Our physician had passed the mid-point in his career. He had resisted temptations to finish his career on the comfortable fringes of his field with those who rallied around ‘Not in my practice!’ He considered patient and practice changes -- e.g., better educated patients, group practice, enthusiasm for ‘natural childbirth’, fathers in delivery rooms, female obstetrician-gynecologists -- through the lens of professional excellence and patient dignity. Though no activist or enthusiast on either side of the abortion issue, he sympathized with the view that being unwanted can be worse than never being born. He dreaded more regulation and scrutiny in the wake of ‘Baby Doe’, while questioning a single-factor ‘Is the heart beating?’ criterion for aggressively intervening in cases involving critically ill newborns. He learned to work under the threat of lawsuits.
As age 70 and a third generation of babies approached, his literature seemed to be signaling the time had come to step aside. Articles such as ‘Whither electronic fetal monitoring?’ questioned the technology he had championed. Two lengthy articles about ‘Interpreting the literature in obstetrics and gynecology’ hinted that his generation might not be able to keep up. An article on ‘Retirement patterns of obstetricians and gynecologists’ provided a frame of reference. In carefully chosen conversations, he admitted, “It’s not fun anymore”. ‘Private practice’ had become an anachronism. He was exhausted. He retired in 1991 . . . almost. He continues to staff a uro-gynecology clinic with residents one day each week. I asked him what he thought about today’s residents. He said cautiously, “I’m encouraged”.
Commentary
1991. If 1951-1971 warranted images of modern medicine such as ‘explosion’ and ‘expansion’, 1971-1991 requires a word such as ‘constriction’. Physicians have become ‘providers’, ‘expert witnesses’, ‘gate-keepers’. Physicians’ discretionary space in clinical decisions has shrunk. ‘Managed care’ has put physicians in a position with patients uncomfortably analogous to real estate agents who represent the seller as they work with potential buyers. HIV infection has ended the assumption -- widespread since the introduction of penicillin -- that medicine is a risk-free profession. The consequences of changing the delivery of health care to extend access and contain cost are yet to be determined. It seems safe to conclude that maintaining integrity between patients and physicians is not getting easier.
And ‘ethics’? During the early ‘70s, ‘bioethics’ emerged within the medical sphere as a discipline of study in search of a voice in a conversation already underway. With patient confidence in physicians eroding, the first generation of bioethicists made its most noticeable contribution by providing justification for placing patient autonomy as the cornerstone in medical decision-making.
It is encouraging to see that the subjects of values and virtue have now reentered medical and ethical literature. More is being heard of casuistic reasoning and attention to the ethical significance of patient histories. We are recognizing that reducing decisions to patient self-determination missed the complexity of hard clinical choices and offered little guidance for public health concerns. ACOG’s Ethics Committee is carefully crafting revisions of earlier statements on such subjects as informed consent, physician responsibilities in an era of HIV epidemic, and end-of-life decision-making.
And so we are left to ask, “Can medical students and residents be taught how to be with patients?” I think the answer is ‘yes’ if the question has to do with what is sometimes called ‘minimalist ethics’ -- i.e., where what ought to be done is equivalent to what by law has to be done. I think the answer is ‘yes’ if the question has to do with communication skills or recognizing varying points of view. I think the answer is ‘no’ if the question has to do with ‘ethos’ -- i.e., with integrity, with character, with virtue, with vision. But I must quickly add that ‘ethos’ can be identified, protected, nurtured, recovered, encouraged, healed, prompted, matured in the medical education/practice settings. The ‘ethics’ that transcends a minimalist threshold essentially derives from and is clarified by one’s defining life experiences.
To illustrate: If the obstetrician-gynecologist whose professional career we have profiled today were asked to account for his consistent and impassioned advocacy of doing what is best for the patient, he would at some point contrast his participation in the indignities and death of battle during World War II with his participation in bringing healthy life into the world as an obstetrician.
To illustrate: Another physician (with whom I have worked closely) began a pediatric practice in 1954 but, a dozen years later, devoted his full attention to disadvantaged inner-city critically-ill newborns who were dying two-to-three times as often as advantaged suburban critically-ill newborns. When asked at an award ceremony to account for his resolve, he said simply, “My grandfather’s toes” and then went on to recount how each evening as a young boy he would meet his Yiddish
grandfather -- a 1901 immigrant to New York’s Lower East Side from Czarist Russia -- in front of the dining room buffet. With unequal strides, the two made their way to the living room where the weary blacksmith settled down in his chair. The stocky, spectacled lad would begin his nightly ritual of unwinding the laces from around the hooks on his grandfather's work boots. Pulling off the boots and socks, he would run his fingers over each foot's single chunk of nailless flesh that had once been separate toes and prod his grandfather to recall the painful memories always just a thought away: “Papa, tell me again. What happened to your toes.” “Son, Cossacks chased me. I hid in the forest for a long time. My toes froze off in my shoes.”
To illustrate: I spoke recently with one of our third-year Ob/Gyn residents at LSU about the explanation he had given in his residency application’s ‘personal statement’ for becoming a physician. After getting past the shock that someone had actually read his ‘personal statement’, he remembered clearly what he had written: “Open the door, please! Get out of the way! We need to see the doctor right away!” Curious to find out what was happening, I -- only six-years-old at the time -- rushed down to my father’s office as the metal door was dragged open to reveal a haggard, panic-stricken man carrying a lady in her mid-sixties. She was pale and almost lifeless. My father quickly stepped out to greet them and immediately started to take her pulse. “How is she, doctor? How is my mother?” the young man asked anxiously. “Don’t worry. She will be fine. We need to get her to the hospital. I will come with you.” As soon as my father spoke, I could see a change in the man’s expression, from panic and insecurity to calm and trust. I can never forget the relief on that man’s face as his terror resolved in response to my father’s words. Simply by being calm and decisive, my father was able to ease his suffering. I remember telling myself that day, “I want to help people the way my father is doing.”
Concluding Remarks
In a few minutes or hours, we will each be back in our niches within the vast health care sphere. I hope our time together has encouraged each of us to ask again – “Can there be integrity between patients and physicians? between patients and physicians who are strangers? who approach each other with suspicion? who need each other but will never know each other? who are assigned to each other?” Those are the most common -- and, I would argue, the toughest -- ethical questions facing today’s clinician. The reflections I have shared with you today can be reduced to three core propositions.
- The central ethical issue facing clinicians is how a patient and a physician form a relationship and how they actually relate to/with each other in the delivery of care. Multiple specific issues either are ways into this central issue (e.g., informed consent, confidentiality, patient self-determination) or are ‘outside’ issues that add complexity to this central issue (e.g., allocation of limited resources, HMO expectations/regulations, third-party disclosure).
- Patients and physicians embody the peculiarities of their time and place. However, in every time and place, ‘respect’, ‘trust’, and ‘gentleness’ sustain patient-physician relationships that retain the humaneness without which medicine ceases to be an art or a profession.
- Various metaphors make vivid the ways physicians relate to patients (e.g., healer, counselor, advocate, friend, mechanic, provider, stranger, entrepreneur, adversary). Physicians would do well to view themselves essentially as guests in their patients’ life-stories. A guest enters another’s space with a grateful disposition, expresses respectful interest, departs gracefully.
Thank you for your attention. And thank you, Dr. Wall, for your enduring example.