An MD’s “Crossing” of DOCTORED. The Disillusionment of an American Physician

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Colleagues,

Last week we sent you Phil Kuehnert’s review of Sandeep Jauhar’s Doctored. The book is currently in sixteenth place on the New York Times list of bestsellers in the “Science” category. That’s one reason for daring to send you another treatment of it this week. A second reason is that most of us listened this past Sunday to Philippians 2:1-13, appointed in the Revised Common Lectionary as the second reading for the sixteenth Sunday after Pentecost, Series A. As it happens, today’s contributor, Jay W. Floyd, MD, uses that very passage to authorize an approach to the practice of medicine that differs dramatically from the one people are hearing about from Dr. Jauhar. Dr. Floyd goes to church with Pr. Kuehnert, and also serves as his primary physician. Have you ever had doubts as to whether the Gospel of Christ Crucified makes a difference in the practice of everyday life? If so, the faith-full doctor is going to cure them. Read on!

Peace and Joy,
Jerry Burce, for the editorial team

A few thoughts on completing Doctored: The Disillusionment of an American Physician:

1. My immediate reaction on completing the book was one of relief: Finally, the vitriolic diatribe had come to an end! The author’s own relief appears to have come only after leaving Manhattan to live in the Long Island suburb, a notion that struck me repeatedly during the book. “You need to leave the city,” I repeatedly urged in my mind. It seemed obvious that much of his dysthymia, depression, and despondence occurred as a result of the overcrowded, bustling, nonstop, wearying lifestyle which comes with big-city dwelling, with its proverbial rat race of working to make money to pay bills to feed the family to keep the wife happy. Moving sooner to an area with a more reasonable cost of living might have brought him closer to peace earlier in his career.
2. I propose that Dr. Jauhar was set up for disillusionment from the beginning. This is because of his worldview. By worldview, I mean all of the socio-cultural-spiritual underpinnings, the thoughts and values and mores, the habits and patterns and processes which form the underlying matrix through which life is lived, decisions are made, actions are executed, both individually and in relationship. While being proud of being a first generation Indian-American, Dr. Jauhar’s worldview is steeped in that culture, one of caste and hierarchy, of patriarchal patrilineage. Repeatedly, he expresses the innate desire—instilled by his mother, mostly—of going into medicine for the purposes of prestige, power, social standing, and earning potential. His primary goal is to make money and be respected in his community and among his peers. This approach rests in the need to get: to get or be given tangible and intangible things in order to feel complete. Such an approach to medical practice—or to any profession, most likely—is a setup for disappointment.
3. My own worldview, on the other hand, is based in Christian spirituality. The starting point for this way of life is not in getting, but rather in giving, not in holding on, but in letting go, not in being filled, but in becoming empty. This is expressed most clearly in Christian Scripture by the apostle Paul, in his magnificent hymn to Christ, in Philippians 2, where God is described as one with Jesus, “who, being in the form of God, counted it not a prize to be on an equality with God, but emptied himself, taking the form of a servant.” Paradoxically, and in the mysterious way of God, fulfillment in the Christian life comes not from getting, but from becoming empty, not from receiving, but from giving away. This giving of oneself as the starting point for Christian living can be taken directly into the exam room. I do not see patients to get RVU’s (the unit of reimbursement for my work done), but to give a listening ear, an examining touch, and a measure of helpful advice or succor. The worries and stresses of prior authorization, utilization review, electronic medical record keeping, insurance denials, personality conflicts in the office, and too few RVU’s to make administrative overseers happy can melt away once the exam room door closes behind me and I enter the giving mode.
4. The Christian worldview is based in love. This love is best expressed as the notion of Greek agape, rather than eros. Agape is a way of love that allows freedom from the constraints of expectation. It is an approach to our neighbor that promotes acceptance and belonging, a bringing in and enfolding, inclusion and community. This is best expressed in Scripture by the feast of the Last Supper, the drama of which is intensified again by the notion of emptying out. Jesus says, on decanting the wine, “This is my blood, poured out for many for the remission of sins.” It is in the giving of himself that Jesus completes his worldly mission, giving even to death on the cross. The words and actions of Jesus, expressed as agape, can form the basis for our own speech and behavior in Christian living. Approaching the patient with agape can lead to a much more fulfilling encounter—and thus a happier professional life—than thinking of the patient strictly as an RVU-generator.
5. I believe that Dr. Jauhar starts his thesis with a flawed notion: that American medicine is, like him, in middle age. He sets the starting point for modern American medicine circa 1950. Doctored is published, therefore, in medicine’s sixty-fourth year. This would imply, to continue his trajectory, that medicine will wither and die in another thirty years or so. What then? His opening chapter displays a naïve nostalgia for golden years that never existed. Why are these “halcyon days” (p. 8)? I would not have cared to practice in a time when children died of infectious diseases that are now easily treated, and when working adults living past forty were lucky. Medicine has no infancy, youth, adulthood, and death; of what value is this anthropomorphizing of a profession? Practicing medicine in the current era is exciting and stimulating. We are not aging as a profession, just evolving. We are on a path of continual innovation and improvement, of amazing discoveries on the research bench and translational movement into the clinical arena. Procedural and pharmaceutical advances occur that, frankly, are beyond belief. Just a few years ago, who would even have entertained the notion of a face transplant? Who could have predicted the worldwide eradication of smallpox, a killer pathogen since antiquity? The remarkable advances in Dr. Jauhar’s own field of cardiovascular medicine, from coronary artery stenting to cardioverter-defibrillator implantation, to the development of heart-, brain-, and life-saving statin therapy? Even the treatment of congestive heart failure has come light-years in pharmaceutical and procedural interventions compared to when I graduated medical school in 1990. By no means are we in an era of middle age, the implication being that it’s all downhill from here. No, we are on a rocket’s trajectory upward, with no end in sight.
6. In his final chapter, Dr. Jauhar’s prose becomes relaxed and unhurried. The bustle of city living is replaced with the serenity of the “country husband” (p. 245). Now, in this quietude, Dr. Jauhar can contemplate the purpose of his life and profession. During the preceding chapters, he never displays a spiritual side to his existence. He and Sonia “try” the Hindu spiritual enrichment center, but to no sustaining or fulfilling avail. Now, he states, “I believe most people who are drawn to medicine desire a career of tangible purpose. What redeems the effort?” (p. 260) The word ‘redemption’, in my view, is vastly overused. It has both lay and theological meaning. In the lay sense of the word, used here by Dr. Jauhar, the meaning is one of salvaging a loss. It is commonly used this way by sports commentators and writers. To me, if the University of Virginia basketball team finally defeats Duke, it has nothing whatsoever to do with redemption. They just won the game. Likewise, Dr. Jauhar seeks to “redeem” the profession of medicine from the evils plaguing it: prior authorization, overutilization of perhaps unnecessary studies, cranking patient numbers for the purpose of generating RVU’s. This redemption, he proposes, is found in the “tender moments helping people in need” (p. 260).
7. I disagree! The process of medical practice—that is, the one-on-one encounter behind closed doors in the exam room; the patient’s revealing of inmost secrets, concerns, and fears; the proffered and accepted hand to shake and the examining touch; the doctoring of the patient, teaching of the physiology, pathology, and treatment approaches to disease states; the give-and-take in negotiating a final treatment plan—this is the starting point of the entire affair. This is where the rubber meets the road. There is nothing to redeem here; this is it! This is what I became a physician to do. This process does not require salvaging; it requires practicing. We don’t need to save it, we just need to do it. This is why I love it. This is where agape takes place, where the giving occurs, where fulfillment is achieved through emptying out. This is where doctors can make a difference in the lives of their patients: in the individual encounter, based in agape, caring for our neighbor in the community of love.