Recently, Malcolm Gladwell sat down with Dr. Robert Pearl and his response to Dr. Pearl’s final question took the doctor aback. In response to the question of what subjects Dr. Pearl should cover for Forbes magazine in the future, Mr. Gladwell said, “Help people understand what it is really like to be a physician.”
At first I was underwhelmed by the suggestion, but as I have ruminated on the phrase more, it has taken on several levels of complexity and woven itself in and out of other thoughts and experiences in my mind. And I came to realize that, like many of Mr. Gladwell’s musings, it is a kind of simple genius that goes straight to the heart of the matter. For many of practitioners of medicine, whether we acknowledge it daily or not, it is an “awesome responsibility,” as Dr. Pearl says. For me, that is not pride talking, it is a double-edged sword. In some situations, I feel it is a terrifying honor that is given to us.
In what seems like another life, just before I began medical school, I was speaking with a friend who had just graduated from the same institution as he kindly passed some of his textbooks down to me. One of his pieces of advice that evening has repeatedly returned to my mind because it has been some of the best advice I have ever received. He said simply, “Go easy on your family.” He elaborated, “Unless this is what they also do for a living, they will not understand what it is that you will do every day. They will try very hard to, but they will probably not completely grasp it.” Four years later, after experiences that all medical students share, yet are completely foreign to the vast majority of souls on Earth, I was just beginning to realize how right my friend was.
I recently had the good fortune of attending a lecture by Dr. Gurpreet Dhaliwal. The term, ‘lecture,’ really sells the man short, as it was more a diagnostic tour de force. ‘Goop,’ as he does not mind being called, has grown quite a reputation for being able to think through a case as it is presented to him in real time - cold. He has been called, ‘The Real Dr. House.’ The diagnosis is obligatorily esoteric and the presentation opaque, but Goop has a mesmerizing way of taking each morsel of data and turning it over and around, examining it from every angle to see how it might fit the puzzle. Then, he tosses it into a figurative bin: useful, not useful, or maybe useful. The most impressive part of the process is neither the dizzying breadth of his medical knowledge nor how incredibly organized his process is, but how boldly he categorizes the data and moreover, how boldly he pronounces that the most mundane diagnosis, something on the order of ‘viral syndrome’ is the most likely answer at the early stages of the patient’s presentation. In a world where defensive medicine is the norm, Goop puts common sense first. Common things are common and he unabashedly puts these diagnoses forth as his analysis of the case begins amorphously and has no hesitation sending the patient home. Of course, there are two very important differences with this forum. One, the patient always returns with more perplexing symptoms and two, Goop does not have to face the repercussions of his diagnosis. Forget that he is usually correct. He will probably not be sued whatever the outcome; unless its by one of the audience for being nauseatingly organized while being a darn nice guy as well.
Would that we could practice in this alternate reality. There would be no fretting about the possibility of missing the rare but horrible diagnosis on the first encounter. There would be less self-flagellation over that subtle sign or symptom that portended that horrible diagnosis, when the patient’s outcome was less than optimal. Why do we do this to ourselves? What are the spectres that lurk in the corners of physicians’ minds? Are we haunted by the angry family or their legal counsel? Those certainly come to mind. However, while I can not speak for every practitioner, I would like to think that Dr. Pearl is correct in his assertion that our deepest fear is failing to live up to the trust that is placed in the physician by the patient and family.
Does the nonmedical community know this? I suspect not. And in a world where it must be somebody’s fault and that somebody should pay, there are many elements of the medicolegal community that benefit from society at large remaining ignorant of practitioners’ private angst. Why is it so hard to believe that physicians do really want to make patients better? More perplexing to me is why is it so easy to believe that physicians are greedy, incompetent or just plain malevolent? The answer is, unfortunately, the latter characterizations are likely better rewarded on a wider social level. I guess evil is more interesting than altruism.
“Help people understand what it is really like to be a physician.” The words are straightforward, but the task is going to be difficult, should physicians decide to accept it. I believe it will require more allies like Mr. Gladwell who can win hearts and minds in their particular sectors.
