Ronald Dworkin, MD, a Washington, D.C. based anesthesiologist who also teaches political philosophy at George Washington University, entitled his recently published book, “Medical Catastrophe, Confessions of an Anesthesiologist.” Upon seeing the book’s jacket, I hoped the main title didn’t reflect an evaluation of our specialty. In fact, the text doesn’t center on medical or anesthetic catastrophes. The principal issue troubling Dr. Dworkin is the lack of clearly defined roles in today’s medical atmosphere.
The book is a combination of a memoir and a meditation on the dilemmas facing medicine. We read about the author’s education and the challenges faced by previous generations of doctors in his family, namely his father and maternal grandfather. The focus, however, centers on how medical politics makes doctors’ lives difficult, and how that can lead to adverse outcomes.
Doctors today reject the authoritarian or paternalistic physician model, but does that make them too weak to insist on what they know to be right? Does the reluctance to exercise authority lead to passivity in the face of patients not following their directions? “Is the doctor a technician who carries out his patient’s will? Or is he a judge who knows better than his patient?”
How about when challenged by nurses and nurse administrators who feel they know as much or more than the doctors? When “team medicine” leads to conflicts on who should be in charge? “I am not subordinate to you young man,” Dr. Dworkin quotes a nurse administrator telling him. “We’re equal. Don’t forget that.”
Dr. Dworkin discusses how corporate medicine pressures anesthesiologists to get cases started on time at the expense of patient safety. He relates the story of an anesthesiologist who felt that his patient needed more of a cardiac workup before surgery but deferred out of fear of being blamed for a late start. The patient had an MI and almost died.
At times, Dr. Dworkin sees the situation darker than I believe most of us experience. He concludes one chapter with, “A person cannot be a doctor unless he or she can endure being called an ‘asshole’ several times a week.”
A couple of Dr. Dworkin’s case descriptions seem problematic. For example, he faults an anesthesiologist for starting an anesthetic on a patient with a leaking abdominal aortic aneurysm without having the patient’s abdomen prepped and the surgeon poised to cut immediately. However, he doesn’t even comment on the absence of an arterial line.
Dr. Dworkin also tells of his own nightmare situation when he couldn’t ventilate or intubate a patient after having given both Pentothal and succinylcholine, but doesn’t explain why he didn’t try to ventilate after just Pentothal. This was in a patient he felt “might be a little hard to intubate” from the start.
Despite a few such lapses, I found the book to be a timely and thoughtful discussion of dilemmas facing doctors. These include the reluctance of residents to call for help from an attending in a timely manner for fear of being judged insecure or incompetent, and a doctor on call faced with a type of case he hasn’t done in a long time and is no longer comfortable doing.
The doctor model, dating back to the Flexner study, is part scientist, part technician, part benefactor, and part gentleman. Others can fulfill all these roles, often better than a doctor. A technician can become highly proficient at performing a given task. Laboratory scientists can conduct disciplined experiments and philanthropists don’t expect to be paid.
“So what is a doctor?” the author asks. Buffeted between advocates for “patient’s rights,” nurses who desire more authority through “team medicine,” hospital administrators who demand more efficiency, burdensome and senseless bureaucratic rules, and doctors who are unsure of what their role should be, our medical system lacks clear direction. Nobody is in charge and that can lead to catastrophe. Dr. Dworkin concludes that the solution is, “Doctors must become leaders.” He doesn’t mean authoritarian leaders, but people who know how to govern.
I believe that anesthesiologists will find this examination of the problems facing doctors and medicine, from an anesthesiologist’s perspective, to be informative, thoughtful, and thought- provoking.