Dr. Samuel Gorovitz discusses the book "Doctors' Dilemmas"

Studs Terkel The doctor, the medical doctor, is perhaps more frequently the subject of discussion than any other practitioner around and about. And, so, when Bernard Shaw, at the turn of the century wrote "The Doctor's Dilemma", a play dealing with precisely that, there is a book called "Doctors' Dilemmas", written by Samuel Gorovitz, who's the head of the Philosophy Department at the University of Maryland and served as senior scholar at the National Center for Health Services Research, and has been connected with the whole subject of healthcare and healthcare technology, and the subtitle is "Moral Conflict and Medical Care", and he raises a very provocative question, indeed, that [unintelligible], I think in the minds of anyone who has ever been under the care of a doctor, which means just about anybody. Macmillan, the publishers of this quite remarkable book. In a moment, Mr. Gorovitz, my guest, Samuel Gorovitz, and "Doctors' Dilemmas".

Samuel Gorovitz "Imagine a different planet on which life is like that on earth with one major exception: there is no illness or injury, people live to a standard age of, say, 90 years, and then, quite predictably, they instantaneously die. There are lawyers to write wills, and morticians to handle funerals, but the role of the physician is unknown. Now imagine a visitor from such a place asking one of our physicians what he or she does. 'I'm a doctor of medicine,' replies the physician. The answer does not help, for our visitor does not understand. 'I treat sick people, cure illness, save lives,' explains the physician to no avail. At this point the baffled visitor might well propose an empirical solution. 'Don't try to explain any more, just let me follow you around for a while and observe what you do. That way I'll be able to see for myself what the practice of medicine is.' A good political cartoon is obviously a satire, yet it captures a truth or insight. The following account should be understood in the spirit of such cartoons. For the visitor might well see the following events: the physician approaches a virtual stranger in a small, austere room. The stranger, who has been waiting a long time, looks up anxiously, yet with some relief, as the physician enters. Calling the stranger by a first name, the physician introduces himself as Doctor whatever and directs the stranger to remove his clothes. The events that then ensue, perhaps over many days, strike our observer as barely credible. The physician examines the exterior of the stranger and then begins to examine the interior, placing instruments of various kinds in all the existing orifices and from time to time creating new orifices for the purpose. The physician directs the stranger to eat certain poisonous chemicals. The stranger complies, but his cooperation seems to do him little good. The physician perseveres, causing to be connected to the victim tubes, through which additional chemicals are inserted. At one point the victim is stabbed with a sharp weapon through which poison is inserted into the body, rendering him unconscious. The physician's henchmen then seize the fallen victim and cart him off to a room filled with various instruments. The visitor is reminded here of the Tower of London and the punishment then escalates; the physician cuts the victim open and looks over the interior parts. He steals one or more of them, discarding them or sending them away, and sews what is left of the victim back together. Only many days later is the victim, perhaps one should say the prisoner, let out on parole. We could not blame the observer for concluding that the practice of medicine is a part of the penal system; indeed, the part that metes out the most severe punishments and humiliations to the worst among earthly criminal elements. He might then observe that on his planet there are also criminals from time to time, but that the kind of invasive physical and psychological abuse he has just witnessed has long since been rejected by the judicial system as not befitting a humane and civilized social order. 'No, no,' our physician protests, 'It isn't punishment. This has nothing to do with the penal system. These are not prisoners or criminals,' and the visitor replies, 'Then what you people call the practice of medicine I would describe as felonious assault.'"

Studs Terkel This is what, say, the visitor from another planet might see more without understanding that the doctor is there to help, to cure or to save a life. We're talking about a certain relationship, aren't we, between this powerful person and the other one who's absolutely under his thumb, for good purposes, of course.

Samuel Gorovitz Right. There's a tremendous differential in the power relationship between physician and patient and that's, of course, what I was trying to illuminate there, and also what I refer to as the dark side of medical practice, that is, in the service of the aspirations that physicians and patients presumably share, and the pursuit of those aspirations, physicians, of necessity, engage in behavior which really has some very extraordinary dimensions. And if we stand back from our common understanding of what medicine is about and just observe that behavior, it helps us to see that negative side of what it is to be a patient or to practice medicine etched more sharply.

Studs Terkel And, so, with you, your essays in this book are designed in a way to make us aware of this, though we are without ever having said it we're aware of it, but to change the relationship, that is, to alter it so that it's more--well, how can we put it so it wouldn't be anti, I don't want to be anti-doctor, you're not either. We're talking about an attitude, aren't we, that has been prevalent--

Samuel Gorovitz That's right.

Studs Terkel In too many cases.

Samuel Gorovitz I'm interested in illuminating the ways in which interactions between physicians and patients go wrong. I've discovered, indeed, increasingly in the discussion that's taken place following the publication of this book, how much lack of mutual understanding there is between physicians as a set of people and patients as a set of people. The transactions between physicians and patients often are very satisfactory and very successful. But all too often, something goes wrong in one way or another that leads to a lot of anger, a lot of disappointment, a lot of unhappiness, a lot of pain sometimes and suffering, and by focusing attention on the ways in which those transactions go wrong, I'm trying to catalyze an increase in constructive conversation between physicians and patients.

Studs Terkel We're talking about power. I suppose if we choose one profession in which the practitioner has the most power, we speak, we hear of judges at a certain moment the judge would at a certain moment or the warden of a prison would at a certain moment, the prisoner of a high school would, but none really touches the power of a doctor.

Samuel Gorovitz That's true, and I think there are reasons for it. One of the most central reasons is that physicians are widely viewed and to some extent rightly viewed as having privileged access to the secrets of life and health, and every one of us as I've indicated here, every one of us at some level of consciousness is aware of the frailty of life and the fragility of health and knows that these most valuable of human goods can diminish or can end at a moment's notice or at no notice at all, and we're all touched by that, and terrified by it.

Studs Terkel Even the phrases, the phrase, "Doctor's orders," that's used generally, "Doctor's orders." You don't say "lawyer's orders," you don't say "judge's orders" except for a specific case, you say, "Well, those are doctor's orders."

Samuel Gorovitz Yes, and that's the case even when the information is not explicitly packaged as orders. The concept of the doctor as providing orders is so pervasively entrenched in the nature of these transactions between physicians and patients, that even if a physician says very gently, "I think it would be best for you to do thus and such," or "I would like you to do this and such," that can be interpreted as orders and part of the reason for that is the sense of peril that people have at the idea of deviating from the physician's wisdom and that's paradoxical in a way because when I talk to physicians they make it clear that one of their main concerns is the problem of compliance, the fact that patients very often don't do what physicians believe they should and have asked or instructed or, indeed, ordered them to do, so we have at the same time a kind of complex overlay of a sense of an almost militaristic hierarchical relationship with orders. And yet, for a variety of reasons, patients acting independently of their doctor's wishes.

Studs Terkel You said like a militaristic hierarchy. We call a lawyer "mister," you know, unless in England somewhere maybe even famous and is knighted, you know. But it's "Dr." PhDs sometimes love to use that. "Dr." Once there was someone--but this was set by the medical doctor, wasn't it?

Samuel Gorovitz Yes, and--

Studs Terkel And if the doctor says it--you know, Mike and Elaine do these marvelous sketches about doctors and, when the woman wants to make a point to her son and she say somebody told her something, is "And that man is a doctor."

Samuel Gorovitz Yes, it is a very special relationship that physicians have to their title and I'm always amused by the experiment that I describe in the book which I've done on a number of occasions that goes as follows: almost anyone over the age of six can write his name on a piece of paper if asked to do so. And I've asked audiences containing large numbers of physicians to perform that task, simply to write their names and nothing else on a slip of paper, and I discovered that large numbers of them are incapable of following that instruction. What one gets on the paper is something like Julia Jones, M.D. as if that little bit of one's educational history, the fact that one earned a certain degree marks such a fundamental transformation in the very nature of the person, the essential being that the name changes. The only counterpart I know to that is when someone becomes and enters a nunnery and takes on a different name because it marks an essential change in the nature of the

Studs Terkel person. And to religion the father or reverend or rabbi, and it's interesting. So religion and medicine, but the doctor--there's a joke connected with it you have in your book, God playing the role of doctor. Would you mind telling that joke? Because that's a pretty telling one.

Samuel Gorovitz Well, it's a joke that now is fairly widely known, but it's about an old chap who dies a very, very slow and agonizing death because medical technology makes possible sustaining his life through his process of dying much more extensively than ever was the case before, so that he has the full benefit of the treatment that Tito and Franco received, tubes and pumps and respirators and so on, so instead of dying in a week or two, he dies of a period of six or eight months, and free at last from the disadvantages of physical embodiment, he floats on up to heaven and as he's checking in at the front desk, he says, "Pete, I'm really pleased to be here and to be done at last with the relentless beneficence of modern medical care. Here at least there'll be no illness, no injury, no suffering, and no medical care. And then he sees an old man rushing by with a beard and a white coat and a stethoscope and a black bag and a look of great urgency and importance. And he is struck by terror; all of the old fears well up in him and he says to St. Peter, "Good heavens, what is this? I thought I was done with all of that." And St. Peter says, "Oh, don't pay any attention to him, that's just God. He loves to play doctor."

Studs Terkel That's a pretty funny story. It's a telling one, isn't it?

Samuel Gorovitz It's telling because apart from how good or bad one thinks the joke is, one cannot construct that joke with any other profession. If you say, "Oh, that's just God. He loves to play architect," you don't have a joke. Not even a bad one. It is only the physician who is described as aspiring to or is actually playing God.

Studs Terkel There's something you said in a moment ago in describing the case of the old man kept alive in humiliation because of the high technology, and we found--I have an agent. Her name was Audrey ward. I should say I had an agent. Audrey Wood was a very celebrated and very powerful woman and in a good sense. She was Tennessee Williams' agent, and many, and she helped immeasurably certain writers. Audrey has always been a woman of great power and honesty, you know. She has been and she's in her late 70s now, 80, she's been in a coma for 18 months. In a coma. Out of touch with the world. And anyway, she has kept alive for 18 months supine. Now, she herself, were she had the power of say, would have long ago said, "Pull the plug," because a woman of great strength and dignity and she is humiliated, lying there, helpless, vegeta--for 18 months. Here, then, is high technology. Medically used in a certain way.

Samuel Gorovitz I think that that's a good illustration of a much more general phenomenon that we need to have much public discussion about, and much serious consideration of and that's this: for most of its history, medicine couldn't do very much. Medical intervention had aspirations that went far beyond its capacities and very rapidly over the last couple of decades, medical science has made it possible for the capacities, sometimes not only to fulfill the aspirations, but to exceed them, and medicine I describe as being in a state of adolescence in a very specific sense; that is, the adolescent is a developing person who is suddenly filled with a sense of new capacities and new powers and physical powers and intellectual powers and sexual powers, without the wisdom to know how to exercise much mature judgment over the use of those abilities. And that's what makes adolescence often a very awkward stage. Now, medicine is in its adolescence in precisely that sense. That is, there are so many new powers that medical science has, newly acquired, that there hasn't been the time to develop the collective wisdom about how best to use those powers. And you gave an example of one, but one among many, areas in which that's precisely the problem. Medicine can now sustain lives in the judgment of many people beyond any reasonable aspiration.

Studs Terkel Now, you offer an horrendous case toward the end of the book, and that is a case that is all too familiar, too, about the parents of someone who was hopelessly this small child who will be hopelessly retarded, a burden. Would you mind recounting that tale? And the doctor's own sense of what he thinks as morality.

Samuel Gorovitz Yes. That, I think, is a very significant case in one special sense. Before mentioning the case explicitly, I just want to step back and say we have to be aware that the motivation of the physician is very complex and it is not solely the interest of the patient. I wouldn't argue that it should be solely the interest of the patient.

Studs Terkel You wouldn't.

Samuel Gorovitz No, because one has to take into account certain other factors: the--What the interest of the patient is may be seriously in conflict with a variety of other values that are very important. I think a simple case that sketches that very dramatically is the patient who says that he wants to sell one of his kidneys and asks a physician to cooperate in a transaction of that sort. Or those lunatic women in Texas in the '50s who had a surgeon remove their little toes so they could fit their feet into very, very narrow shoes and they thought that they'd look more fashionable. I mean, I think there are limits to the extent to which the patient's wishes should dominate. But the physician is also the practitioner of a very difficult and complicated art, and people who have sophisticated skills like to use them, and physicians are motivated often by the challenge of the case before them. And that isn't always the same as the interest of the patient. One of the places that shows up very searingly is in neonatal intensive care, and that's the kind of case that we're talking about here, where it is a challenge to physicians to save the life of a 600-gram newborn, a 500-gram newborn, a 480, I mean, they're all aware of what the record is, and--

Studs Terkel What would that mean when you say 400 gram of--

Samuel Gorovitz Oh, we're talking about a one-pound, basically a one-pound very premature child with very, very scant prospects of survival. And often these children are born with serious indications of damage and there's real questions about the extent to which there should be psychic and economic investment in an effort, a maximum effort, to save these lives. But the physicians often are so absorbed in the challenge of trying to do so. Well, in this case, the case you asked me to describe, the baby was very seriously damaged. It was clear that there was going to be profound, irreversible retardation. The physician was strongly committed to the sacredness and sanctity of life, and--

Studs Terkel Now, the parents said, "Let it go."

Samuel Gorovitz Well, the parents reached a point--you must understand that they were in a state of almost a diminished capacity, beset by searing tragedy, by despair, by confusion, by a complex whirlwind of emotions and guilt and despair and distress of all sorts. The physician's view was crystal-clear, and that is, "We save life when we can. That is our commitment, that is our creed, that is our mission, that we must do," and the parents came around to the view that it would be for the best if treatment were withdrawn, every effort were made to keep the child as comfortable as possible, and in effect to let it die.

Studs Terkel Now, there is a basis here, that is, that it's hopeless, a child is hopeless, hopelessly--

Samuel Gorovitz Hopeless from the point of view of achieving life as an independently functioning human being capable of meaningful relationships with others. Well, the end of the tale is really quite simple. The physicians saved the life of the child and the child recovered in a certain sense and was sent home with the parents. Now that child at that time I learned of the case was eight years old, he was blind, he was without speech, he could not care for himself, he had no meaningful interactions with anybody, he required total custodial care at all times, and the parents very poignantly pointed out that the physician acted in pursuit of his own moral convictions, and once the case was ended he went along on his way, and it was they who were left to bear the full psychic and human and economic costs of the physician's moral fervor.

Studs Terkel So abstractly the physician was moral. Abstractly. That is, it had nothing to do with the life of this child from then on. They did. The parents did. He just went on his way. As you say, several years old now, that child is profoundly retarded, incapable of speech and independent action. The parents' lives are largely absorbed by the costs and Labors associated with caring for the child. They are keenly aware that their circumstances result from the physician's having imposed his values on the situation, also whereas their lives and not the physician's that have been impoverished as a result. And, so, we come to that doctors' dilemma, don't we?

Samuel Gorovitz That's right, and--

Studs Terkel Or for that matter, the parent's dilemma.

Samuel Gorovitz Contrasting that case with the case of Sir Thomas More, where he put his moral convictions on the line, he had the courage of his convictions and he lost his life as a result. But the cost at which he stood his ground was cost that he was to bear. And the difference here is that the cost that was at issue when the physician was morally intractable was cost to be borne by someone else, not by him. And it's that contrast that I think is so important. Now, if there's a particular theme that this book has, I think it has several, and some of them are methodological, some of them are about processes and how physicians and patients can have constructive interaction. But if there's a substantive theme that I'd want to emphasize most it's this: that the patient's values and the physician's values aren't necessarily always the same. And for medical care to be as good as it's possible for it to be, it's necessary for both physicians and patients to recognize that fact, to admit its legitimacy, and to try to fashion ways of adjudicating value conflicts between them.

Studs Terkel Before we come to that, the matter of autonomy on the part of a patient that has been to a large extent foreign to this relationship, but now more and more we hear of that. You spoke of the high technology. Now, there's a new machine, isn't there? And it's a very attractive machine. I mean, there's something happening here in which there are more tests than would be necessary because the doctor is so taken with the challenge, "Hey, let's see how that works," that that may not necessarily be to the benefit of that patient.

Samuel Gorovitz There's quite a bit that goes on between physicians and patients that's not motivated entirely or solely or in some cases only by the interest of the patient. One example is the example of physicians practicing a diagnostic procedure on a patient because they want to learn how to do it better, when it's clear that it can't possibly benefit that patient at all, and I've discussed that to some extent there. It's a real problem and a very sensitive one, to ask how physicians can learn to be good physicians if they're not allowed to do things before they have the ability to do them well. But that's one category of action that's not directed to the patient's benefit entirely. Yeah, the new machine has its appeal. Many physicians are technophiles, if you like. They're attracted by the new capacities and the challenge of exercising them. I don't think that's a primary or sole motivation, but it's a part of the picture. Another part of the picture is the fear that runs very deep in physicians of being sued for malpractice, and many tests that are medically superfluous are done for legal motivation, the physicians--they're disinclined to discuss this openly. Publicly--

Studs Terkel You call this defensive medicine.

Samuel Gorovitz Defensive medicine.

Studs Terkel Now, what is defensive medicine?

Samuel Gorovitz Defensive medicine is when a physician believes he has all the evidence he needs to handle the case, but there is a test that can be done. It may be expensive, it may be invasive, he thinks it's superfluous, but he knows that if he does the test, he cannot then be accused of lack of thoroughness, lack of meticulousness. If something goes wrong, as commonly happens in medical practice, if something goes wrong he is protecting himself by seeing to it that that test is included, so that there's no possibility of charge of negligence on that account. And in the doing of it, he regrets the necessity, perhaps; believes that it's not a part of optimal medical practice, but is necessary.

Studs Terkel That is defensive medicine.

Samuel Gorovitz That is defensive, where the physician's decisions are made in his own defense.

Studs Terkel Does that come about as a re--you mention a certain case, the Canterbury decision. What was the Canterbury?

Samuel Gorovitz That's--that has to do with what it's reasonable to expect of or to require of a physician. Now, physicians can be sued for malpractice, and I think there's a tremendous amount of confusion about the way in which things go wrong medically in medicine. Physicians get sued typically by patients who are not merely disappointed by the outcome of their medical care, but are angry, and that's a separate factor. The standard defense has been that the physician acted in accordance with prevailing medical standards in his community. What the reasonable physician would do. Now, the Canterbury case really has more to do with the elusive concept of informed consent.

Studs Terkel Informed consent.

Samuel Gorovitz Yes. What The patient needs to be told for the physician to be authorized in doing the medical intervention.

Studs Terkel Informed consent becomes the subject of several essays in this book. My guest is Mister--I say, Dr. Samuel Gorovitz, who is the head of the Philosophy Department at the University of Maryland and one whose primary interest is medical technology and medical ethics. We come to the subject of medical ethics, too, and your approaches to that, and your suggestions. "Doctors' Dilemmas", plural, is the name of the book, the subtitle "Moral Conflict and Medical Care", Macmillan the publishers. Informed consent. We know that a patient sometimes you describe someone who is under sedative and, "Sign this. It's permission to do something." It's not exactly informed consent, is it?

Samuel Gorovitz That's right. The legal requirement now--let's go back to that passage at the very beginning where I describe certain kinds of medical intervention as looking like assault. They are literally assaultive, but they are also legally assault if they're not done without, with permission. I mean, if you--if a physician who is a neighbor of yours decides that a certain medical treatment would be good for you, and he simply apprehends you and does it without your consent, that's an assault. The fact that he's a physician and even the fact that he's right that this was good for you is no defense at all, because we believe in the autonomy of persons. We believe that people have a right not to be interfered with except with their consent in general. Now that means that it's a requirement, for a physician to do what he or she wishes to do, that the patient agree and acquiesce, so that the physician has to get from the patient informed consent. Now, that's a real problem because of the unclarity of the concept of "informed"; how much does a patient need to know to be informed? Do you have to interrupt the illness, send the patient through medical school so that the patient understands all the physician does, and then the patient's informed and can give consent? Surely not. So one of the very difficult issues is how much must the patient understand for his consent to be valid so that the physician can proceed. That's very complex for many reasons. One of them is that patients are so different. Some of them are very smart and well-informed, and some of them are very ignorant but bright, and some of them are just hopelessly dim, and physicians have a very difficult time knowing to what extent they must in their role as a physician be an educator of the patient, and medical education doesn't address these things well at all. So, the question of autonomy is closely linked to the question of informed consent. We do believe that patients have the right to make decisions about their own medical care, but we also recognize that there are limitations on what patients know and can understand, and limitations to the amount of teaching that their physicians can do, so respecting the autonomy of the patient sometimes is a goal that's in conflict with getting on with the business of providing care.

Studs Terkel So informed consent, as you point out, is an act of will and not merely a signature on a piece of paper.

Samuel Gorovitz That's right. And one of the problems institutionally around informed consent has been the par--the tendency on the part of some healthcare providers to think that the objective is to get a signature on a consent form which provides legal protection. Of course, if the patient is misled, misinformed, coerced, drugged at the time or in any other way not acting freely and voluntarily, then the signature on a consent form is just fraudulent evidence and consent hasn't occurred.

Studs Terkel As you say that I think of one or more of the essays in the book, Mr. Gorovitz, the resident is testing a dying patient, some of his junior guys are doing it too. And they're--the nurse, very humane and knowing nurse, "Hey, this is cockeyed." She's not going to follow through on it, what they're doing because this--they're just--not horsing around, but they want to find out certain things that has nothing to do with this patient.

Samuel Gorovitz Yes. I think that's the case with the Swan-Ganz line where the young physicians performed this diagnostic procedure because the patient was comatose and dying, and they had never done this procedure. And they wanted to know how to do it, they wanted the experience of doing it, and the nurses tried to prevent them, but the power differential is so great that the nurse couldn't do that. And the young physicians did the Swan-Ganz procedure and subsequently, the same day, in fact, the patient died, probably not injured in any serious way by this test, but it was nonetheless an action of a medical intervention that was not motivated by the interest of the patient. And what really set the nurses off and activated them in that case was that the patient account was billed $200 for a Swan-Ganz diagnosis. And it took some courage and some tenacity on the part of the nurses to bring it about that that these young physicians in training were called on the carpet for it.

Studs Terkel So now we come to another development, a good one, we know there's more and more awareness on the part of more speaking out. This is happening with nurses, too. The top of the hierarchy is the doctor.

Samuel Gorovitz Yes.

Studs Terkel The big one. And then there are the young ones. But is there now more of a questioning than there has been in the past?

Samuel Gorovitz It varies very substantially. Some physicians, of course, are genuinely and thoroughly good doctors in all of the senses, and they work well with other members of the healthcare team and they work well with their patients. And I don't mean to suggest that medical practices is devoid of good doctors. I'm concerned about the statistical distribution of quality. There are very bad doctors. And I would like to see a greater percentage of those in medical practice doing that very important and very difficult task. Well, nurses are in a very difficult position. And the--I would say the category of nursing ethics is a different one from the category of medical ethics or physicians' ethics because nurses are in an ambiguous and a conflicted role. They take certain vows, they have certain obligations to the interest of the patient, but they are subservient in a hierarchical structure to higher authorities, and they are trained in nursing education increasingly to be independent in their thinking and to be assertive and, yet sometimes, they're caught in the middle and they are sort of at their peril.

Studs Terkel You know, something remarkable happened. I went down there, it was in Hamilton, I think it was a small Ohio town near Erie, and there was a nurses' strike, and you know what the basis of the strike was? Better patient care. Although there was talk about hours, of course, but it dealt with better and the big doctors were furious about it, there were a few allies. The strike was settled. It was sort of a victory for the nurses, sort of, but that was the issue.

Samuel Gorovitz Yes, that's happening, I think, increasingly. One of the factors that nurses have increasingly asked to be built into their job description and the structure of their job description is time for talking with patients. And often I think it's widely known and, among good physicians, taken as uncontroversial that a very important part of medical practice is what used to be called bedside manner, the caring presence of a physician, a physician who will listen as well as talk. There's a world of difference between the physician who whooshes into the patient's bedside, stands by the patient, and asks a few perfunctory questions, perhaps answers questions if the patient has his resources mustered quickly enough to ask them, and then disappears. That on the one hand and the patient, the physician who comes in and just pulls a side chair over to the bed and sits down, and just the very psychological difference of the physician sitting down even if it's for 30 seconds, and the physician standing over the patient as if he can't wait to dash off makes a tremendous difference, and nurses are very sensitive to this and they believe that part of their responsibility is to fill that gap where the physician isn't listening to the patient and, yet, nurses themselves have severe time constraints. There's a well-known physician in the Midwest, I won't say anything more to identify him, but he is widely viewed as highly skilled as a surgeon in his specialty. And it is also well-known that he gets to the hospital and makes rounds at five o'clock in the morning. Now, when a patient who is convalescing from surgery is awakened by the presence of the great man at five or five-thirty in the morning, even if that patient has complaints, questions, uncertainties, anxieties, it's going to be the extraordinary patient who can muster the resources to say in those circumstances, "Hold on, Buster, there are some things we need to go over." So that is another aspect of--

Studs Terkel Funny.

Samuel Gorovitz One thing, I want to dispel one confusion and I was waiting for a natural point and there isn't and probably won't be one, just to set the record straight. I was head of the Philosophy Department at Maryland, but after nine years of administrative responsibilities stopped doing that about three weeks ago.

Studs Terkel So now you're writing.

Samuel Gorovitz Now I'm doing more writing and lecturing.

Studs Terkel So you speak of the great man visiting the hospital bed at five in the morning and immediately evoked a memory for me. I was in the hospital one reason or another several years ago and sharing the room with an old man who was in very bad shape. And sure enough, at five in the morning a couple of young interns came in, just I say to horse around. That wasn't it. Two--they were learning, and they want--I forget what it was they wanted so they saw me and they--and this guy was terrified because they were making noise. They were talking very, not whispering at all. And casually woke me, but this--the old man was terrified. He knew what it was about. He had been sleeping, I trust soundly, he was sleeping and he hadn't been sleeping for several days, I noticed. So there you are. Now, why did they do that?

Samuel Gorovitz Of course, I don't know what their motivation was. But, as you describe the case, and all the evidence I have is your description, it sounds like at the very least there was a lack of sensitivity in their approach, and I've observed that many people enter the practice of medicine with no experience as patients, and, indeed, very little by way of surrogate experience, and that's why I made one of the more controversial proposals in the book in the section where I discuss the training of physicians and necessary changes in medical education. I propose that no one receive a medical degree who hasn't spent a couple of days in a hospital in a bed, if not ill, receiving treatment, just being there and perceiving on a round-the-clock basis what it's like to be on the receiving end of modern medical care, and that the medical literature has a number of very moving accounts written by mature physicians who've been healthy all their lives and suddenly were ill, of what it was like for them to be patients.

Studs Terkel That book by the doctor's widow. It was a good book.

Samuel Gorovitz Oh, Martha Lear's book.

Studs Terkel Martha Lear's.

Samuel Gorovitz "Heartsounds".

Studs Terkel "Heartsounds".

Samuel Gorovitz A magnificent book.

Studs Terkel It's on that very theme.

Samuel Gorovitz Yes. Very, very moving. And I would say if people in the audience are only going to read one or the other of these books, they should read hers. I think it's--

Studs Terkel She's been a guest on the program about a year ago or so. Martha Lear. And precisely that, her discovery as the wife of an eminent doctor who had become ill.

Samuel Gorovitz Yes. And who received medical care which was not atypical in a lot of respects. I think that's a book that should be read by every physician. Of course, I also think this is, but that one first.

Studs Terkel Absolutely. But you're saying, one of your suggestions, and one of the chapters, deals with medical school, deals with the need for this, and a matter of medical ethics, too, at one--a friend of mine, Dr. Quentin Young, who is quite remarkable, he is a doctor who always questions. And he says the medical school is the greatest behavior modification instrument in the world. Some of the young guys are brilliant, they're bright, as you say, the cream of the crop. Very few get in. You know, many apply, few are chosen, so they're the very best indeed, it would seem. And they come in idealistic, but each year they hear about things such as doctors will, blue-chip stocks, yacht, Bahamas, and bit by bit something happens to them, further and further from Hippocrates, closer and closer to "The Wall Street Journal".

Samuel Gorovitz Yes. I think that's fair. It has at least a charge that points a direction to an area of concern. It has its roots in a number of quite separate factors, I think. One is, of course, the tremendous selectivity and competition to get into medical school. Now, there are some people who believe, and there is some evidence that they're right, that it isn't the cream of the crop who get in, but rather the people who have the best ability to accumulate a certain kind of record that may not correlate very well with excellence of medical practice in later life.

Studs Terkel So, make the grade.

Samuel Gorovitz Who make the grade. That's right. But there's also an important point about the way medical care is financed in this country. The tuition at many a medical school now is on the order of $15,000 per year. Now if a very sensitive and bright and idealistic student goes through medical school and comes out with indebtedness on the order of 60, 70, 80 thousand dollars, that person has of necessity to have rather substantial financial aspirations in the short run. And I think that by the time those debts are paid off, the habits of acquisitiveness and money orientation have become pretty well internalized so that we, societally we pay a price for the fact that we don't support medical education. In full understanding that the license to practice medicine is a public trust and we really need to rethink all of that. But it's also something else called the process of professionalization whereby those teaching students to become physicians realize rightly that a physician cannot be a good and effective physician if he is so emotionally involved in the suffering of his patients that he is simply overcome with involvement.

Studs Terkel So we come to that, another of the doctors' dilemmas, the matter of detachment.

Samuel Gorovitz The matter of detachment.

Studs Terkel And concern. So how does that--now we come. "That guy's cold," we say, "He's a cold doctor. This guy is very"--now, some detachment is needed.

Samuel Gorovitz Some of it's necessary. A man cannot perform surgery if he cries at the sight of a person who's been cut. Someone who is so imp--

Studs Terkel Or the dear close friend of his is the patient.

Samuel Gorovitz That's why it's commonly believed in medical practice and, I think rightly so, that it's a mistake to have one's own family members as patients, that people should not care for those in their most intimate circle because the emotional involvement can impede objective decision-making.

Studs Terkel Yet, without that emotional involvement, not too much, without that, you have a cold kind of detachment, one who has never, it would seem has never suffered, has never been the patient, thing we were talking about earlier. So you have that, too.

Samuel Gorovitz That's right. And what this comes down to is that there's a very delicate balance between sensitivity and detachment. And many physicians overcompensate. They are unable to walk that tightrope along the optimal margin between sensitivity and detachment, and they just leap away from the problem to the side of detachment and part of what I'm suggesting here is that physicians can do better, but they need help. And part of the help they need is more understanding on the part of patients of what it's like to be a physician and why it's so difficult to do well. I've said a number of things that are critical of the way physicians practice medicine, but we must understand that there is widespread ignorance on the part of patients about just what the dilemmas are that physicians face and how patient behavior can exacerbate those dilemmas. So if there is, again, a second main thesis of this book, it's that physicians need to learn more what it's like to be a patient, and patients need to have a deeper understanding of what it's like to try to be a good physician.

Studs Terkel But do you find patients more and more now becoming aware, that is, asking more pertinent questions?

Samuel Gorovitz Indeed, it's part of a growing movement of consumer activism, I think, that patients as healthcare consumers are to some extent beginning to behave more in the spirit of active consumers.

Studs Terkel So, they're not questioning God anymore. That's the point.

Samuel Gorovitz That's right. And even there we have to be careful, because we--

Studs Terkel I mean, they are questioning God. I beg your pardon.

Samuel Gorovitz Well, I took your question to mean that in questioning the doctor they are no longer perceiving it as a divinity that is being challenged, but another human being, or perhaps a somewhat special sort. They are questioning, they are challenging, one of the areas of concern that I have and I had a little piece about this a few weeks ago in the "Los Angeles Times" and it generated a lot of interesting mail and I learned a lot from responses this way, the discontented patient has very little channels, a very few channels available for expressing that discontent. You can keep quiet or you can sue, and there's not much in between if you don't have a sensitive physician who wants to know for his own benefit and his own learning what your discontents are, and, so, I've discovered that there is rather a substantial gap in what physicians believe about how well they're doing and interacting with patients, and what patients believe very often, and we need to construct mechanisms to facilitate a much greater and more honest flow of communications. There's a conspiracy of silence that we hear about how physicians band together and close ranks and won't tell on one another about mistakes, but there's a conspiracy of silence on the other side that nobody talks about, and that is, patients are so deferential to their physicians and so respectful partly out of fear.

Studs Terkel Fear.

Samuel Gorovitz Right. And they seem to be satisfied and quiet and then they go home and the rage comes pouring out.

Studs Terkel Of course, you have a chapter here on "waiting." Now we know that relief clients, or welfare clients, that's part of their life, waiting, waiting, for the case worker to come out or something. Now if the patient waits and there's no--I realize that doctors are very busy of course, the doctor's busy. But there is no apology for a long wait, whereas that same doctor who attends a cocktail party comes a little late to a dinner, is apologetic.

Samuel Gorovitz That's right.

Studs Terkel But never to the patient.

Samuel Gorovitz The conventions of medical practice are so structured as to see to it that the physician does not wait because the physician's time is of crucial importance. The patient waits. That's, again, a reflection of the power differential. And I've talked about this quite a bit and it's not my thesis that physicians must always be on time, obviously they cannot. I would rather see a physician take the extra 10 minutes to talk to a patient who's unexpectedly upset than be abrupt and keep to the schedule. It's rather that the physician who is late must always be aware that that is an affront to the dignity of the waiting patient if the physician is not respectful of that patient's time and simply says, "I'm sorry you had to wait, here's why." Just the acknowledgment that the patient's time is a part of the patient's life.

Studs Terkel To tell why, the patient knows why. There's also, he's treated with a little more dignity, there's less humiliation.

Samuel Gorovitz That's right.

Studs Terkel By the way, there's so many things to talk about, Mr. Gorovitz, in your book, which is very revealing one, indeed, and exciting one. "Doctors' Dilemmas" that Macmillan has published, two more perhaps, there are many more que--but one in your suggestion for medical school, ethics. Medical ethics is taught toward the end, is that--you're suggesting it be integrated in all the courses.

Samuel Gorovitz I'm suggesting there is much dispute about the proper way of teaching medical ethics to medical students, and by ethics I don't mean teaching them a code or a list of commandments for medical practice, that's not what's at issue. I have something quite different in mind, and that is teaching them to be sensitive to the values of their patients, and of, and aware of their own values, and understanding of the processes by which patients and physicians can adjudicate disparity of values. Now, some people say, "You can't do that. The value structure is determined by the time the medical student is selected. And, so, there's no point in trying." I don't believe that. And if that were true, I would say to the medical schools, "Why, then, Aren't you taking this into account in your admissions selection procedures?" Other people say they can only learn this by patterning their behavior after their mentors, after the senior physicians whom they emulate. But that won't work either, because as medical students it isn't even clear to them which among the physicians are the ones they should emulate, which are the proper mentors. I think it's got to be explicit. I think it's got to be something to which attention is directed in a focused and explicit and reflective way at the beginning and in the middle and at the end. And when they are house officers in medical training and also when they're in medical practice, it should be a part of continuing education.