The November 27th New York Science Times section led with a story entitled “The Feud,” by Lawrence Altman. This piece is an excellent reminder that big egos can be unhealthy; even in the field of medicine where patient care is supposed to trump personal ego. “The Feud” addresses the relationship of two of the leading surgeons of the 1950’s and 60’s – Michael A DeBakey and Denton A Cooley – both legends of the operating room and pioneers of cardiovascular surgery. The conflict between them began when Cooley pilfered an artificial heart from DeBakey’s lab at Baylor Medical College and placed the half-pound piece of plastic in the chest of one of his own patients. DeBakey was informed about the theft from colleagues at a conference and was none too pleased. “I never quite understood it other than his ambition was almost uncontrolled,” DeBakey later said, adding that Cooley “kind of suffered from the fact that I was considered more prestigious than he was.” Cooley justified his unprecedented betrayal not by invoking patient care (his patient gained just four and half days of life out of the ordeal) but rather on the self-indulgent (he was doing more heart operations than anyone else so therefore deserved to be the first to implant an artificial heart) and the patriotic (he didn’t want the Russians to beat us to this milestone). The fallout from this feud was massive and not only caused bad blood between DeBakey and Cooley for decades, but may have also setback the development of implantable cardiac assist devices by 10 years or more. Now, Altman reports, Cooley (age 87) and Debakey (age 99) have finally made peace; just in time, a cynic might say, to become demented and forget that the whole thing happened.
The issue of ego is not frequently discussed in medicine, but doctors are human and humans have egos. And egos affect decisions, sometimes for the better and sometimes for the worse. I’ve seen it myriad times, both in my training and later in my community practice. Especially at academic medical centers, specialty services often have “pissing matches” regarding which service should admit a particular patient to the hospital. At the heart of these conflicts is a desire to avoid work but the dispute often degenerates into a battle of ego. The surgeon, for example, may demand that the medicine service admit a patient with an inflamed gallbladder, not so much because this is in the best interest of the patient, but simply because they are the surgeons and have been indoctrinated with the idea that other services are not their equal. Mortality and Morbidity (M&M) conferences often become a theater in which faculty members can demonstrate how smart they are to their trainees and each other. I recall several M&M conferences from my residency in which a fellow resident who was presenting a case with a bad outcome was nearly brought to tears by the barrage of second-guessing from retrospectoscope-enabled faculty. Physicians should and must have a process of vetting cases in which patient care goes awry, but to do so in a manner in a way which serves to placate ego does not make sense.
Physician-patient interactions can also become colored by physician ego. I see this most commonly if the patient requests (or demands) a certain treatment. Often, the patient is being unrealistic, but not always and sometimes it is not so much the nature of a patient request, but its manner that irritates physicians. I have certainly fallen victim to this; a patient arrives having googled the bejeezus out of their symptoms and having formed a definite opinion about their diagnosis. If I feel like I am being treated as nothing more than the gatekeeper to their preferred treatment, rather than a professional with years of training, I may push back. I can only imagine that more veteran physicians, who trained in an era in which physician judgment was rarely questioned and in which medical decisions were made primarily by doctors rather than through a “shared” approach, find this type of internet-savvy patient to be bedeviling.
There are other examples, but I won’t belabor the point. I will just conclude with a variation on an age old maxim that applies equally to physicians (dealing with each other or patients) or patients (who want something from their doctors): you can cure more colds with honey than with vinegar.