Complications

by Atul Gawande

  A few months after the lecture, I flew to Minneapolis to see Neff in action. His program was at Abbott Northwestern Hospital, near the city’s Powderhorn district. When I arrived, I was directed to the fifth floor of a brick building discreetly off to one side of the main hospital complex. There I found a long, dimly lit hallway with closed, unmarked doors on both sides and beige, low-pile carpeting. It looked nothing like a hospital. A block-lettered sign read “Professional Assessment Program.” Neff, in a tweed jacket and metal-rimmed glasses, came out of one of the doors and showed me around.

  Each Sunday night, the physicians arrived here, suitcases in hand. They checked in down the hall and were shown to dormitory-style rooms where they would stay for four days and four nights. Three doctor-patients were staying during the week that I visited. They were permitted to come and go as they pleased, Neff assured me. Yet I knew that they were not quite free. In most cases, their hospitals had paid the program’s fee of seven thousand dollars and told the doctors that if they wanted to keep their practices they had to go to Minneapolis.

  The most striking aspect of the program, it seemed to me, was that Neff had actually persuaded medical organizations to send the doctors. He had done this, it seemed, by simply offering to help. For all their dithering, hospitals and clinics turned out to be eager for Neff’s assistance. And they weren’t the only ones. Before long, airlines began sending him pilots. Courts sent him judges. Companies sent him CEOs.

  A small part of what Neff did was just meddle. He was like one of those doctors whom you consult about a coughing child, and who then tell you how to run your life. He’d take the doctors in hand, but he was not shy about telling organizations when they had let a problem fester too long. There are certain kinds of behavior—what he calls “behavioral sentinel events”—that should alert people that something may be seriously wrong with a person, he explains. For example, a surgeon throws scalpels in the OR, or a pilot bursts into uncontrolled rages in midflight. Yet, in case after case, such episodes are shrugged off. “He’s a fine doctor,” people will say, “but sometimes he has his moments.”

  Neff recognizes at least four types of behavioral sentinel events. There is persistent, poor anger control or abusive behavior. There is bizarre or erratic behavior. (He saw a doctor who could not get through the day without spending a couple of hours arranging and rearranging his desk. The doctor was found to have severe obsessive-compulsive disorder.) There is transgression of proper professional boundaries. (Neff once saw a family physician who was known to take young male patients out alone for dinner and, in one instance, on vacation with him. He turned out to have compulsive fantasies of sex with pubescent boys.) And there is the more familiar marker of incurring a disproportionate number of lawsuits or complaints (as Goodman had). Through his program, Neff has persuaded a substantial number of hospitals and clinics—and airlines and corporations—to take such events seriously. Many organizations have now specified, as a part of their contracts, that behavioral sentinel events could trigger an evaluation.

  The essence of what he did, however, was simply to provide a patient consultation, the way a cardiologist might provide a consultation about someone’s chest pains. He examined the person sent to him, performed some tests, and gave a formal opinion about what was going on, about whether the person could safely be kept on the job, and about how things might be turned around. Neff was willing to do what everyone else was extremely reluctant to do: to judge (or, as he prefers to say, to “assess”) a fellow doctor. And he did it more thoroughly and dispassionately than a doctor’s colleagues ever could.

  Neff’s first step with the three doctors seeing him the week I was there was to gather information. Starting on Monday morning, and throughout the next two days, he and four clinicians separately interviewed each of the doctors. They were made to tell their stories over and over again, half a dozen times or more, in order to break through their evasions and natural defensiveness, and to bring out the details. Before they arrived, Neff had also put together a thick dossier on each of them. And during the week he did not hesitate to call their colleagues back home in order to sort through the contradictions and ambiguities in their versions of events.

  Neff’s patients also underwent a full exam, including blood work, to make sure that no physical illness could account for any dangerous behavior. (One doctor, who was sent to Neff after several episodes of freezing in place in mid-operation, was found to have advanced Parkinson’s disease.) They were given alcohol and drug testing. And they underwent psychological tests for everything from gambling addiction to paranoid schizophrenia.

  On the last day, Neff assembled his team around a conference table in a drab little room to make their determinations. Meanwhile, the physicians waited in their rooms. The staff members spent about an hour reviewing the data in each case. Then, as a team, they made three separate decisions. First, they arrived at a diagnosis. Most doctors turned out to have a psychiatric illness—depression, bipolar disorder, drug or alcohol addiction, even outright psychosis. Almost without exception, the condition had never been diagnosed or treated. Others were simply struggling with stress, divorce, grief, illness, or the like. Next, the team decided whether the doctor was fit to return to practice. Neff showed me some typical reports. The judgment was always clear, unequivocal: “Due to his alcoholism, Dr. X cannot practice with reasonable skill and safety at this time.” Last, they spelled out specific recommendations for the doctor to follow. For some doctors deemed fit to return to practice, they recommended certain precautions: ongoing random drug testing, formal monitoring by designated colleagues, special restrictions on the doctor’s practice. For those found unfit, Neff and his team typically specified a minimum period of time away from their practice, a detailed course of treatment, and explicit procedures for reevaluation. At the end of the deliberations, Neff met in his office with each doctor and described the final report that would be sent to his hospital or clinic. “People are usually surprised,” Neff told me. “Ninety percent find our recommendations more stringent than what they were expecting.”

  Neff reminded me more than once that his program provided only recommendations. But once he put his recommendations down on paper it was hard for hospitals and medical groups not to follow through and hold doctors to the plan. The virtue of Neff’s approach was that once trouble occurred everything unfolded almost automatically: Minneapolis, evaluation, diagnosis, a plan. Colleagues no longer had to play judge and jury. And the troubled doctors got help. Neff and his team saved hundreds of careers from destruction—and possibly thousands of patients from harm.

  Neff’s was not the only program of its kind. In recent decades, medical societies here and abroad have established a number of programs to diagnose and treat “sick” physicians. But his was one of the very few independent programs and more systematic in its methods than just about any other.

  Yet his program was shuttered a few months after my visit. Although it had attracted wide interest across the country and had grown rapidly, the Professional Assessment Program had struggled financially, never quite paying its own way. In the end, Neff was unable to persuade Abbott Northwestern Hospital to continue to subsidize it. He was, when we last spoke, seeking support to set up elsewhere.

  But whether or not he succeeds, he has shown what can be done. The hard question—for doctors, and, even more, for their patients—is whether we can accept such an approach. Programs like Neff’s cut a straightforward deal—maybe too straightforward. Physicians will turn in problematic colleagues—the ordinary, everyday bad doctors—only as long as the consequence is closer to diagnosis and treatment than to arrest and prosecution. And this requires that people be ready to view such doctors not as sociopaths but merely as struggling human beings. Neff’s philosophy is, as he put it, “hard on behavior but soft on the person.” People may actually prefer the world of don’t ask, don’t tell. Just ask yourself, could you abide by a system that rehabilitated drug-addicted anesthesiologists,
cardiac surgeons with manic psychosis, or pediatricians with a thing for little girls if it meant catching more of them? Or, to put it another way, would you ever be ready to see Hank Goodman operate again?

  Hank Goodman’s life, and perhaps his career, was one of Kent Neff’s saves. In mid-December of 1995, after pondering suicide, Goodman called Neff at his office. Goodman’s lawyer had heard about the program and given him the number. Neff told him to come right away. Goodman made the trip the next day. They met for an hour, and at the end of the meeting Goodman remembers feeling that he could breathe again. Neff was direct and collegial and said that he could help him, that his life wasn’t over. Goodman believed him.

  He checked into the program the next week, paying for it himself. It was a difficult, at times confrontational, four days. He wasn’t ready to admit all that he had done or to accept all that the members of Neff’s team had found. The primary diagnosis was long-standing depression. Their conclusion was characteristically blunt: The doctor, they wrote, “is unable to practice safely now because of his major depression and will be unable to practice for an indefinite period of time.” With adequate and prolonged treatment, the report said, “we would expect that he has the potential for a full return to practice.” The particular diagnostic labels they gave him are probably less important than the intervention itself: the act of telling him, with institutional authority, that something was wrong with him, that he must not practice, and that he might be able to do so again one day.

  At Neff’s suggestion, Goodman checked into a psychiatric hospital. After that, a local psychiatrist and a supervising medical doctor were lined up to monitor him at home. He was put on Prozac, and then Effexor. He stuck with the program. “The first year, I didn’t care if I lived or died,” he told me. “The second year, I wanted to live but I didn’t want to go to work. The third year, I wanted to go back to work.” Eventually, his local psychiatrist, his internist, and Neff all agreed that he was ready. Largely on their advice, Goodman’s state medical board has given him permission to return to practice, although with restrictions. At first, he would have to work no more than twenty hours a week and only under supervision. He had to see his psychiatrist and his medical doctor on a regular schedule. He could not operate for at least six months after returning to the clinic. Then he would be able to operate only as an assistant until a reevaluation determined that he could resume full privileges. He would also have to submit to random drug and alcohol tests.

  But what practice would take him? His former partners wouldn’t. “Too much baggage,” he said. He came very close to securing a place in the rural lake town where he has a vacation home. It has a small hospital, visited by forty-five thousand people during the summer months, and no orthopedic surgeon. The doctors there were aware of his previous problems, but, having searched for an orthopedist for years, they approved his arrival. Still, it took almost a year for him to obtain malpractice insurance. And he thought it prudent to be cautious about returning to the stresses of a full-fledged practice. He decided to start off by doing physical examinations for an insurance company first.

  Not long ago, I visited Goodman at his home, a modest brick ranch-style house full of dogs and cats and birds, tchotchkes in the living room, and, in a corner of the kitchen, a computer and a library of orthopedic journals and texts on CD-ROMs. He was dressed in a polo shirt and khakis, and he seemed loose, unhurried, almost indolent. Except for the time he spent with his family, and catching up on his field, he had little to occupy himself. His life could not have been further from that of a surgeon, but he felt the fire for the work coming back to him. I tried to picture him in surgeon’s greens again—in an OR, with another assistant on the phone asking about a patient with an infected knee. Who could say how it would go?

  We are all, whatever we do, in the hands of flawed human beings. The fact is hard to stare in the face. But it is inescapable. Every doctor has things he or she ought to know but has yet to learn, capacities of judgment that will fail, a strength of character that can break. Was I stronger than this man was now? More reliable? More conscientious? As aware and careful about my limitations? I wanted to think so—and perhaps I had to think so to do what I do day to day. But I could not know so. And neither could anyone else.

  Goodman and I went out for a meal together in town and then for a drive. Coming upon his former hospital, gleaming and modern, I asked him if I could have a look around. He didn’t have to come, I said. He had not been inside the building more than two or three times in the previous four years. After a momentary hesitation, he decided to join me. We walked in through the sliding automatic doors and down a polished white hallway. A sunny voice rang out, and I could see that he regretted having come in.

  “Why, Dr. Goodman!” a smiling, matronly, white-haired woman said from behind the information desk. “I haven’t seen you in years. Where have you been?”

  Goodman stopped short. He opened his mouth to answer, but for a long moment nothing came out. “I retired,” he said finally.

  She tilted her head, obviously puzzled: Goodman looked robust and twenty years younger than she was. Then I saw her eyes sharpen as she began to catch on. “Well, I hope you’re enjoying it,” she said, recovering nicely.

  He made an uncomfortable remark about all the fishing he was getting to do. We began to walk away. Then he stopped and spoke to her again. “I’ll be back, though,” he said.

  Part II

  Mystery

  Full Moon Friday the Thirteenth

  Jack Nicklaus would not play a round of golf without three pennies in his pocket. Michael Jordan always had to wear University of North Carolina boxer shorts under his Chicago Bulls uniform. And Duke Ellington would not play a show, or allow his band members to play a show, wearing anything yellow. For people who have to perform for a living, superstitions seem almost de rigueur. Baseball players, for example, are notoriously superstitious. Wade Boggs, the Boston Red Sox’s former star third baseman, famously insisted on eating chicken before every game. Tommy Lasorda, on the other hand, when he was managing the Los Angeles Dodgers, always ate linguine—with either red clam sauce if his team was facing a right-handed pitcher, or white if up against a lefty. Even in this crowd, however, the New York Mets’ pitcher Turk Wendell seems unusual. For luck during games, he used to wear an animal-fang necklace, refuse to wear socks, never step on the foul line, and brush his teeth between innings. When he signed his contract for the 1999 season, he insisted that his salary be $1,200,000.99. “Hey, I just like the number ninety-nine,” he told the press.

  I have yet to know, however, any doctors with such superstitions. Doctors tend to have a fierce commitment to the rational—surgeons especially. For one of the main satisfactions of science, and operating on people in particular, is the success of logical planning and thinking. If there is a credo in practical medicine, it is that the important thing is to be sensible. And we who are in it are usually uncomfortable, if not outright contemptuous, of the mystical. At the most, you might find a surgeon with a favorite pair of operating shoes or a quirky way of dressing a wound after closing up. And even then we are always careful to account for our idiosyncracies with at least a plausible-sounding explanation: “Other shoes aren’t as comfortable,” the surgeon might say, or, “That dressing tape causes blisters” (though no one else seems to have trouble with it). As a rule, you will not find doctors saying that, actually, we just think a thing is unlucky.

  So it struck me as odd to find, one afternoon when I and my fellow surgical residents sat around a table divvying up the next month’s schedule of nights on emergency room duty, that no one was volunteering to take Friday the thirteenth. We were taking turns making picks, and for the first few rounds, everything seemed normal. We left all the Fridays alone, weekend nights not being popular. But as the nights remaining dwindled to just a few, it became apparent that that one Friday was being conspicuously bypassed. C’mon, I thought, this is ridiculous. So when my turn came up again, I put my n
ame down for duty that night. “Rest up,” one resident said. “You’re going to be in for a busy night.” I laughed and dismissed the idea.

  Looking at my calendar a few days later, however, I noticed that the moon would also be full that Friday night. Then someone mentioned that a lunar eclipse would be occurring then, too. And for a moment—only a moment, mind you—I felt my confidence slip. Perhaps I really would be in for a miserable night, I began to think. But being a sober and well-trained doctor, I did not let myself succumb to such thoughts so easily. Surely, I thought, the evidence is against such preposterousness. And then, just to confirm it, I went to the library to check.

  I managed to find exactly one scientific study assessing whether or not luck actually does go bad on Friday the thirteenth. (I’m not sure which is more surprising: that people have in fact researched this question, or that I could only find one such example. This is, after all, a world with studies on almost anything you could think of. Once, poking around the library, I even found a report on how saliva distributes around the mouth when chewing gum.) The 1993 study, published in the British Medical Journal, compared hospital admissions for traffic accidents on a Friday the thirteenth with those on a Friday the sixth in a community outside London. Despite a lower highway traffic volume on the thirteenth than on the sixth, admissions for traffic accident victims increased 52 percent on the thirteenth. “Friday the thirteenth is unlucky for some,” the authors concluded. “Staying at home is recommended.” How you escape the bad luck at home they didn’t explain.

  Still, I told myself, you really can’t make much of one study of one Friday the thirteenth in one town. Random variation could easily have accounted for the increase in crashes. You would need to see consistently bad results across a number of studies to be convinced. And that has yet to be shown.