Did you ever expect to find doctors acknowledging errors? Surely, when you were young, you never thought that the people who wear long white coats would confess themselves to be fallible.
Atul Gawande is one of the new breed who does. Along with Jerome Groopman, Lisa Sanders, and others, Dr. Gawande has gone public with recognition of the mistakes that he himself has made and those made by his colleagues.
A surgeon by training and practice, Gawande also writes well. Like Groopman, he publishes in leading journals and writes books. He must be well organized indeed to combine the roles of active physician and prolific author.
In Gawande’s case, it must help this year to have received one of those generous MacArthur awards that most other high achievers can only dream of. With all this success, he seems a fine person: in one brief conversation in a book store I found him genuine and unassuming.
However, despite the new frankness, I suspect that many people do not welcome the chance to read about physician errors. They would rather take their chances than learn, in sometimes gory detail, what can go wrong in the operating room or the doctor’s office. Though it may be liberating for physician-authors to recognize their own errors, it’s not always comforting for patients to discover what might happen to them.
Writing in The New Yorker for April 30th, Dr. Gawande focuses on old age, the pervasive physical decline that it brings, and what physicians trained in geriatrics can do for their patients.
I quarrel with the way Gawande portrays old age because he describes the march toward late life as relentless decline. First, he focuses on how your teeth, from age 60 on, will soften, making it difficult to eat well enough to stay healthy.
He then goes on to show how, by contrast, other parts of the body harden. The heart, for instance, must cope with stiffened blood vessels. He describes it with graphic realism: “When you reach inside an elderly patient during surgery, the aorta and other major vessels often feel crunchy under your fingers.”
A leading geriatrician whom I asked about Gawande’s article winced and called it “a treatise on decrepitude.”
However, later in the piece he makes a crucial discovery ─ he discovers geriatrics. In doing so, he acknowledges a major error of judgment of his own. Speaking of geriatrics, he admits: “Until I visited my hospital’s geriatric clinic, I did not fully grasp the nature of that expertise, or how important it could be for all of us.”
As he sits in on a colleague’s interview with a patient, he comes to see how the geriatrician focuses neither on that patient’s back pain nor on a possible threat of colon cancer. Instead, the doctor spends most of the visit examining the patient’s feet. That’s where he sees the greatest danger for her, the chance that she might fall and perhaps break a hip.
Too many doctors, the geriatrician explains to Gawande, treat only disease, and they judge the rest not to be a medical problem. But with older patients, that’s not enough. Geriatricians know how to inquire into details of the patient’s daily life so as to help them avoid becoming more infirm and perhaps unable to continue living at home.
“Most of us in medicine, however, don’t know how to think about decline,” Gawande writes. “We’re good at addressing specific, individual problems: colon cancer, high blood pressure, arthritic knees. But give us an elderly woman with colon cancer, high blood pressure, and various other ailments besides─an elderly woman at risk of losing the life she enjoys─and we are not sure what to do.”
Unfortunately, as Gawande regrets, not nearly enough doctors trained in geriatrics are available in the United States. In view of the explosive increase in people past middle age, it is nothing short of scandalous that so few such physicians can be found to treat us.
From my own experience, I judge that this situation will not change anytime soon. When I have talked with college students headed for medical school, I have never heard even one of them express the intention to specialize in geriatrics. Commenting on this tendency, Gawande attributes it in part to geriatricians getting paid less; but he also claims that “most doctors don’t like taking care of the elderly.”
Of course, I too recognize the power of decline in later life, often so difficult to put up with. But in my later years, and those of many others whom I know, I continue to experience surprisingly rich changes of imagination and affect, among other things. And both the spiritual life and the intellectual life have retained or even increased their vibrancy.
I do not welcome decrepitude any more than other people do. But I take some comfort from the savvy of some doctors who know how to put physical decline into a larger framework of a person’s life.
Richard Griffin