Life as a doctor

B''H

Dear Readers,

Hanna Rose has been very ill and thus has not been able to place any entries for several months.  Her husband, the "Historian", yours truly, as you can guess (vide infra) is a physician and is taking up her cudgel.  I do not write as well or as easily as she which will result in far less frequent entries. One final note, please pray for her.

Reflections on William Halsted

William Stewart Halsted (1852 – 1922) was, and still is, the most famous American surgeon. He was one of the founding faculty members of Johns Hopkins University, which was consciously set up to be the finest medical institution in the world. Instrumental in pioneering aseptic technique, use of rubber gloves in surgery, wearing surgical garb rather than street clothes, wound healing, vascular surgery, mastectomies, hernia work, and excision of goiters, he was, and is, the father of modern surgical training. Many of the finest physicians of the first half of the 20th century considered him to be their mentor.

For example, William Sidney Thayer said, "In Halsted's little operating room with the old wooden table, the antiseptic technique was so perfect that there was never a moment of anxiety. I could not believe my eyes. It was like stepping into a new world. At this time Halsted's technique was unique, the sureness and perfection of his results seem to me then… The nearest thing to a miracle that it has been given to me to witness."[1]

I commonly joke with my patients that when they see a surgeon "flipping out" on a TV show or in person that that individual is imitating someone, who imitated someone, who imitated Halsted. Dr. Halsted was famously known for withering, biting sarcasm, aloofness, and mean-spiritedness.[2] He almost never complemented anyone and his teaching was abysmal, so much so that his teaching rounds were euphemistically called "shifting dullness"[3]. Finally, he was sequentially and concurrently addicted to both cocaine and morphine, which probably caused his frequent absences from work and, oh by the way, his visit for several months at an insane asylum prior to his appointment at Johns Hopkins. Nevertheless, if I needed an operation in 1895, there is no doubt in my mind that I would have chosen William Stewart Halsted as my surgeon.

Today Dr. Halsted would be called a disruptive, impaired physician. Let alone imagine the type of scores he would get from patients on satisfaction surveys. Thus, perhaps the greatest surgeon in American history would be thrown onto a trash heap. It is difficult to defend Dr. Halsted's behavior but it gives me pause to think how he would be treated today. In On Liberty, John Stuart Mill opines that the society which does not allow for eccentricity will not allow for genius. I ask, have we reached that point?

Alexis de Tocqueville in Democracy in America mourns the passing of an aristocratic society while at the same time praising the development of the new egalitarian one. He states that the "democratic man" will be more moderate and less extreme than the "aristocratic" one. Aristocratic societies produce great men and great scoundrels. Democratic societies, however, will be more pleasing in God's eyes as far more people benefit.

When I started clinical medicine in the early 1980s, there were great many "scoundrels" around. For instance, one intern I knew would sign off all his notes with the military acronym AMF YOYO (Adios Mother F***er You're On Your Own). I saw neurosurgical residents, totally unsupervised, in a county hospital walking around wearing Hawaiian shirts disparaging patients and telling interns how to insert intra-cerebral pressure monitors over the telephone.

On the other hand, I saw a senior physician of remarkable probity, in front of medical students and residents, turn to a junior faculty member, who had refused to come in the night before to see a patient when a nurse begged him, and say, "You're fired". In my medical school class, there was obsequious sycophantic student, gunning for Alpha Omega Alpha[4] and would have made it but for this event, who thought he would get close my favorite professor (a jokester) by calling a patient a SHPOS (Sub-Human Piece Of S***, an acronym from The House of God). The professor promptly took the young man into his office and told him he failed the rotation. The Dean of Students backed the professor to the hilt. Today both of these mentors of mine would be sued and with certainty no Dean would back them up. Some people can be trusted with that sort of power and some cannot. All of us old enough to remember these times can also remember attending physicians (all of them men by the way) who abused such power.

When I try to explain how insane medicine used to be to my junior partners, I tell them to watch the movie M*A*S*H, not the TV show. But the Halstedian era is over. The cowboys and the lunatics are gone forever. Abusive and drug-abusing physicians are not countenanced. But will the truly passionate physician, striving for excellence, be tolerated? In general, over the last 10 years or so of my practice quality of care has markedly improved: more use of evidence-based practice, national standards in pathology and radiology reporting, web-based national guidelines, and better coordination of care. I believe this new model of medicine will probably be of greater benefit to more patients than the old model, missing the highs and lows, being more moderate and safer. It will, however, sparkle less, innovate less, and, perhaps most importantly, be less fun.

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[1] Bliss, Michael William Osler, A life in Medicine (1999)

[2] Ibid.

[3] A physical finding on examining a patient with ascites.
[4] A medical honor society akin to Phi Beta Kappa.