The Good Doctor: A Father, a Son, and the Evolution of Medical Ethics - Couverture souple

Lerner, Barron H.

Couverture souple

ISBN 10 : 0807035041 ISBN 13 : 9780807035047

Editeur : Beacon Press, 2015

A propos du livre

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Chapter Two
Super Doctor
 
I have written several books on the history of medicine, and I readily admit to having had unrealistic expectations about how many copies of each would be bought. Tuberculosis, breast  cancer, and even celebrity patients were less compelling topics than I had anticipated. Still, I had to chuckle when I read of my father’s onetime plan to publish a book entitled Consultant, detailing his experiences seeing patients with infectious diseases at the Veterans Administration
Hospital, Mount Sinai Hospital, and other Cleveland medical institutions in the 1960s and 1970s. As my agent could have told him, the subject was too “specialized.”
 
Fortunately, however, my father saved his notes, which not only illuminate his early medical career but also provide a moving depiction of him at the height of his powers, as he was practicing an intense type of medicine that might best be described as all-consuming. My dad provided a crucial service to internists, surgeons, and other physicians by diagnosing the illnesses of their sick patients and then prescribing effective antibiotics. His overarching concern for the physician-patient relationship also shone through in many of the cases that he documented.
 
As an infectious diseases consultant, my father turned out to have a front-row seat to some of the emerging ethical issues—such as medical errors and the limits of medical technology—that would soon burst forth into the public spotlight. But his approach to these issues remained largely based on paternalism and beneficence: How could and should the doctor help his patient navigate these complicated and often controversial questions? Given his background and training, which stressed “Doctor knows best,” he could hardly have chosen a different approach.
 
Meanwhile, I was a fairly typical teenager, trying to balance schoolwork, friends, and jobs. Two important decisions I made during these years were to have a bar mitzvah and to work for two summers at a nursing home at which my father was the medical director. The first represented an important exploration of my Judaism, although, like my father, I had great ambivalence about religion. The second turned out to be a dry run for my becoming a doctor.
 
Not all cases of infection require an infectious diseases consultation. Garden-variety pneumonias and urinary tract infections, for example, can be treated with a standard assortment of antibiotics. The task becomes even easier if a culture of the infectious material—such as sputum, urine, or blood—grows a specific organism. The microbiology laboratory can then test specific drugs against the bacteria in question, simplifying the choice of medication.
 
So when my dad was called in on a case, it was a good bet that it was complicated, either because the source of infection could not be determined or because the choice of antibiotic was unclear. For the most part, my father was happy with this arrangement. Like most physicians, he loved difficult and unusual cases, as they made for interesting discussions in the hospital corridors, on rounds, and at the citywide infectious diseases conferences he inaugurated in Cleveland in the late 1960s. Plus, even though my dad was incredibly busy, being a consultant provided him with considerably more flexibility and independence than his colleagues had, with their regular office hours and hundreds, perhaps thousands, of patients.
 
A typical case that my father saw in the early 1970s was a man with a lymphoma and an unusual pneumonia whose doctors were deciding whether or not to do a lung biopsy, which would involve opening the man’s chest. Deducing that the man had pneumocystis pneumonia, which occurred in immunosuppressed patients and would later become a common malady of the AIDS era, he convinced the team to skip the biopsy and treat the patient empirically with antibiotics. The man recovered completely.
So did a teenager with congenital heart disease who had endocarditis. Despite being treated with penicillin, he was still running temperatures as high as 105. The patient’s cardiologist was worried because the infection was not getting better, and he consulted a surgeon about replacing the infected heart valve—a major operation that the boy might not have survived. Noting that, despite his high temperature, the patient appeared to be improving, my father implored the physicians to hold off on surgery. He added another antimicrobial agent to treat what he thought was a small pneumonia. The patient never required surgery and was cured of both infections.
 
A man with pancreatic cancer had recurrent bacterial blood infections. He had recently become infected with a highly resistant strain of an organism called Serratia. The team was at a loss as to what to do to save the man’s life. My father reached into his bag of tricks and suggested trying an older antibiotic, tetracycline, not normally used for this type of blood infection. The patient recovered, although he ultimately died from the cancer.
 
When an eighty-five-year-old man was admitted to the hospital with a severe infection of his neck, my father was able to diagnose a condition that was very rare: Ludwig’s phlegmon. The infection, which had first been described by German physician Wilhelm Frederick von Ludwig in 1836, had become uncommon in the antimicrobial era but was still featured in infectious diseases textbooks. The infection required drainage of the abscess in the operating room, and my dad scrubbed in for the procedure. The surgeon had so little experience with such cases that he took my father’s recommendation that he do an extra-long “guillotine incision” of the neck to help treat the patient.
 
My dad’s consult notes, which reflected his intimate knowledge of the diseases in question, were often tutorials for the doctors (and patients) involved. When an elderly man with advanced lung disease continued to have fevers and positive sputum cultures, my father wrote: “In patients with chronic restrictive pulmonary disease, who have trouble raising secretions, antibiotic therapy of an acute pulmonary infection leads to bacterial overgrowth of the respiratory secretions.” The treatment: stop antibiotics and pound on the man’s back four times daily to mobilize his phlegm. It worked.
 
As in this case, my father’s successes often resulted from using fewer as opposed to more antibiotics, an approach he had learned early on from Louis Weinstein and one that he would impart to generations of Case Western Reserve medical students, house officers and fellows. One woman with multiple myeloma, who had been admitted repeatedly for infections, had a pneumonia that would not respond to any treatment. Given her overall condition, my dad, thinking it was cruel “to put her through any more torture,” recommended that antibiotics be withdrawn and the patient made comfortable. The pneumonia, or whatever the lung condition was, resolved.
 
In another case, a woman had severe diarrhea probably related to previous use of an antimicrobial. A visiting professor had seen the patient and recommended “massive antibiotic therapy” to clear out what he thought was an infection in the intestines. But my father had noticed that in addition to the diarrhea, there was mucus in the stool, indicating that the patient’s immune system was already fighting the diarrhea. He recommended stopping all antibiotics and simply giving her sugar water, “the way one would treat an infantile diarrhea.” The patient recovered over the next several days.
 
Finally, my father consulted on a man who had been admitted with three weeks of high temperatures from an unclear source, a condition termed fever of unexplained origin (FUO) in a well-known 1961 paper by Paul Beeson and his Yale colleague Robert Petersdorf. With antibiotics, the patient’s fevers had come down but had not gone away. My dad convinced his colleagues to avoid any further invasive testing and send the patient home. They agreed, and the temperatures gradually disappeared.
So how did my father instinctively know when to be aggressive and when to cut back? He would have cited his clinical expertise, beginning with his years as a medical resident and an infectious diseases fellow in Boston and continuing with his experience as an attending physician in Cleveland. Indeed, after the case described above, he planned to compile a series of his FUO cases, those patients “who spontaneously recover without any definitive diagnosis and without ever again getting into trouble.” This, after all, was the sort of clinical research that my father did during his years in Cleveland—retrospective studies of cases that shared a common characteristic, usually infections caused by a particular rare organism. The research was top-notch and published in excellent, peerreviewed journals. In order to improve his knowledge and conduct his research, my dad diligently tracked down patients who had been discharged, often sending them personal letters.
 
But my father’s style of research belonged to an earlier era. By the late 1970s, the randomized clinical trial—in which large numbers of patients were enrolled in formal studies and followed prospectively over time—had come into ascendancy. Researchers sought major grants from the National Institutes of Health (NIH) and often collaborated at multiple medical centers throughout the country. Only through this type of sophisticated scientific analysis, biostatisticians argued, could true knowledge be obtained. Case studies like those done by my father were interesting but not necessarily representative.
 
Still, on any given day at any given hospital, consultants like my dad and Weinstein could amaze colleagues, students, and patients. In one instance, the VA doctors asked my father to see an unusual case of pneumonia that had stumped everyone. But he knew this bacterium well. “It was Nocardia,” Robert Bonomo, who trained under my dad, told me a few years ago. “He came over and nailed it.” On another occasion, when several physicians were evaluating acomplicated skin infection, my dad was the only doctor present who knew all the planes of tissue where bacteria could hide. J. Walton Tomford, another Cleveland infectious diseases specialist, fondly recalled attending the citywide conference at which my father and the two other local infectious diseases gurus, Marty McHenry and Manny Wolinsky, had the opportunity to show off their vast knowledge about the field—even taking one another on at times. “It was
like our church and synagogue,” Tomford told me. These doctors also loved to visit their colleagues’ hospitals. In one memorable case, my father asked McHenry to come to the Mount Sinai to convince a very reluctant Orthodox Jewish woman that she needed to have a lung biopsy. When McHenry, a devout Catholic, took out his rosary to pray for the woman, she quickly acquiesced.
 
In another instance, when no source of infection could be found in an older woman with a high fever, my father suggested that an artery along the side of her head—which was not at all tender—be biopsied to look for inflammation. The medical literature suggested that the condition he was looking for, temporal arteritis, caused only low-grade temperatures in the elderly, but my dad had seen three other cases with high fever. To the surprise of everyone, even my father, the biopsy was positive and the diagnosis was made. “This really represents the evolution of a consultant’s experience,” he subsequently wrote.
 
Once, an internist asked him to see a young woman who had developed a rash on her right forearm several days after receiving the antimicrobial ampicillin for a fever and sore throat. My father saw her at her home because she lived near us. I presume he took with him his black doctor’s bag, which he used for his infrequent house calls and which contained the slides, syringes, and other equipment he needed to make a diagnosis. The rash was very distinctive, extending in a linear pattern from her elbow to her wrist. It was petechial—that is, composed of small purple spots caused by broken blood vessels. My dad immediately suspected meningococcemia, the severe bacterial blood infection on which his future mentor Weinstein had been lecturing on the day they met in 1960. Employing a bit of showmanship, my father asked the woman if she had recently been playing tennis. Startled, she said that she had, a
few days before, around the time she had first seen her internist. He later attributed this feat of clinical acumen to the concept of locus minoris resistentiae (place of least resistance), taught to him by Weinstein. Due to the vigorous motion in the patient’s forearm caused by playing tennis, the meningococcal bacteria had preferentially settled there and caused a rash. Before leaving, my dad put a drop of liquid from one of the lesions onto a slide, returned to the hospital, and did his own Gram stain, confirming the diagnosis.
 
In yet another case, my father overruled an “excellent internist and competent ophthalmologist” and prescribed a low dose of an antileukemia drug for a woman who had shingles that involved her eye. The patient’s symptoms dramatically improved by the next morning. The basis of his decision? Observations that he and an infectious diseases colleague at nearby University Hospital had made that, in fact, contradicted a controlled study of the medication that had recently been done at the NIH. “Another aspect of the case that is certainly worth commenting on is the beautiful demonstration of the value of a specialist in a given situation,” my dad later wrote. “This is really a minutia type of therapeutic maneuver and can only come about through word of mouth and personal experience.” Although he closely reviewed the results of major clinical trials, he passionately asserted that keen clinical observation remained
the most important way to approach illness and care for sick people.

To what degree was my father truly bucking the trend in medicine that increasingly favored population-based data over clinical intuition? In her 2013 book on Sister Kenny, the famous polio nurse of the 1930s and 1940s, the historian Naomi Rogers argues that Kenny actually constructed an alternative pathophysiological model of the disease based on her personal bedside observations. That is, she rejected the then-current scientific explanations for how polio
crippled patients, feeling that the mechanism responsible was the muscle spasms she observed, as opposed to nerve damage. Kenny’s novel treatment strategy for polio, which involved mobilizing paralyzed muscles as early as possible, followed directly from her unorthodox perspective. Seeing, in other words, was believing. I encountered this epistemological conundrum when researching breast cancer: certain patients insisted that their cancers were caused by toxic exposures and others assured me that screening mammograms had saved their lives even though controlled-study data indicated that both scenarios were unlikely.
 
Firmly grounded in scientific medicine, my f...

Présentation de l'éditeur :

The story of two doctors, a father and son, who practiced in very different times and the evolution of the ethics that profoundly influence health care
 
As a practicing physician and longtime member of his hospital’s ethics committee, Dr. Barron Lerner thought he had heard it all. But in the mid-1990s, his father, an infectious diseases physician, told him a stunning story: he had physically placed his body over an end-stage patient who had stopped breathing, preventing his colleagues from performing cardiopulmonary resuscitation, even though CPR was the ethically and legally accepted thing to do. Over the next few years, the senior Dr. Lerner tried to speed the deaths of his seriously ill mother and mother-in-law to spare them further suffering.
  
These stories angered and alarmed the younger Dr. Lerner—an internist, historian of medicine, and bioethicist—who had rejected physician-based paternalism in favor of informed consent and patient autonomy. The Good Doctor is a fascinating and moving account of how Dr. Lerner came to terms with two very different images of his father: a revered clinician, teacher, and researcher who always put his patients first, but also a physician willing to “play God,” opposing the very revolution in patients' rights that his son was studying and teaching to his own medical students.

But the elder Dr. Lerner’s journals, which he had kept for decades, showed the son how the father’s outdated paternalism had grown out of a fierce devotion to patient-centered medicine, which was rapidly disappearing. And they raised questions: Are paternalistic doctors just relics, or should their expertise be used to overrule patients and families that make ill-advised choices? Does the growing use of personalized medicine—in which specific interventions may be best for specific patients—change the calculus between autonomy and paternalism? And how can we best use technologies that were invented to save lives but now too often prolong death? In an era of high-technology medicine, spiraling costs, and health-care reform, these questions could not be more relevant.
      
As his father slowly died of Parkinson’s disease, Barron Lerner faced these questions both personally and professionally. He found himself being pulled into his dad’s medical care, even though he had criticized his father for making medical decisions for his relatives. Did playing God—at least in some situations—actually make sense? Did doctors sometimes “know best”?
 
A timely and compelling story of one family’s engagement with medicine over the last half century, The Good Doctor is an important book for those who treat illness—and those who struggle to overcome it.

À propos de cette édition

• Éditeur: Beacon Press
• Date d'édition: 2015
• ISBN 10: 0807035041
• ISBN 13: 9780807035047
• Reliure: Paperback
• Nombre de pages: 240