Dr. Sherwin Nuland, a clinical professor of surgery at Yale University School of Medicine and a Fellow at Yale’s Institute for Social and Policy Studies, turned to writing after more than 30 years as a surgeon. He won a National Book Award for his 1994 book How We Die, which spent many weeks on the New York Times bestseller list, and he’s contributed essays and articles to many national publications. In his latest book, The Soul of Medicine (Kaplan), he shares vivid stories from doctors he’s known and been associated with over the years. His own commentary completes the collection.
Our interview with Dr. Sherwin Nuland:
The Fiscal Times (TFT): Tell us why you wrote this book.
Dr. Sherwin Nuland: Of all the medical specialties, surgeons have probably told and heard more stories than anybody, because strange things happen in the operating room. They are marked on one’s memory. You yearn to tell them to people if you can just maintain the necessary confidentiality. I decided to ask doctors in other specialties for their stories, too. I asked them to tell me about the most fascinating patient experience they’d ever had. Their responses surprised me. Almost all these people are academic physicians, some of them internationally known. Yet in almost every case, they wanted to talk about a unique experience with a patient and what they learned from it and what the patient, too, had learned. These turned out to be stories about human beings working together to get one of them into a good state of health.
TFT: Your thoughts on health care reform?
Dr. Nuland: I take a rather radical position. I think our whole system is sick, and when someone is sick, sometimes you have to do very radical things to make that person well.
TFT: So what would you do?
Dr. Nuland: Our medical system, once so excellent, has gradually had bits and pieces added to it in a completely unplanned way. The cost of medical care has gone up so dramatically as a percentage of our GDP that everything’s gotten out of hand. What we need is a commission of highly qualified physicians and others to study the American health care system, starting with its educational aspects and going on to its care. We need to rip the whole system apart and create a very different method of education and care.
TFT: Weren’t rising costs inevitable, to some degree?
Dr. Nuland: Yes. We now have a lot of technology, whereas we used to rely on the history and the physical exam for something like appendicitis, let’s say. Now, every patient who comes in gets an ultrasound. And if there’s any question about the results of that ultrasound, the patient gets a CT scan. These are astronomically expensive modalities that are probably unnecessary for a large proportion of patients. Years ago, physicians liked to think of themselves as masters of the history and physical. Now, young people in training are taught to be what I call masters of the menu. They have a technological menu laid out for them, and they take one from column A and two from column B. From there they follow a formula.
TFT: Does part of the problem lie with what insurance will reimburse?
Dr. Nuland: You might be asked by an insurance company, “Did you do an ultrasound?” If you say no, they may say, “Why should we pay you if you didn’t do an ultrasound?” Also, very often patients will ask for these technical procedures and tests to be done. They may have seen a commercial on TV about an ultrasound, which incidentally was in an advertisement for the company that makes the ultrasound equipment. One of the major reasons for overuse of technology is that patients come in demanding certain tests that a clinician may feel are not necessary. And he worries: Suppose something is wrong, and he hasn’t done what the patient asked for?
TFT: How quickly does the talk among surgeons these days, or any doctors for that matter, turn to health care reform and its financial aspects?
Dr. Nuland: It’s very often the first thing that comes up. Everybody is so frustrated and so disappointed right now. Everybody, including the older physicians, finds themselves in a position that would have been unrecognizable in their earliest years of clinical work.
TFT: Name those frustrations.
Dr. Nuland: During all my years of practice – and that includes 30 years of surgical work, plus six years of training – surgeons would see a patient in consultation, work the patient up, discuss with the patient what needed to be done, and make sure the surgical procedure was carried out. The patient would stay in the hospital for anywhere from four to eight days or longer, and you’d get to know them pretty well. After they went home from the hospital, you filled out an insurance form. And the payment came. Now, a surgeon’s office is a beehive of activity. Forms must be scrupulously filled out so that methods of approaching certain diseases are applied as ‘best practices’ demand. There’s a lot less autonomy, it seems to me, in making individual therapeutic or even diagnostic decisions for patients, and a lot more frustration about the administrative aspects of care.
There is the question of overseeing the increased administrative functioning of your office, as well as the increased number of personnel. Many internists have gone back to school and gotten a business degree, simply because they felt it was the only way to keep ahead of the business aspects of running a department.
TFT: If President Obama or members of his cabinet were to reach out to you or other physicians today, would you tell them what you’ve just told us about health care reform?
Dr. Nuland: Yes. I would say we’ve got a tremendously complex piece of machinery that doesn’t work, and have you considered that maybe we need a different piece of machinery? In reality, the chances of my ever talking to the President are very small! There are tremendous economic interests against the kind of system I envision.
TFT: Would you ever take it upon yourself to reach out to him?
Dr. Nuland: By the time he got my email or letter it would’ve been filtered through plenty of hands who would say, “We can’t bother the President with this. This is just some guy in Connecticut who’s written a few books.” I would love to give him my advice, but it won’t happen.
An excerpt from The Soul of Medicine by Sherwin B. Nuland:
Diagnosis is today swifter and more accurate (though much more expensive) than it was in the past, as is therapy. But something has been lost, and it is impossible to tell whether the loss is important or not. The ultimate mainstay of diagnosis is not data, information, or even knowledge—it is judgment.
Are the advantages of being able to obtain so much data being lost by the disadvantages of categorizing patients or thinking algorithmically about diagnosis and therapy? The medical schools have recognized this problem, and they provide courses in clinical judgment. As Hippocrates told his colleagues almost two and a half millennia ago, judgment will always be the most difficult aspect of the art of medicine.
From The Soul of Medicine by Sherwin B. Nuland, © 2010 by Sherwin B. Nuland, published by Kaplan Publishing, a division of Kaplan, Inc.
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