Dilemmas for Doctors

In the November 5 issue of The New York Review, Dr. Jerome Groopman wrote about his experiences observing interns and residents at Massachusetts General Hospital and the way that new technologies and practices have affected the work of young doctors. He recently talked about the subject with Andrew Martin of The New York Review.^*

AM: In your review, you wrote about leading a clinical conference at Massachusetts General Hospital, thirty-three years after training there yourself. Could you give a picture of what your experience as an intern there was like when you first began?

JG: It was a very jarring experience to begin as an intern. As it happened, I was on call the first night of my first day as an intern, and in those days, you were supposed to be an iron man, meaning that you were on call alone and you were actually discouraged from asking for backup from a more senior resident.

Everything seemed to be under control, and then in the late evening, a middle-aged man whom I was talking to, just getting a social history, sat bolt upright in bed. His chest started to heave and he was gasping for air. I had been a high-achieving medical student. I had gotten good grades in all my courses. I had thought I was prepared and I completely froze. My mind just went blank. I gave myself an F. And almost deus ex machina, there was a cardiologist who had trained at Mass General years before who was strolling through the wards in some sort of memory lane experience.

And he saw me there, and he saw this man in bed, gasping for air. And he walked up behind me, introduced himself, took the stethoscope out of my pocket, listened to the man’s chest, and said, “He just ruptured his aortic valve and he needs to go for open heart surgery immediately.” And so then I was unglued, rushed to the nurse’s station, and fortunately, the man’s life was saved.

AM: Is there more of an attempt now, do you think, to give young trainees more backup or give them more of a sense of community?

JG: That kind of macho, you know, you’re on alone, hold the fort, baptism by fire, all of those clichés are really quite counterproductive and, frankly, dangerous. And it’s very, very different now. There’s much more backup, much more encouragement at every major teaching hospital to have green interns feel completely comfortable and ready to ask for help when it’s needed.

AM: You mentioned in your article the sleep deprivation being a significant factor in the lives of medical students. There have been attempts to cut down on that. But is that still a major factor in the practice?

JG: Well, there are very strict rules now around length of shift from the point of view of safety. There are a lot of data showing that the more exhausted you are, the more you’re apt not only to make mistakes, but also not to realize that you may have made a mistake. They’ve actually done pilot testing giving residents in the hospital a cardiogram to interpret at the beginning of the shift, in the middle part of the shift, and then after being up all night long. It’s clear that they miss many more important findings on the cardiogram the more tired they become. But when they’re asked to evaluate themselves, they actually feel more confident that they found all of the important abnormalities on the cardiogram. Then there were the effects of the Libby Zion case in New York—when an eighteen-year-old patient died at New York Hospital. The full story has been debated, but many believed that the intern assigned to the case was exhausted and didn’t have enough backup and time to attend to her, and she’d had an unnecessary death.

That led to a major national overhaul. The unintended consequence, I wrote in my piece, is that with this rapid turnover of personnel, there’s a risk that when you’re giving information repeatedly to new staff, there’s the tendency to cut corners and important data are not transmitted. Also, the experience of the trainee is that you don’t really get to see, for example, what happens through the evolution of a heart attack.

So if a patient comes in in the midst of a heart attack and you stabilize him, there’s a lot of important learning that goes on in attending to them over the course of many hours. And you don’t do that anymore because you’re obligated to stop your shift.

AM: So what do you think is the best way to reconcile these two necessities?

JG: Well, I think that the best way to reconcile safety with education is to allow the trainee to be present, but not in charge. The difficulty with this, of course, in an era of cost containment is that you potentially have to hire more trainees.

And also, you need to readjust the schedule to make sure that if someone, say, wants to spend an extra three or four hours to really gain the full clinical experience of caring for someone through the evolution of a heart attack, that person can still get enough rest to come on and be fresh and ready. So I think that there needs to be more flexibility and creativity than what exists now, which is very, very rigid.

AM: You mentioned that a physician’s productivity is now often measured by how much money they generate for their department. I’m wondering if you can talk about that and maybe discuss some ways that we can lessen the influence of the monetary metric.

JG: I think it’s a very dangerous change in the culture of medicine. Clearly, everyone understands that there are sky-rocketing health care costs, and there needs to be containment. But there’s quite a bit of research in the psychological literature that shows that if you persistently pester people about money, they begin to act in a very selfish and uncooperative way, which is antithetical to the spirit of medicine with regard to working as a team with other physicians and nurses, and also, frankly, with regard to the principle of extending yourself to families and patients who are in need.

The entire compassionate dimension of medicine, which is really key to the profession and which is so gratifying—all of that is threatened, severely threatened, if not erased, when you are put into an environment where you are constantly hectored around money and efficiency and making sure that time is minimized with patients in delivering care, in order to maximize revenue.

And I believe that there’s a lot of lip service that comes from all quarters about humanism in medicine, compassion in medicine, that doctors are healers, and so on. But such sentiments are contradicted if you look at all of the proposals for reform now being made in the United States, and particularly what we’ve already experienced in Massachusetts, where there fortunately has been universal coverage, but no intelligent way to restructure payments.

The hardest-hit hospitals and clinics are those that care for the very poor. In fact, the state is being sued by such care organizations because of cutbacks in payments for the indigent, while other hospitals can shift costs and charge more for those with private insurance. I have a managed-care insurance plan, and the premiums have risen sharply since the introduction of universal coverage because there has been no serious cost containment to date.

There may be a critical moment in the history of medicine when doctors will become so focused on money, and will come to see themselves as shift workers, that the humanistic, compassionate dimension will be lost.

AM: Do you have a sense of what can be done in the near term to fix that?

JG: If you look at other countries, even though they’re also struggling with cost containment, there is a wide gulf between the methods used in the US and the ways that foreign insurers pay hospitals and doctors, as well as in the actual practice and functioning of medicine. There are set budgets in those countries, and there is much less motivation to game the system, which is what’s going on now.

And that gaming—by which doctors and hospitals have a huge volume of patients come through in a minimal amount of time in order to maximize revenue—doesn’t go on when you have a different payment system, which they have in European countries. And there are many, many models in countries with more or less centralized governmental control ranging from Switzerland and the Netherlands, which are more capitalistic, to France, which is in the middle, and Britain, which is more socialistic. But in all of these, we have examples where costs can be contained, while the practice and the profession of medicine are well preserved.

AM: You talk about the reliance on clinical guidelines and the practice of evidence-based medicine. I was wondering about whether evidence-based medicine contributes to the monetary practice you’ve described.

JG: Well, there are important reasons for having a scientific statistical analysis of evidence. I’m a scientist. I’m a professor at Harvard. I’ve done the clinical trials in my own field that have led to such “evidence.” But I’m also acutely aware of their limitations. Statistical analysis is not a substitute for thinking. Unfortunately, to my mind, because I voted for President Obama and certainly support many of the current reform efforts, there is a very powerful group with an ideology emphasizing evidence-based medicine, what they call “best practices.” That is a wonderful term, because how can you argue with best practices?

But if you look at some of the bills, like the House bill, HR3200, and you look at many of the incentives in the Baucus bill from the Senate Finance Committee, they clearly want doctors not to think and lead, but to simply follow. And the incentives are that you are paid more by adhering to specific guidelines, and, according to some proposals, your malpractice liability will be tied to whether you follow guidelines or not.

Now many times, there are patients whose illnesses don’t conform to the direction of guidelines. Many people do not realize that in general the committees that draw up clinical guidelines force a consensus, and there are often experts who disagree with some aspects of the guidelines or contend that they are flawed. There are numerous examples of this that are familiar to the public. One was the treatment of nearly all women after menopause with estrogen to prevent heart disease and dementia. We now know that the case for such treatment is far from clear and some credible experts had doubts about it from the start. A recent analysis of more than a hundred evidence-based conclusions about clinical practice reported that after two years more than a quarter of the conclusions were contradicted by new data, and that nearly half of the “best practices” were overturned at five years. This shows that guidelines are not gospel from a scientific point of view. Also, patients have different goals with respect to how much treatment they want, what kind of treatment, and, frankly, how much they are willing to comply with prescribed treatment. And you are punished in this system if your patients don’t comply.

And so what’s happened in Massachusetts is that patients who are in the most need of a caring and communicative doctor, patients who are confused about their treatment, patients who are resistant, patients who don’t like to take pills, diabetics who are too poor to eat healthy food—all of these patients now may be shunned by physicians because of the risk that you’re going to look bad on a report card. I just learned of an older woman who was very fragile and in the midst of heart attack whose cardiologist hesitated to perform a necessary procedure to open the coronary arteries because her outcome might well be poor, and this could be counted against him in assessing his performance. These are the unintended consequences of much of the movement for what is called “pay-for-performance.”

AM: You mentioned malpractice, and there has been much discussion about the need for malpractice reform. How do you see that functioning in any kind of health care reform? Do you think that’s an essential element?

JG: There clearly should be tort reform. And what’s been proposed, what President Obama proposed at his meeting with the American Medical Association, I think is misguided. Again, he said if you follow guidelines, then you’ll have protection. What happens when the guidelines are shown to be wrong? Or there are dissenting experts who contest the guidelines, or the guidelines are not clearly applicable to the individual patient but are broadly mandated by the government? It is difficult to imagine guidelines protecting the physician from frivolous lawsuits. And the fact is there are frivolous lawsuits. And many physicians do practice defensive medicine and order unnecessary tests to protect themselves.

Still, there are egregious cases of negligence and malpractice in which injured parties should have the right to redress. So there’s a middle ground between the right and the left here, which is to have cases arbitrated, first, by an expert tribunal of neutral, independent people, rather than to make the complaint into a jury trial. Because it’s very easy for tort attorneys to manipulate juries.

On the other hand, I don’t believe there necessarily should be limits on the amounts of damages if someone has really had his or her life ruined because of negligence.

AM: You wrote about the Victorian English surgeon William Arbuthnot Lane, who gained renown with his thesis that people would live longer and be healthier if they had their colons removed. Are there recent medical treatments that you fear we’ll look back on with similar horror or regret?

JG: Yes. There are a number of surgeries that are not proven to be beneficial. In fact, they have been shown to be no better than placebo. There are two very large studies now that are fascinating for people like myself who are in their fifties, were once very athletic, and whose knees are starting to ache.

If you do an MRI on an aging athlete like myself, you’re going to see all sorts of changes in the cartilage, and there will be a fair amount of discomfort from the knees. A very common problem. And there is a procedure that is done hundreds of thousands of times every year in the United States where orthopedic surgeons put in something called an arthroscope, and they snip little pieces of frayed cartilage, and they wash out the knee joint, and then people report that they have much less pain and much greater mobility.

Well, there are studies that have been done, extraordinary studies, where half of the patients were taken to the operating room and the surgeon and the nurses mimed doing the arthroscopic clean-out of the knee. They made little cuts on the side of the knee with the patient, of course, partially anesthetized. They sloshed water around so it sounded as though there was water going through the knee. They talked as though they were doing the procedure, but it was a sham. And it turned out that equal numbers of patients report marked decrease in pain and marked improvement in mobility with the sham procedure compared to the real procedure.

AM: That’s astonishing.

JG: But studies are very encouraging that show when you give patients these results most opt not to have the procedure. That is the basis of fully informed decision-making. It shows you the power of the placebo effect. Another major issue is that devices in the United States can be approved by the FDA without showing clear benefit to patients. They just have to show safety. Drugs have to show both benefit and safety. So for example, with regard to back pain and collapsed vertebrae, there was a recent study inTheNew England Journal of Medicine that showed that the use of an expandable disk, called a vertebroplasty, which is inserted to expand and support the partially collapsed vertebrae in your back, is no better than placebo.

So I think we will look back on many of these kinds of procedures that are very popular, and realize that there was a placebo effect at work that accounted for the apparent reports from patients of benefit.

AM: You write about the importance of the symbolism and meaning attached to a patient’s illness. I was wondering how keeping sight of those kinds of concepts can help a doctor in his treatment of a patient.

JG: I think it’s important that a physician try to understand the experience of illness as best as he or she can. It’s clear in certain necessary but difficult and disfiguring surgeries like mastectomy. There are patients who experience gastrointestinal disease, colitis, inflammatory bowel disease. And these are sensitive and often highly symbolic parts of our bodies. It’s incumbent upon a doctor who cares for patients dealing with maladies that affect these organs that have resonance with us on a symbolic level to probe and to try to understand the experience of the patient.

And it varies. Some patients may see malfunction in such parts of the body in a highly charged way, and others may not. And in making decisions in trying to help the person make choices that potentially could be life-saving, you want to be sure that you have as much insight as you can into how the person thinks about his or her body and how those thoughts and feelings factor into their preferences.

It’s a lot more than what you would find in some algorithm or guideline that says, well, if you have this tumor, this is what you do. If you have this inflammation in the bowel, this is what you do. That is not enough.