Who You Gonna Call?

 After more than a decade of getting to know the physicians near where I lived and worked, I had finally identified some physicians I could turn to in case of a disaster. I say, ‘disaster,’ because I had long ago decided never to go to a doctor unless I was out of options.  Because I was a physician with hospital privileges, I was required to get a physical examination every year or two to maintain my credentials.  This was an innocuous procedure: my internist would check a few important organs, draw some blood, and make several recommendations.

If she asked whether I planned to take her advice, I always assured her that I would not.  That I was a physician did not make me inclined to follow medical advice. Nonetheless, I spent many years and much effort trying to identify those physicians I could turn to if I was nearly dead, but then I moved to Connecticut. Once again I faced the dreadful task of finding doctors for me and my family that I could trust.

You might ask, “What is the problem? The state licenses doctors only after they demonstrate competence on a variety of written tests. They cannot even take these tests until they complete medical school training.  Even after getting licensed, they need to participate in continuing education to maintain their licenses, and if they get sued a lot, the state keeps track of the actions, thereby alerting you to potential problems. We even have magazines to tell you who are the best doctors and which are the best hospitals. Finding good doctors is a no-brainer.” If only that were true.

The training, testing, affiliations, state registries and even the magazines are all unreliable and uninformative. Start by looking at medical school admissions. Getting into a prestigious school is as often a result of ‘legacy,’ family largesse, or political connections as it is a consequence of academic achievement or original thinking. Legacy refers to the practice of moving to the front of the line relatives (usually children) of those (usually white men) who previously attended the institution. 

I worked at an Ivy League institution that was routinely flooded with applications for a limited number of medical school seats.  A member of the Admissions Committee boasted to me about how ‘equitable’ their system for accepting students was. Simply put, they would identify 200 applicants out of more than 1,000 who appeared ‘qualified’ for the school.  They would interview these 200 and, based on the interview, would identify 100 for enrollment in the school. This all sounded suspiciously even-handed to me, until my colleague noted, “All legacies get an interview.”

This meant that if your father had attended that medical school you would get an interview and had a 50-50 chance of being accepted. An Ivy League school with more than a century of graduates was likely to have nearly 200 legacy applicants. If you had no relative connected to the school, you would be wise to save yourself the cost of postage on your application.

Having achieved entrance to a distinguished institution is no guarantee that you will get an education worth the price of admission.  The teachers have been given offices in the Ivory Towers on the basis of their publications, political positions, or other nonmedical achievements. Isaac Asimov, a biochemist and brilliant science fiction writer, noted that promotions committees might not be able to read, but they certainly knew how to count.

I studied under a physician in England who wrote numerous unoriginal and uninformative ‘scientific’ papers and was rewarded with a department chairmanship and a royal title. I worked at a state-run medical school in a department whose chairman told me explicitly, “We get paid to write papers,” not to teach. Teachers had no future at the school.

Fortunately, much of what is taught in medical school is of little practical importance. Knowledge is acquired more through apprenticeship than through academic exertions, and it is primarily those in training who provide the training. Learning to be a physician was summarized by the motto, “See one, Do one. Teach one. Try not to kill one.” Good physicians are those who want information and who critically assess information. Bad physicians are hard to identify.

After all is said and done, it is best to ask the nurses.  They usually can tell you who is reliable and who is dangerous. The most memorable demonstration of this was my experience with a particular doctor.  He had amazing credentials.  He not only went to a top-ranked college and medical school, but he had a PhD in mathematics and had been accepted into one of the best specialty training programs in America.  When I first dealt with him, he seemed distracted and ill-informed, but I attributed this to originality, rather than stupidity. 

This doctor was on-call for patient emergencies late one night when the nurse working with him called me.  She said I needed to see one of several terminally ill patients on the ward.  Because I valued few things more than my sleep, I told her she needed to contact the doctor to manage whatever the problem was.  She whispered into the phone, “We have had him here several times already.  [The patient] needs you.” One might misconstrue this as a vote of confidence in my competence, but at 3 a.m., it sounded to me like a cry for help.

The patient was dead.  There was no doubt whatever about that. I asked the nurse what was the problem: The patient had a terminal disease and had died. The nurse explained that the doctor had come down to examine the dead man three times and each time declared him to be alive.  She refused to call him again, because his stupidity frightened her. She pointed to the EKGs the doctor had performed to check for signs of life. Despite the patient’s not breathing, not having a pulse, not having a blood pressure and approaching room temperature, the EKG did show a tiny electrical spike 40 times a minute on all of the recordings.  The patient had a cardiac pacemaker. The doctor could not distinguish a heart beat from a battery discharge. Despite his diplomas and distinctions, the doctor completed his training without acquiring any consequential skills and was let loose on an unsuspecting public.

There are many good physicians in America, but there are also many doctors like this in circulation.  Even as a physician I am hard-pressed to distinguish doctors like this from the Albert Schweitzers (a great healer) without spending a night looking over their shoulders. We need a reliable mechanism for identifying doctors like this rather than a system that has physicians identified as distinguished by those who cannot distinguish. First of all, let us ask the nurses which doctors frighten them.

Dr. Lechtenberg is an Easton resident who graduated from Tufts University and Tufts Medical School in Massachusetts and subsequently trained at The Mount Sinai Hospital and Columbia-Presbyterian Medical Center in Manhattan.  He worked as a neurologist at several New York Hospitals, including Kings County and The Long Island College Hospital, while maintaining a private practice, teaching at SUNY Downstate Medical School, and publishing 15 books on a variety of medical topics. He worked in drug development in the USA, as well as in England, Germany, and France.

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