. Because the woman was scared, and slightly claustrophobic, Dr.
F defused the situation with a shameless tease. “Don’t worry, I’m just
tying you down so you don’t reach over and pinch the surgeon’s butt,” he
said. He laughed, while the woman and her husband laughed along with
him. The rest of the surgery was uneventful.
I decided to use Dr. F’s line in the future. And I needed “a good line.”
I wasn’t very good at putting people at ease. Many young doctors lack
this social skill. When they go to a party or meet new people for dinner, they know that if they talk about their important medical cases or enlarge on their own decisions that vitally affected a case, people will listen with rapt attention. They don’t need the social graces to converse, and so those graces remain underdeveloped. Many young doctors rationalize away
their limitations, thinking that at least people can learn things from them, compared to everyday banter, where people are left bored after speaking
with someone who talks about everything but only lightly touches on
anything, and people get nothing out of it. Talk with a doctor at least
leaves a person edified, they think. But when caring for patients, a doctor really does have to be able to charm patients, to put them at ease. That’s why I wanted “a line.”
Three days later, I was managing another cesarian section on obstet-
rics. My patient was nervous and reaching for her abdomen, as my earlier
patient had. I taped her arms to the armboards and, with her husband
present, frenetically uttered Dr. F’s line about not wanting her to reach over and pinch the surgeon’s butt. There was gaiety in my tone. I chuckled after my delivery and said nothing more so the couple would know it
was the punch line.
I expected laughter. Instead, there was dead silence. The patient stiff-
ened and turned her face away, while afterward her husband complained
that I had been flirting with his wife.
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What went wrong?
On one level I had been a bad actor. Sometimes medical practice is a
large stage on which an endless play is going on. Doctors must connect
with their patients in the same way that actors must connect with their
audience. Sometimes actors cannot connect in their roles simply because
of who they are. Dr. F was old and wrinkled, whereas I was young and
succulent; at my age, I should have never used that line with a female
patient. Yet actors can also be bad, especially if they try to connect in a forcible way as I had. My “line” obviously had a studied, bookish flavor.
I had defeated my own object, as the forced friendliness destroyed the
illusion of friendship the line was intended to create.
Yet the deeper problem was that I had been acting. Dr. F had not.
When Dr. F had uttered the line, he had simply been himself. Instead of
thinking, “This is what a doctor who wants to be my friend says,” his
patient probably thought, “A friend is saying this.” Dr. F was an oddball.
Nevertheless, he was authentic. The feeling of friendship patients experienced with him was also authentic. It’s why patients liked him.
The following week I was on the obstetrics ward again. An overhead
call announced an emergency cesarian section. I rushed into the operating room. The patient was a young Japanese woman who spoke no English.
She was lying on the operating room table and shivering in fear. No
translators were immediately available in those days, and so it was impossible for me to take a quick medical history. The only thing the obstetrician could tell me was that the woman had a history of angioedema. In
that disease people swell in different parts of their bodies, including in their airways, in response to an allergen. The airway swelling can be
severe enough to cause suffocation.
“What do you mean by ‘angioedema’?” I asked him with concern
while checking my anesthesia equipment.
“Just what I said. She has a history of angioedema,” the obstetrician
rep
lied matter-of-factly, thinking the information not especially impor-
tant. “Now put her down. I need to get the baby out.”
“Yes, but there are different kinds of angioedema. What kind is hers?”
I asked, rushing to place monitors on the patient.
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“Hell, I don’t know. Maybe she swells when she eats sushi,” the
obstetrician teased. “Now get going.”
“Fine, but why would you even know that? Do you ask every patient if
she swells when she eats sushi?” I asked, connecting my syringes to the
patient’s intravenous and preparing to inject.
“Listen, she’s had angioedema all her life. That’s all I know. I don’t
remember how I know. Maybe her husband told me. I guess they start
eating sushi pretty early over there,” the obstetrician joked. Then, growing more serious, he barked, “Now let’s go!”
“Hereditary angioedema”—the phrase raced through my mind. She
might have that particular variant of the disease if it had been a problem all her life. It is the most dangerous kind. Not just allergens trigger swelling; simple instrumentation can also cause it—for example, putting a
laryngoscope in a patient’s mouth when inducing general anesthesia. Nor
can the swelling be treated with epinephrine, unlike other allergic reac-
tions. The disease involves a blood protein deficiency. Airway swelling
must be treated with fresh frozen plasma.
I hesitated for a moment, then decided to forego general anesthesia—
to avoid airway instrumentation—and place a quick spinal anesthetic.
The small delay put the baby at risk, but my first duty was to the mother.
Also, the patient was thin; I felt confident I could get a spinal in her in less than a minute.
I asked the nurses to help me flip the woman onto her side so I could
get to her back. The obstetrician protested and called me “ridiculous,” but I ignored him. I tore open the spinal set, cleaned the patient’s back,
inserted the spinal needle, found the right spot on the first pass, and
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