On the notion that doctors are not God

On the notion that doctors are not God

Memo From the Editor

By Jeff Forster, Editor

In The Wizard of Oz, when Dorothy discovers that the Wizard issimply a timid old soul hiding behind a curtain, she scolds, "You'rea very bad man!"

"Oh no, my dear," he corrects her. "I'm a very good man.I'm just a very bad wizard."

Doctors, too, often think they need to be--or that they're expected tobe--wizards. But, from my own vantage point as a "covered life"(aka "patient"), you don't have to be a whiz of a wizard to bea good, caring, effective doctor.

One physician who's thought a lot about this conundrum is William B.Elderbrock, of Kingsport, TN. After more than 35 years in rural generalpractice and another five years of teaching family practice residents, he'sretired and pursuing new goals, such as reading the Modern Library's top100 novels of the century. (He's up to No. 61, and he started with "Ulysses"!)"Many of the problems of the present-day physician," he says,"stem from the belief that doctors must be perfect and make no mistakes,and that if they do commit an error, they must be punished. Doctors arehuman, and must face up to their mistakes. I also feel strongly that theyneed to discuss those mistakes freely with their peers or with someone theycan trust."

Marshall B. Kapp, an attorney and health researcher, has also exploredthis dimension of the doctor's psyche. "Most physicians are much worsethan judges or juries in distinguishing between honest misjudgments andnegligent errors," he wrote in the Journal of General Internal Medicine,"often confusing blameworthy deviation from acceptable professionalstandards [with] blameless misfortune or bad luck. Even in circumstancesin which they would not be found legally liable, physicians often stillpicture themselves as lifeguards upon whose shift no one should be allowedto drown." *

Doctors often hold themselves to an impossibly high standard, and theyloathe the notion of being wrong, even when the consequences are not dire.I think about my recent visit to a dermatologist (yes, I obtained a properreferral), who said he was "99 percent sure" that the red lesionon the side of my nose was a basal cell carcinoma. He was so sure of itthat, when the first scraping came back negative, he called me in for asecond, deeper cut. In the meantime, he set a tentative date for Mohs' surgeryand shared some wonderfully graphic color brochures on the technique.

The second scraping was just as negative as the first. So this doctorwas wrong, and my nose was sore--but not out of joint. He'd been meticulousin his approach. He'd explained the reasons behind his thinking and slicing.And he hadn't charged for the second slice.

It's okay not to be perfect, and it's okay to understand that the pathwayyou choose won't always lead to the outcome you expect. We'll soon be publishingan account by a doctor who only thought she knew what was best for a patientrendered quadriplegic by a gunshot wound. Look for her article, "Myhardest lesson: I'm just a doctor" in our Sept. 20 issue.

Another doctor, Max Burger (Below), a family physician in Medford, NJ,recalls a case in which "my best judgment and intentions were overwhelmed"and the experience that helped him put things in perspective:

"A young mother suffered from Budd-Chiari syndrome, an idiopathicthrombosis of the hepatic vein that causes liver damage and portal hypertension.She had a shunt that required ongoing anticoagulant therapy. It had to bemonitored regularly, but she didn't always come in for her prothrombin timeor even keep her other appointments. She was clearly a high-risk patient.Then she became pregnant.

This woman had a 3-year-old son and was utterly devoted to him. Whenshe came to me for advice on what to do about this second pregnancy, I calledher obstetrician. He was as concerned about getting her through the pregnancyas I was. He referred her to her hepatologist, who felt that, on heparin,she would have a decent chance of making it through the pregnancy. But Iwas concerned about the fetus and the Coumadin she had been taking duringearly gestation, so I referred her to a neonatologist. The neonatologisttold her there was a good risk of abnormalities to the fetus because ofthe medication she'd been taking.

We all emphasized to her that this would be a difficult pregnancy atbest, and that she was as much at risk of a bad outcome as her unborn child.I recommended an abortion, which she considered. But she was a religiouswoman, and her husband shared her faith. She decided to go through withthe pregnancy.

The outcome was better than any of us could have imagined. She was compliantwith the self-administered heparin, got through without any major complications,and delivered a healthy baby. With all the information at hand, the heart--notthe head--decided. It makes me remember that I am merely a guide in people'slives, and I am humbled. "

That story echoes a thought expressed almost 75 years ago by Sir WilliamOsler, a man of some stature in medicine: "Nothing in life is morewonderful than faith--the one great moving force which we can neither weighin the balance nor test in the crucible."

Amen.

*"Legal anxieties and medical mistakes," Journal of GeneralInternal Medicine, Dec. 1997, pp 787-788.

James Hendricks, ed. Jeff Forster. On the notion that doctors are not God. Medical Economics 1999;16:6.