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August 9, 2006

BehindTheMedspeak: Why your 'great doctor' might be a quack


Abigail Zuger, M.D., wrote an August 1 New York Times Science section essay entitled "Dr. Good Has Left the Building," lamenting the exodus of excellent clinicians to careers in administration and research.


I weighed in with a letter to the Times which was published yesterday and appears above and (far) below.

    In the Examination Room

    To the Editor:

    Re “Dr. Good Has Left the Building”: The writer quoted a famous doctor as saying to her that “any idiot can make a patient feel better” to illustrate why she wouldn’t want to work for someone so cynical.

    The doctor was 100 percent correct. Why do you think many of the doctors consistently at the top of best-doctor lists are known to peers to be barely competent?

    Because they’ve learned to compensate for their lack of medical knowledge with tremendous interpersonal skills that invariably “make a patient feel better.” Be careful is all I’m saying.

    Joseph A. Stirt, M.D.
    Charlottesville, Va.


Note the embedded homage to my head crack team researcher in the final sentence: it's one of her favorite tropes.

And no — when a trope goes missing it doesn't mean you dislike people.

But I digress.

Here is Dr. Zuger's column in its entirety, so you have a level playing field, as it were, on which to judge the merits or lack therein of my response.

    Dr. Good Has Left the Building

    When people ask me to recommend a doctor for them, half a dozen spring to mind immediately.

    They are all intelligent, kind and committed, intellectually imposing but down to earth, practical but visionary, and leavened with a good sense of humor. You couldn’t ask for a better person to oversee your health than one of them.

    There’s only one problem: not one of them sees patients anymore.

    No, they haven’t retired. They have simply moved onward and upward into the medical stratosphere. They have arrived at positions of power and influence; they do groundbreaking research, set policy, write guidelines and generally shape the health of the planet.

    As for figuring out why you can’t stop coughing, forget it. They don’t do that kind of thing anymore.

    Doctors without patients: can such creatures really exist? Or do they automatically negate themselves into some other sphere of existence, a cloudy existential plane where teachers without students and merchants without customers all wander around in search of a new identity?

    It is a purely rhetorical question, because not only do doctors without patients exist, they thrive. They top most heaps: they are the administrators, the professors, the chairmen, the directors and the chief executives.

    In fact, if truth be told, little baby doctors often go to bed at night thinking, I want to be just like them.

    In the memoir “Teacher Man,” Frank McCourt described “the situation in the public schools of America: the farther you travel from the classroom, the greater your financial and professional rewards.”

    The situation in the health care arenas of America may not be identical, but there are certainly parallels. Like the blackboard, the examining table is where the grunt work is done. Brilliant career paths often lead in the opposite direction.

    Some medical movers and shakers head off without a backward look: they never liked that “say ahhh; where does it hurt?” business to begin with.

    Some wax nostalgic: “If I only had the time,” they say, gesturing at the toppling piles of papers on their desks. “I miss patient care.”

    But they never quite make it back to that buffer-free zone of the examining room, to that lonely hot seat where the decisions are all theirs, and the fallout is too.

    Instead, their horizons expand, and in some sense, so do their patient loads. After all, to write an article establishing that one treatment is better than another is effectively to participate in the health care of millions. So is taking a new chemotherapy from test tube to pharmacy, or configuring an insurance company’s preferred drug formulary. And should something go wrong, the seat still gets plenty hot.

    But the work is not quite the same. Most of medicine these days is based on the big picture — trends set by thousands of research subjects (or hospital admissions or insured lives) moving in synchronies visible only to high-speed computers. The patterns can look very different writ small.

    In other words, a giant study may show that two pain relievers work about the same. But if only one helps Mrs. Jones (the gallant, delightful, terminally ill and utterly impoverished Mrs. Jones) and her insurer pays only for the other one, Mrs. Jones’s physician will quickly come to realize that they are not the same after all.

    Doctors who never get to know Mrs. Jones seldom learn this lesson. In fact, after enough years away from the examining table, it is easy to forget that people like Mrs. Jones exist at all.

    Some say that’s for the best. Many years ago, a famous professor and researcher interviewing me for a job remarked, in the tones of one imparting a secret of the universe, “Any idiot can make a patient feel better.”

    Research was the key to medicine, he continued, to really making a difference. Otherwise, wishes and hopes and idiosyncrasies, both yours and those of your patients, would tangle you up so completely that you would never break free.

    At least, I think that’s what he was trying to say. I actually never saw him again, deciding to take a job elsewhere, with a somewhat less famous man who still saw his own patients, one of the few graying heads in a sea of young medical grunts.

    “Keeps you honest,” he said.


It may or may not be good news to you that bookofjoe has burst the bounds of virtuality and now grabs a toehold in the old media space.

We are everywhere.


To paraphrase Joyce Kilmer:

Letters are written by fools like me,
So that you can go, 'hee hee'

August 9, 2006 at 10:01 AM | Permalink


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A letter in the Times? Wow. Some people write letters for many years before realizing that goal.

Posted by: Waldo Jaquith | Aug 9, 2006 12:15:03 PM

One of my favorite jokes from medical school:

Q: What do you call the student who graduates last in their class in medical school?


Posted by: Yoni | Aug 9, 2006 10:25:23 AM

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