Practicing Medicine Without a Swagger

Practicing Medicine Without a Swagger

The New York Times, 23 August 2005

It was hard not to feel entitled when working 36 hours straight as a medical resident. By the end of my shift, I found myself interrupting conversations and being rude to co-workers and even patients. After all, I had been up all night.

But it was not only long call nights that allowed physicians to rule the roost. For decades, doctors enjoyed privileges and perquisites that made colleagues alternately envious and furious. But these days, doctors are less likely to be treated like royalty than – egads! – like employees. How are we dealing with this?

Physicians actually enjoyed relatively little power until the early 20th century. Then, a series of scientific discoveries, most notably the germ theory of disease, enhanced what the sociologist Paul Starr called the “cultural authority” of the medical profession. With improved tools like insulin, penicillin and the polio vaccine, the reputation of doctors accelerated further over the coming decades.

As communities and charitable agencies built hospitals, they rewarded their medical staffs. Doctors were given their own parking lots, replete with personalized nameplates. They ate separately in special doctors’ dining rooms. Nurses and other employees parked and ate in regular areas, often alongside the public.

Rewarded in terms of money and prestige, some physicians became vain and arrogant, making extraordinary demands and openly misbehaving. Most notorious were certain surgeons who ran operating rooms like fiefs, screaming at staff members and even throwing surgical instruments to signify their discontent.

Why was such behavior tolerated? To start with, physicians often ran hospitals and thus made exceptions for their peers, especially those who saved lives. Indeed, recalls Dr. Arthur H. Aufses Jr., professor of surgery at the Mount Sinai School of Medicine, people who complained about surgeons were themselves at risk of being fired.

One of the best depictions of surgical bravado occurs in the 1991 film “The Doctor,” in which William Hurt plays Dr. Jack McKee, an arrogant surgeon who eventually develops cancer. In one scene, Mr. Hurt’s character, accompanied by a crowd of overeager residents, brusquely dismisses a chaplain from a patient’s bedside with a shake of his head. The message is clear: the doctor trumps even God.

It was not only surgeons strutting around the hospital halls. Internists and other physicians ignored or made fun of patients who annoyed them, behaviors best depicted in the 1978 novel “The House of God.”

When I was a house officer in the 1980’s, certain residents explicitly modeled themselves after the book’s “Fat Man,” who was less interested in patient care than in giving patients derogatory nicknames and in entertaining his peers.

How and why did things begin to change? For one thing, society changed. By the 1970’s, thanks to the civil rights movement and the Vietnam War, authority figures were under attack.

Physicians were not immune, especially those who had participated in unethical activities, like the infamous Tuskegee syphilis experiment. Suddenly, things like doctors’ parking lots and dining rooms seemed to underscore medicine’s elitist nature.

Women entering the profession also played a crucial role. Men, who constituted a vast majority of physicians, could act out, but women could not.

When Dr. Bonnie L. Bermas, now on the Harvard faculty, was training in the 1980’s, she always felt she had to be on her best behavior, she said. As the percentage of women in medicine grew, fraternitylike behaviors became increasingly unacceptable.

A more humane schedule is also a factor. New regulations have made the 36-hour shift a thing of the past. It is harder for doctors to expect favors when they are working shifts like everyone else.

Most hospital employees, including physicians, believe that the humbling of doctors has been for the best. The “days of the giants” may have been fun, but humanistic patient care has become paramount.

There are still occasional reminders of the past, however. For example, almost everyone involved in clinical care – nurses, social workers and nutritionists – is generally addressed by his or her first name. Yet physicians are still called “Dr. Smith” or “Dr. Jones,” even, I might add, when they ask to be called by their first names.

And there are also the periodic perks. One morning last winter, I stopped by the employee health department to get a flu shot. Because of the earlier shortages, about a dozen employees were waiting ahead of me.

Soon the nurse who was to administer the shots appeared. She had known me since I was a resident. When she spied me, she asked, “Doctor, what are you doing here?”

Waiting for a flu shot, I explained.

“You get in here right now,” she said.

I paused for a moment, nervously glanced around the room, and quietly followed her into her office.

Barron H. Lerner is an associate professor of medicine and public health at Columbia University.

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