the 1950s screened for conservative tendencies; today’s MCAT screens
for liberal ones, such as tolerance and political sensitivity, but the principle is the same. 6
Medical schools push the company personality in a second way. Their
list of desirable personality traits is long and almost impossible to find in one person. Medical schools want a rose without thorns, an angel without
wings. They want a perfect creature. Instead, they get people who know
how to transcend an application and give examiners what they are look-
ing for; they get people who know how to appear as perfect creatures. In the 1950s, journalist William Whyte described such people in The Organization Man. Referring to applicants to corporate training programs, he wrote, “They are predisposed to read a good bit more between the lines
than many of their elders would like them to.” 7 In medicine today, these people exist among the thousands of applicants who pay premed consulting companies to help them write the perfect essay to convey all the
desired personality traits.
Sadly, a good company person does not necessarily make a good
doctor. Good company people excel at using the system to protect them-
selves. When a catastrophe occurs, they know the importance in company
warfare of thinking quicker than others, and of getting your blow in first, before the bureaucracy starts to crank. They know how to show how
seemingly unconnected incidents in their lives fit into a pattern, which, taken as a whole, is exonerating. They know how an affable personality
works as vital social capital to draw upon when one’s medical abilities
are suddenly called into question. They know all these things because
they excel at knowing what their supervisors are looking for. After all,
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they started their medical careers by writing a personal statement about
why they wanted to be a doctor, thinking the whole time about the admis-
sions officer who would read that statement, check it against their at-
tached autobiography, compare one answer with another, comb for
contradictions, and put a plus or minus after each sentence. They knew
the application was a game, just as they know that saving their skins is a game. They know how to play both games. But they do not necessarily
know how to rescue a patient from a catastrophe.
Here is one example: To maximize efficiency and worker productiv-
ity, many hospitals today want their operating rooms to start simultane-
ously. If a hospital start time is, say, 7:45 AM, then a mad rush occurs at 7:43 AM. Employed doctors and nurses desperately push to get their
patient into their particular operating room to avoid being penalized.
Indeed, if they have too many late starts on their record, they risk being fired. Already at 7:44 AM, the surgeon, the anesthesiologist, the nurse,
and the orderly—all company employees—are plotting how to offload
blame for a potential late start onto someone else.
In one hospital on the West Coast, an anesthesiologist interviewed his
patient at 7:20 AM. He thought his patient, who had recently experienced
some mild chest pain, needed more cardiac workup, including a second
EKG, which would push the operating room start time well past 7:45
AM. He looked on the sheet the hospital gave to doctors and nurses to
justify a late start. There were boxes to be checked if the late start was the anesthesiologist’s fault, the surgeon’s fault, or the nurse’s fault; there was a box for when the patient arrived late at the hospital; there was also a box for a delay in getting the patient’s lab results. But there was no box for when a second EKG was needed. The anesthesiologist panicked. He
knew that if he delayed the case to perform the second EKG, then his box, the anesthesiologist’s box, would get checked and he would be blamed.
He had already been associated with several other late starts. Those late starts had not been his fault; nevertheless, administrators were watching—they had told him they were watching. He decided to forego the
second EKG and bring the patient in at 7:45 AM.
During surgery the patient suffered a myocardial infarction and almost
died. Afterward, the anesthesiologist tried to weasel out of all blame. He told the administrators that the need for the second EKG had been ques-tionable. He downplayed the patient’s chest pain that had spurred him to
seek the second EKG. He gave a thoughtful explanation about how medi-
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cine is an inexact science. He was proactive and asked to be on a commit-
tee that would review similar situations going forward. He talked about
formulating new policies. He advocated for more input from nursing and
other departments. He discussed reaching out. The administrators loved
it. He spoke their language, which reassured them; he shared in their
ideas fully. True, they probably knew he was afraid of losing his job; yet they also knew that fear is what made the 7:45 AM policy work. A scared
anesthesiologist is an efficient anesthesiologist. So they let him off.
I would rather be taken care of by an oddball.
Medical schools may argue that graduating doctors need a company
personality to secure employment in the emerging health care order. Yet
it is not the medical schools’ job to do corporate medicine’s bidding.
Their job is to produce the best and safest doctors they can, even if that means graduating oddballs. To prevent catastrophes, it is corporate medicine that must adjust, not the medical training programs.
8
WHEN DOCTORS LOSE CONTROL
OF THEIR OWN RULES
Ms. O was a morbidly obese sixty-year-old woman with a history of
reflux and severe asthma needing an emergency hip pinning. In the back
of my mind, I had already decided on spinal anesthesia, since general
anesthesia with a breathing tube risked an asthma attack. But while re-
viewing Ms. O’s labs I noticed that her platelet count was seventy-seven
thousand, which was low, putting her at increased risk of bleeding. Bleeding at the operative site wasn’t the problem so much as bleeding around
her spine from the spinal needle. This rare but dreaded complication,
called an epidural hematoma, can put pressure on the spinal cord and even cause paralysis. In the past, the rule among anesthesiologists was
that at least a hundred thousand platelets were needed to safely place a
spinal needle. Later studies dropped that number to eighty thousand, es-
pecially if the doctor had good reason to place a spinal—as, for example, in a patient with severe asthma. A few doctors will insert spinal needles in patients with fewer than eighty thousand platelets, as the risk of epidural hematoma increases arithmetically as one drops below eighty thou-
sand, such that a patient with seventy-seven thousand platelets has only
slightly more risk than a patient with eighty thousand platelets. Below
fifty thousand platelets no anesthesiologist will go.
I was in a quandary. I really wanted to use spinal anesthesia, but the
number “77,000” kept staring me in the face. Yes, it was below the magic
“80,000”; then again, maybe the patient’s real number was 80,000, and
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C H A P T E R 8
the difference was merely lab error. Even then, 77,000 was close to
80,000.
I must have looked doubtful, as Ms. O asked me, “Is everythi
ng all
right, doctor?” Rather than confess the truth, I feigned nonchalance and
said, “Everything is fine.” Why did I hesitate to tell her my concerns at that moment? Because I saw myself as a scientist, and a scientist hates to admit ignorance of anything. A scientist thinks himself disgraced if he
has to reply, “I’m not sure.”
My father was less anxious about being caught without an answer. If a
patient asked him a hard question, my father would often put the tip of his reading glasses in his mouth, ponder the question in silence for several
seconds, and say, “I don’t know,” or “We shall see.” Doing so never
embarrassed him. He readily accepted the notion that doctors cannot have
an answer for everything and must often choose a course with some
doubt. To change his views, to admit to the change, and to appear change-
able was the “gentleman” side to being a doctor, he once told me, com-
pared to the scientific side, where precise laws determine a course of
action.
Many doctors today feel vulnerable when they have no ready answer
to give patients. It makes them feel like bad doctors. It also unnerves
them to have to think individually and to choose a course without the
security of a defined rule to back them up. They hate vagueness. When
learning about a new drug, for example, they will wait for the drug rep to tell them the drug’s loading dose, the dose frequency, the side effects, and the cost. They want to know figures and advantages, expressed in numbers. There is security in numbers. Other gadgets are sold to them in
similar manner. Nothing abstract. No philosophy. The doctors are told the numbers. These are the figures. That is understandable. The doctors are
happy with that. The pattern is repeated when they learn new approaches
to disease management. They eagerly await the last slide at a conference
when everything is summed up in the form of a therapeutic algorithm: if
the number is this, then do this; if the number is that, then do that.
Although patients resent being crammed into a treatment algorithm, they
overlook the peace of mind that many doctors enjoy when they know
what to do, at all times and in all cases, based on an algorithm.
I showed another anesthesiologist Ms. O’s lab report. When she saw
the number “77,000,” she froze. The hypnosis of simple figures can act
with remarkable power on doctors. She knew why I wanted to do the
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spinal, but she was also aware of the “eighty thousand platelet rule.” She gave me very circumspect and enigmatic advice. “I suppose I would
consider doing a spinal. It’s a reasonable thing to consider,” she said.
I reread the platelet studies, but moved no closer to a decision. I began to think that some paradox was hidden in the “eighty thousand platelet”
rule. When pondering something intangible, as, for example, the idea of
justice or virtue, the worm of self-doubt naturally crawls into my mind,
and I cannot help asking myself, “Does this mean the same thing to
everybody?” A scientific rule, in contrast, is supposed to mean the same
thing to everyone. And yet the platelet rule could be interpreted in different ways and mean different things to different people. This made the rule useless, even dangerous, for a doctor never knows for sure how much
individual judgment to use when working with a vague rule. The rule
becomes like a map whose contours are confused and whose boundaries
keep shifting; nevertheless one feels obligated to use the map constantly.
A vague rule can befog doctors and make them act counter to their own
consciences.
I asked another colleague. He winced when I gave him the patient’s
history. “I guess you’re screwed either way,” he said, referring to the
inevitable malpractice suit. Ms. O’s platelet count was destined to usher in a new chapter in my life, it seemed. A glimpse of beggarly destitution, after my trial, flashed through my head.
I asked a third anesthesiologist. He declared, “No way! Don’t do a
spinal!” I was inclined to agree with him; yet I could see that his instinct for self-preservation had been aroused, and I wondered how much it was
affecting the integrity of his thought processes. A doctor thinks with his mind. A doctor also thinks with his body, as when placing an intravenous
or a breathing tube. But sometimes, like an animal, a doctor thinks with
the herd. If panic seizes a flock of sheep, each animal runs with the flock, not because it understands the reason for the panic but because it has an instinct that teaches the sheep that if it does not follow the flock, it will be at the mercy of its enemies. My colleague seemed to be thinking with the
herd and hewing closely to the platelet rule to stay out of danger.
As I thought further about what to do, a nurse anesthetist approached
me and asked me what I was doing. I told him I was trying to decide
whether to put a spinal in a patient with seventy-seven thousand platelets.
The nurse anesthetist haughtily replied, “Maybe you didn’t know this, but eighty thousand is the limit.” I shot back, “I know the rule.” The nurse
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C H A P T E R 8
anesthetist snickered, “Some doctors don’t. And if you didn’t, now you
do. Because I told you.” I could see how his mind was working. The more
rules he knew, the more on par with doctors he felt himself to be, for, to his mind, what makes a doctor is knowing the rules, just as, to his mind, what makes a doctor is knowing how to do procedures.
In the end I asked the most senior anesthesiologist in the department.
“I wish I could tell you the right course,” she responded. “But I can’t. I think you’re probably okay if you do a spinal, but I can’t say for sure.”
“So I’ll be okay, until the point when I’m not okay,” I replied.
“I’m afraid so,” she said, sheepishly.
Such was her advice and warning: Follow medicine’s rules, but some-
times don’t follow them; sometimes act as if they don’t exist; you’ll never come to any grief by disregarding them—up to a point, only it’s impossible to fix that point. All doctors learn this eventually. They learn there is nothing absolutely safe in the world of medical practice, nothing that is not subject to the law of “up to a point.” Much of medicine is balanced on that cornerstone. Many doctors follow rules, guidelines, and algorithms,
and by doing so they hope to get through an entire career unscathed. They want to hear, “It is forbidden to do this,” or “It is the duty of the doctor to do that”—the kind of straightforward counsel that comes with rules and
guidelines. They prefer not only to be given direction but also to be made aware of the penalties for not following that direction, and to have the
magnitude of those penalties defined beforehand. Then they discover that
rules and guidelines come with exceptions and gray areas that they are responsible for navigating through. This scares them.
Practicing medicine is about living in a state of fear, in the knowledge that rules must be followed but only “up to a point,” and what that point is a doctor never knows for sure. Doctors hope in their imaginations that
someone will tell them what that point is, that a colleague will say,
“Don’t worry, this is one of those exceptions to the rule. Ignore the rule,”
or “If you follow the rule, you may suffer a penalty, but at most that
penalty will be a small misfortune,” or “On this one you�
��d better follow
the rule.” But doctors hope in vain. They are sentenced to fear, often, and at a moment’s notice, for rules exist everywhere in medicine, to guide
them, but also to worry them, to paralyze them, and possibly to ruin them.
Some doctors recognize it is useless to try to define what “up to a point”
means, and that there’s nothing a doctor can do about it other than wallow in a bog of insecurity. They just ignore the contradiction and let the chips
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fall where they may. Some reputable doctors think this way, although so
do many physician-cowboys. Other doctors just live in fear.
I thought about what drug I might use for spinal anesthesia. The case
was scheduled for two hours, so I needed something that lasted longer
than lidocaine. Bupivicaine seemed like the best choice. Because Ms. O
would be lying on her side with her broken hip up during the operation, it made sense to use a preparation called “normobaric bupivicaine.” When
injected, the drug numbs a patient on both sides, no matter what position the patient is in, unlike “hyperbaric bupivicaine,” which settles down by gravity and numbs the down side preferentially. Normobaric spinal bupivicaine exists in the form of straightforward epidural bupivicaine. Curiously, the label on the bottle reads (to this day), “Not to be used for spinal blocks”; yet I thought for sure I had seen other anesthesiologists use it for spinal anesthesia. I asked another anesthesiologist about it.
“I’m pretty sure you can use it for a spinal. The label is leftover from
the old days, when they thought these solutions were neurotoxic. They
know that’s not the case now,” he said. 1
“Then why didn’t they change the label?” I asked. I kept staring at the
label and the rule printed on it: “Not to be used for spinal blocks.” I felt uneasy. Like the platelet rule, it hypnotized me, although it was suppos-edly no longer a rule.
“I guess the FDA forgot to. Listen, the rule must have been crazy,
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