Authors: Atul Gawande
The anthropologist Lawrence Cohen describes conferences and conventions not so much as scholarly goings-on but as carnivals—“colossal events where academic proceedings are overshadowed by professional politics, ritual enactments of disciplinary boundaries, sexual liminality, tourism and trade, personal and national rivalries, the care and feeding of professional kinship, and the sheer enormity of discourse.” Certainly, in surgery, this seems apt. It did not take long here to realize that some had come just to be seen, others to make their name, still others for the spectacle of it all. There were battles for office (a new president and board of governors were elected) and muckety-mucks meeting behind closed doors. There were residency reunions. There were nights out at Spago and no doubt some love affairs, too.
Yet, true as all of this was, one still had the sense that the draw was deeper than mere carnival. You could see it, for example, on the bus. Every day we surgeons rode back and forth between the convention center and our hotels in fleets of long tour buses. (They were like the ones Greyhound runs to Atlantic City, except ours had drop-down mini-televisions running ads for the “Surgical Zipper.”) We were by and large strangers—I never knew anyone on those bus rides—but if you had watched us, it wouldn’t have seemed that way. Consider the simple matter of seating. Normally, people boarding a bus, plane, or train distribute themselves like repelling magnets, keeping a respectful, anonymous distance from one another and sharing seats only if they have to. But embarking our buses, we found ourselves choosing to sit two-by-two, even as other seats were empty. Somehow, without anyone saying so, the social rules had been inverted. On any other bus in Chicago, you would have felt almost physically threatened by a stranger sidling up to you when three-quarters of the seats sat empty. Here, however, it would have been the person who set himself apart who provoked the most unease. You were, you felt, among your tribe—connected though knowing no one. You felt the need to say hello. Indeed, it seemed impolite not to do so.
On one shuttle ride, I sat down next to a forty-something-looking man in a blazer and open-collared shirt. We started talking almost immediately. He was, I learned, from a town of thirty-five hundred on the northernmost tip of Michigan’s lower peninsula, where he was one of only two general surgeons for fifty miles. Together he and his partner handled everything: pickup-truck crashes, perforated ulcers, appendectomies, colon cancers, breast cancers, even the occasional emergency childbirth. He’d been there for some two decades, he said, and like my parents was a native of India. I was impressed that he had learned to tolerate the winters. I told him of how, almost thirty years before, my parents had narrowed their choices of where to take up practice to either Athens, Ohio, or Hancock, Michigan, in the upper peninsula. Arriving in Hancock by
prop plane for a mid-November visit, however, they found three feet of snow already on the ground. Stepping out in her sari, my mother nixed the place immediately and chose Athens, though she had yet to visit it. My seatmate burst out laughing and then said what all deep northerners say about the bitter cold, “Oh, it’s really not so bad.” Our conversation drifted from weather to our children to my residency to his residency to a piece of laparoscopic equipment he had seen and was thinking of buying. In the seats around us, it was much the same. Bright chatter filled the bus. There were people arguing about baseball (the Mets-Yankees Subway Series was on), politics (Gore versus Bush), and the morale of surgeons (up versus down). On shuttle rides that week, I traded trauma stories with a general surgeon from Sleepy Eye, Minnesota, learned about Chinese hospitals from a British-accented vascular surgeon from Hong Kong, discussed autopsies with the University of Virginia’s chairman of surgery, and got movie recommendations from a Cleveland surgical resident.
This is, I suppose, what the public relations professionals would call networking. But the word misses the essential hungriness of the doctors on those buses, and throughout the convention, for contact and belonging. We may have each had good practical reasons for coming here: the new ideas, the stuff to learn, the gizmos to try, the chasing of status, the break from the grind of unending responsibilities. But in the end, I came to think, there was also something more vital and, in a certain way, poignant drawing us in.
Doctors belong to an insular world—one of hemorrhages and lab tests and people sliced open. We are for the moment the healthy few who live among the sick. And it is easy to become alien to the experiences and sometimes the values of the rest of civilization. Ours is a world even our families do not grasp. This is, in certain respects, the experience of athletes and soldiers and professional musicians. Unlike them, however, we are not only removed, we are also alone. Once residency is over and you’ve settled in Sleepy Eye or the northern peninsula of Michigan or, for that matter, Manhattan, the slew
of patients and isolation of practice take you away from anyone who really knows what it is like to cut a stomach cancer from a patient or lose her to a pneumonia afterward or answer the family’s accusing questions or fight with insurers to get paid.
Once a year, however, there is a place full of people who do know. They are everywhere you look. They come and sit right next to you. The organizers call the convention its annual “Congress of Surgeons,” and the words seem apt. We are, for a few days, with all the pluses and minuses it implies, our own nation of doctors.
H
ank Goodman is a former orthopedic surgeon. He is fifty-six years old and stands six feet one, with thick, tousled brown hair and outsize hands that you can easily imagine snapping a knee back into place. He is calm and confident, a man used to fixing bone. At one time, before his license was taken away, he was a highly respected and sought-after surgeon. “He could do some of the best, most brilliant work around,” one of his orthopedic partners told me. When other doctors needed an orthopedist for family and friends, they called on him. For more than a decade, Goodman was among the busiest surgeons in his state. But somewhere along the way things started to go wrong. He began to cut corners, became sloppy. Patients were hurt, some terribly. Colleagues who had once admired him grew appalled. It was years, however, before he was stopped.
When people talk about bad doctors, they usually talk about the monsters. We hear about doctors like Harold Shipman, the physician from the North of England who was convicted of murdering fifteen patients with lethal doses of narcotics and is suspected of killing some three hundred in all. Or John Ronald Brown, a San Diego surgeon who, working without a license, bungled a series of sex-change operations and amputated the left leg of a perfectly healthy man,
who then died of gangrene. Or James Burt, a notorious Ohio gynecologist who subjected hundreds of women, often after they had been anesthetized for other procedures, to a bizarre, disfiguring operation involving clitoral circumcision and vaginal “reshaping,” which he called the Surgery of Love.
But the problem of bad doctors isn’t the problem of these frightening aberrations. It is the problem of what you might call everyday bad doctors, doctors like Hank Goodman. In medicine, we all come to know such physicians: the illustrious cardiologist who has slowly gone senile and won’t retire; the long-respected obstetrician with a drinking habit; the surgeon who has somehow lost his touch. On the one hand, strong evidence indicates that mistakes are not made primarily by this minority of doctors. Errors are too common and widespread to be explained so simply. On the other hand, problem doctors do exist. Even good doctors can go bad, and when they do, colleagues tend to be almost entirely unequipped to do anything about them.
Goodman and I talked over the course of a year. He sounded as baffled as anyone by what had become of him, but he agreed to tell his story so that others could learn from his experience. He even put me in touch with former colleagues and patients. His only request was that I not use his real name.
One case began on a hot August day in 1991. Goodman was at the hospital—a tentacled, modern, floodlit complex, with a towering red-brick building in the middle and many smaller facilities fanning out from it, all fed by an extensive network of outlying clinics and a nearby medical school. Situated off a long corridor on the ground floor of the main building were the operating rooms, with their white-tiled, wide-open spaces, the patients laid out, each under a canopy of lights, and teams of blue-clad people going about their business. In one of these rooms, Goodman finished an operation, pulled off his gown, and went over to a wall phone to respond to his messages while waiting for the room to be cleaned. One was from his
physician assistant, at the office, half a block away. He wanted to talk to Goodman about Mrs. D.
Mrs. D was twenty-eight years old, a mother of two, and the wife of the business manager of a local auto-body shop. She had originally come to Goodman about a painless but persistent fluid swelling on her knee. He had advised surgery, and she had agreed to it. The week before, he had done an operation to remove the fluid. But now, the assistant reported, she was back; she felt feverish and ill, and her knee was intolerably painful. On examination, he told Goodman, the knee was red, hot, and tender. When he put a needle into the joint, foul-smelling pus came out. What should he do?
It was clear from this description that the woman was suffering from a disastrous infection, that she had to have the knee opened and drained as soon as possible. But Goodman was busy, and he never considered the idea. He didn’t bring her into the hospital. He didn’t go to see her. He didn’t even have a colleague see her. Send her out on oral antibiotics, he said. The assistant expressed some doubt, to which Goodman responded, “Ah, she’s just a whiner.”
A week later, the patient came back, and Goodman finally drained her knee. But it was too late. The infection had consumed the cartilage. Her entire joint was destroyed. Later, she saw another orthopedist, but all he could do was fuse her knee solid to stop the constant pain of bone rubbing against bone.
When I spoke to her, she sounded remarkably philosophical. “I’ve adapted,” she told me. With a solid knee, though, she said she can’t run, can’t bend down to pick up a child. She took several falls down the stairs of her split-level home, and she and her family had to move to a ranch-style house for safety’s sake. She cannot sit on airplanes. In movie theaters, she has to sit sidewise on an aisle. Not long ago, she went to see a doctor about getting an artificial knee, but she was told that, because of the previous damage, it couldn’t safely be done.
Every physician is capable of making a dumb, cavalier decision like Goodman’s, but in his last few years of practice he made them
over and over again. In one case, he put the wrong-size screw into a patient’s broken ankle, and didn’t notice that the screw had gone in too deep. When the patient complained of pain, Goodman refused to admit that anything needed to be done. In a similar case, he put a wrong-size screw into a broken elbow. The patient came back when the screw head had eroded through the skin. Goodman could easily have cut the screw to size, but he did nothing.
Another case involved an elderly man who’d come in with a broken hip. It looked as if he would need only a few pins to repair the fracture. In the operating room, however, the hip wouldn’t come together properly. Goodman told me that he should have changed course and done a total hip replacement. But it had already been a strenuous day, and he couldn’t endure the prospect of a longer operation. He made do with pins. The hip later fell apart and became infected. Each time the man came in, Goodman insisted there was nothing to be done. In time, the bone almost completely dissolved. Finally, the patient went to one of Goodman’s colleagues for a second opinion. The colleague was horrified by what he found. “He ignored this patient’s pleas for help,” the surgeon told me. “He just wouldn’t do anything. He literally wouldn’t bring the patient into the hospital. He ignored the obvious on X rays. He could have killed this guy the way things were going.”
For the last several years that Goodman was in practice, he was the defendant in a stream of malpractice suits, each of which he settled as quickly as he could. His botched cases became a staple of his department’s Morbidity and Mortality conferences.
Sitting with him over breakfast in a corner of a downtown restaurant, I asked him how all this could have happened. Words seemed to elude him. “I don’t know,” he said faintly.
Goodman grew up in a small northwestern town, the second child of five in an electrical contractor’s family, and neither he nor anyone else ever imagined that he might become a doctor. In college, a local state university, he was at first an aimless, mediocre
student. Then one night he was up late drinking coffee, smoking cigarettes, and taking notes for a paper on a Henry James novel when it came to him: “I said to myself, You know, ‘I think I’ll go into medicine.’ ” It was not exactly an inspiration, he said. “I just came to a decision without much foundation I could ever see.” A minister once told him that it sounded “more like a call than I ever got.”
Goodman became a dedicated student, got into an excellent medical school, and headed for a career in surgery after graduation. After completing military duty as a general medical officer in the Air Force, he was accepted into one of the top orthopedics-residency programs in the country. He found the work deeply satisfying, despite the gruelling hours. He was good at it. People came in with intensely painful, disabling conditions—dislocated joints, fractured hips, limbs, spines—and he fixed them. “Those were the four best years of my life,” he said. Afterward, he did some subspecialty training in hand surgery, and when he finished, in 1978, he had a wide range of choices for work. He ended up back in the Northwest, where he would spend the next fifteen years.
“When he came to the clinic here, we had three older, rusty and crusty orthopedic surgeons,” a pediatrics colleague of his told me. “They were out of date and out of touch, and they weren’t very nice to people. Then here comes this fellow, who’s a sweetheart of a guy, more up to date, and he doesn’t say no to anybody. You call him at eight o’clock at night with a kid who needs his hip tapped because of infection, and he’ll come in and do it—and he’s not even the one on call.” He won a teaching award from his medical students. He attracted a phenomenal amount of business. He reveled in the job.