Not big on rules
Experienced physicians turned off by intrusive intervention
One of my wife’s uncles is a prominent internist in Chicago. He is getting near the end of his career, but he still plans to work for several more years. He is, however, scaling back his practice and seeing fewer patients under fewer circumstances, including not accepting Medicare. He and I were talking the other day at a family event, and while he expressed having received tremendous satisfaction from his work as a physician, he is backing off because, he told me bluntly, “Too many people who aren’t doctors are telling me what to do.”
Soon after this conversation, I received an e-mail with an attachment from my father. The attachment was a 42-page document titled, “Post Modern Biomedical Ethics.” It was an essay written by my father, a retiring general surgeon, and while it was much longer than my wife’s uncle’s remarks, the sentiments were similar.
My father, who had a successful private practice after serving for years as a surgeon in the Navy and working as a professor of surgery and biomedical ethics, penned the work and is submitting it to medical journals in the hopes that what he has learned over his career can influence those who are wielding the real influence today—the people setting up the rules, regulations and guidelines future physicians must practice by.
Like many surgeons, my father is not big on rules. He sees surgery being as much a dance as a science, and, a lot like my wife’s uncle, does not appreciate when non-physician bureaucrats weigh in on what he does without having the proper context.
In his paper, my dad points out an interesting fact about the public’s view of a phrase that many people see as central to the medical profession—“Primum non nocere,” or “First, do no harm.” My father writes that the phrase is “another simulacra of virtue that fits the ‘manage- ment by objective’ standards of contemporary production. It is easier for bureaucratic experts to correct deviations from standard operating procedures than to promote excellence, such as the correction and prevention of medical errors.
“Primum non nocere is not in the Hippocratic oath, it’s not even Greek, it’s Latin. The ‘doctrine of informed consent’ does not work, and cannot work. I don’t mean that physicians should not discuss their actions with their patients, but patients cannot synthesize cogently the facts of the proposed procedure, producing a true informed status where he can actually decide for himself. …”
Or, in other words, “Too many people who aren’t doctors are telling me what to do.”
There are certainly cogent, and data-rich, arguments that could be used to refute what my father believes about informed consent. There are also a lot of surgeons who would strongly back up what he says. That being said, I think his real point is more about the erosion of the doctor’s ability to develop and use his or her own personal wisdom and experience in the wake of an ever-expanding array of rules, regulations and guidelines being developed to direct what doctors do. In the end, I think what we are seeing is a real shift in the kind of people who will be going into medicine. My dad says that the regulatory nature of his profession is such that if he were a young person today, he might choose a different line of work.
That scares me. I certainly think there is more room for doctorpatient collaboration and intelligent oversight when it comes to what doctors do. But when I consistently hear from experienced physicians nearing the end of their careers that they have had it with intrusive interventions into how they operate, that’s a bright red flag.
JOHN D. THOMAS Chief of Editorial