room an ambush; every morbidly obese patient sends an unpleasant shud-
der down his spine. He looks at the patient and his first instinct is to think,
“How can this patient ruin me?” An anesthesiologist learns during train-
ing that another person will leave you in the lurch, and not to trust anyone—that, for example, if a technician says the oxygen is turned on, look yourself to make sure it is turned on—and that such suspicion will never
let you down; it will see you through everything and help you avoid
getting into trouble. Such suspicion goes hand in hand with attention to
detail, which helps prevent catastrophes. Dr. B had lost this habit, forgetting, for example, to check whether the blood bank had performed the
necessary crossmatch.
Anesthesiologists often work on instinct more than on scientific
knowledge. It is instinct that gets them through a tense situation when
panic threatens to blot out their knowledge base. Anesthesiologists who
work sporadically risk losing this instinct, much the way an animal, once domesticated, loses the instinct to survive in the wild. Not all part-time doctors, but some.
The result is a characteristic personality. Creeping into an operating
room after having been away for many weeks, part-time anesthesiologists
anxiously put their patients to sleep. When they succeed and everything
goes smoothly, they are lulled into thinking that everything is easy, that they can put anyone to sleep, that their work is a no-brainer. Then, when
T H E P R O B L E M O F G O I N G P A R T - T I M E A N D W H E N T O R E T I R E
1 7 3
catastrophe approaches, they swing to the opposite side and panic, think-
ing everything is impossible. Anesthesiologists with healthy instincts
manage an impending catastrophe in stages, with each stage getting their
attention—for example, in a trauma case, first take care of the airway,
then take care of the breathing, then take care of the patient’s circulation.
They do not look further than each stage while concentrating on a particular stage; they are like the mountain climber who cuts steps in the ice and focuses on the level he is at, refusing to look up at the heights or down into the depths because the sight of either might distract him. Part-time anesthesiologists, however, are sometimes petrified by the enormity of
the situation they face. They look at the whole situation, all at once,
instead of trying to build themselves a path to safety, step by step; they look up and they look down, and grow terrified and paralyzed.
One solution to the problem of the part-time doctor is to prevent
doctors from going part-time in the first place. But this is impossible. My father and grandfather saw being a doctor as something special. With the
collapse of that vision, today’s physicians look at being a doctor as a job.
And once doctoring becomes a job, the lure of part-time is often too
strong to resist.
Can anyone blame them? Many young doctors want to save them-
selves from a hellish life made up of long work hours and few happy
moments. Some people try to make them feel guilty for wanting to go
part-time, only why should they feel guilty? Yes, they’re a little to blame, because of their strong sense of entitlement, but life itself is also to blame.
They slave away at their jobs. Suddenly temptation comes their way. It
sucks and sucks at them, drawing all the time, and they’re supposed to
turn it aside? That’s the right turn in life? But how can that be? How can it be not to want to have a family and see that family grow up, or not to have time to read, or to think about something beyond medicine, or to
bend down and smell the flowers? Many doctors in the past, including my
father, took a half-day off every week. They often took their staff out for lunch. They didn’t need to go part-time because medical practice in those days allowed them some wiggle room. Such civilities went by the way-side long ago. No, if a doctor’s life is all work, monotonous work, little-respected work, and employed work, then life is just as much to blame for a doctor’s desire to go part-time.
The only solution to the problem of the part-time doctor is to make
sure that the doctor never goes part-time in his or her mind. Even when a
1 7 4
C H A P T E R 9
part-time anesthesiologist is away from work, he must constantly run
scenarios of difficult cases in his mind. Whether he’s hiking in Europe or sailing on the bay, he must take time out from his activity to imagine
what he might do in a particular case. He must give that case his full
attention. He must be so in the moment of his daydream that his heart
races with expectation when he imagines injecting the life-saving drug,
while his fingers twitch as he imagines inserting an emergency intrave-
nous. When out in the everyday world, he must look at passersby and
study their facial anatomy and imagine how he might care for them if
they arrived for surgery, and whether he might intubate them awake or
asleep. He must carry his art with him wherever he goes during his time
off. Like a shadowboxer who spars with an imaginary opponent, he must
use his art constantly, daily, in his mind, so that when hospital life returns, his instincts and reflexes are ready to go.
I know this because I have been part-time now for more than twenty
years.
An anesthesiologist lives a good life and earns quite a bit of money,
but his life is overshadowed by fear. And for good reason. Odds are that
sooner or later, no matter what, he’ll kill a patient by accident. When he does, he is often traumatized, both by the death and by the inevitable
lawsuit. This risk causes some anesthesiologists to dream of the day when they no longer have to go into a cold operating room and put patients to
sleep, but instead can teach or do administrative work. Sometimes they
dream of suffering the perfect injury—left arm weakness—that will put
them on disability without sidelining them from tennis or golf.
An anesthesiologist’s fear intensifies when he’s handed the operating
room schedule for the day. He quickly surveys it to see if he’s posted to work in a room with sick patients, where the chance of killing someone is high. If so, his heart is gripped with fear of the impending clash; he has an inexplicable feeling of savage agitation, the kind that a soldier feels in the trenches, before the captain’s whistle blows, sending him over the top and into battle. Sure enough, the surgical nurse will often shout over the
lounge intercom, “We’re going in!” to tell the anesthesiologist as he waits anxiously in his chair that his patient is being wheeled back to the operating room, and that the test of nerves is about to begin.
T H E P R O B L E M O F G O I N G P A R T - T I M E A N D W H E N T O R E T I R E
1 7 5
In the healthy anesthesiologist there is usually a period of inward
transformation when he steels himself against what is to come and re-
minds himself that he can only do what he thinks is right. He goes over
his plan again and feels himself equipped to carry it out. His fear starts to dissipate; he goes back to acting as if there are no dangers in medicine, or, if there are, he has never come to any grief by disregarding them. He
walks toward the operating room with a clear mind.
An anesthesiologist who is about to retire—or who needs to retire—
finds it hard to control such fear.
Dr. P was such a physician. In his early sixties, he had been a good
anesthesiologist with a s
olid safety record, a pleasant colleague, and a
happy man. But his partners began to notice a change in his personality.
Something was bothering him. He grew less social. He would eat lunch in
silence, as if afraid to look at others, afraid to reveal his inner thoughts.
He became indifferent to everything, interested in nothing, and only
wanted to be left in peace.
His behavior in the operating room also changed. He grew supersti-
tious. After learning his room assignment he would hesitate to switch
rooms with another doctor, as if thinking, “Perhaps the disastrous case to come is in my partner’s room, and had I only stayed in the room that fate had decreed for me, I would have been fine. Then again, maybe the
disastrous case to come is in my room, and if only I had done my partner
a favor and switched, I would have avoided it.” He would wrestle in his
mind with what to do, go back and forth between the two different pos-
sibilities, and begin to hate the doctor who asked to make the switch,
thinking him some kind of devil put on earth to trick him. Later, when
setting up his workspace in the operating room, he would draw up every
emergency drug in his cart as if it were insurance against needing them. It was as though he were playing some kind of cat-and-mouse game with
destiny. When inducing anesthesia he would demand that everyone in the
operating room be quiet. Staring angrily at the surgeon and nurse as they talked to each other about their weekend, he would mutter to himself,
“Death is staring us in the eyes, and here you are chattering away about
some trip to the beach.”
The habits of a lifetime were disintegrating, and he was uncertain as
he had never been before. Soon he began to have problems clinically. He
was unable to intubate some easy patients. Maybe the light on the laryn-
goscope was dim, or maybe he was too fidgety, or maybe he took his eyes
1 7 6
C H A P T E R 9
off the windpipe at the last minute, but in any event he couldn’t get the tube in. Once, when another anesthesiologist came in to do it for him, he sent his stool flying, kicked it toward the cabinet, and flung the scope to the floor. Both the surgeon and the nurse in the room drew back in fright.
Then Dr. P grew quiet, as though the violent behavior had released some
pent-up truth from his heart.
One day, Dr. P was assigned to put a child to sleep for a tonsillectomy.
Although I had just finished my shift, he asked me to stay a few extra
minutes to talk about something. I shrugged my shoulders and agreed.
Once we were in the operating room he picked up a few syringes and a
laryngoscope and presented them to me, implying that I was expected to
participate in this anesthetic and not simply listen to him talk. I grew
suspicious and slightly resentful, but I grabbed the laryngoscope and
began to breathe the child down with gas without bothering to ask Dr. P if that had been his plan. I had no doubts. Dr. P seemed relieved to have the instrument removed from his hand, and his face relaxed even more as I
took over the case.
After the child was asleep, I looked over at Dr. P and asked, “Okay,
what did you want to talk about?”
“Talk about?” asked Dr. P. He seemed confused.
“Yes, you said you wanted to talk to me about something.”
Dr. P suddenly remembered his deception, and he replied, “Oh, well,
it’s late, why don’t we just talk about it tomorrow?”
“Wait a minute. You said you wanted to talk.”
Whatever relief Dr. P had felt from my presence passed into embar-
rassment, then into anger at having been found out. Suddenly he
thundered:
“I said we’ll talk about it tomorrow! I’m too tired to talk about it
now!”
I flinched in surprise. “What are you boiling over like that for? You’re
the one who asked me. . . . Oh, forget it. Good-bye.” I turned away in
open dissatisfaction and walked out, angry at having been cheated out of
a half-hour of time off.
I should have been more understanding. Dr. P needed to retire. If he
continued working, he risked injuring a patient or even a catastrophe.
This phenomenon is not new in medicine, but changes in medicine
have made it more of an issue. In my father and grandfather’s time, a
physician like Dr. P would have retired. The problem with older physi-
T H E P R O B L E M O F G O I N G P A R T - T I M E A N D W H E N T O R E T I R E
1 7 7
cians in those days was different. Doctors then often loved being doctors.
They loved all the trappings that went with being a doctor, from the free food at the hospital to the free pens given to them by drug company reps
(indeed, after graduating medical school, a doctor need not buy a pen for the next fifty years). Doctoring defined their identities. Since doctors
were typically independent professionals in those days, and since doctors often “covered” for one another, an impaired physician could cling to
medical practice and continue working long after it was safe for him or
her to do so, and risk causing a catastrophe. I know of two physicians in the 1980s, one with Parkinson’s disease, another with early Alzheimer’s,
who severely injured patients because they refused to stop practicing
medicine and no real mechanism existed to make them stop.
This is less of a problem now. Physicians increasingly are employed,
and employers have no problem firing an impaired employee. In the past,
hospitals were almost proud of their old doctors the way zookeepers are
proud of their old lions. This is less the case now. For their part, physicians increasingly view their work as a job. They love doctoring less and are often happy to get out when they can.
Still, the indelicate subject of money will likely rear its ugly head in
the future. With doctors employed and making less in salary, the question remains whether a doctor will have enough money to stop practicing
when his or her career has begun its downward arc—in other words,
when he or she has started to get scared of taking care of patients.
Some jobs recognize that workers cannot necessarily continue into
their seventies without endangering the public. For example, firefighters are often pensioned off at fifty-five, since no one wants an elderly firefighter carrying them down a ladder from a burning window. Pilots face
mandatory retirement at sixty-five. Already in their sixties, pilots must often be paired with younger copilots and undergo intensive medical
screening. Still, these jobs force retirement because of presumed physical decline. Doctors, however, can be healthy physically while still showing
important psychological signs of decline, especially fear, putting them at increased risk of causing a catastrophe. Nervous doctors who need to
retire but who stick it out another five or ten years because they can’t
afford to do so present a new and ill-defined problem.
Dr. P retired shortly after our case together. I saw him several years
later looking happy and like his old self again. When I asked him how his life had changed, he smiled and said, “Whenever I need a new pen now, I
1 7 8
C H A P T E R 9
have to buy one. Otherwise, I’m fine.” He winked at me, and I under-
stood.
10
I COME FULL CIRCLE
My patient was a forty-year-old obese man with a thick neck and an o
verbite, going for nasal surgery. I thought he might be a little hard to intubate, but I decided to put him to sleep in the routine way rather than place a breathing tube while he was still awake. I injected the Pentothal, then the short-acting muscle relaxant succinylcholine. Still, I was uneasy.
I felt those brief seconds of inward tension that precede a tough intuba-
tion, when the pulse quickens in an anesthesiologist no matter how many
patients he has put to sleep. The anesthesiologist feels an icy chill of
loneliness, for once the drugs are given, only he stands between the
patient and suffocation.
After the patient lost consciousness and stopped breathing, I looked
into his mouth with my laryngoscope and searched for the windpipe. I
saw nothing. I removed the scope and anxiously tossed it on my cart.
Then I pressed the mask tightly against the patient’s face with my left
hand while my right hand squeezed the bag at my side. The patient’s
chest failed to rise. I pressed the mask harder. With the enormous tension in my fingers invisible, I looked like an anesthesiologist doing something completely natural, especially with my right hand collapsing the breathing bag every two seconds like clockwork. The nurse watching me prob-
ably thought my movements were directed by a cold, unemotional reason,
so assured and confident they seemed. But my hand hurt and my palm
sweated, while inside I experienced a premonition of disaster.
Grabbing the scope back, I tried to imagine the sudden crisis away. I
peered into the patient’s throat again, thinking, I’m sure to reach the 1 7 9
1 8 0
C H A P T E R 1 0
airway this time. Then everything will be fine, and I will go home like I do every day. But I saw nothing. I removed the scope, inserted an oral airway, put the mask back on the patient’s face, and squeezed the bag
again with my right hand, furiously, as though I were squeezing a bellows to start a fire. I tried to calm myself down. I thought, Things are fine every day when I squeeze this bag, so if I squeeze this bag, things will be fine. Still, the patient’s chest failed to rise.
Medical Catastrophe Page 25