“Our Dedicated Dad”

Chapter 1


“OUR DEDICATED DAD”


Scenario


Robert and Belinda were shown into the unfamiliar corner office on the top floor of the hospital’s old wing by a man in scrubs who introduced himself simply as Barry. They had never met Barry.


“You will need to clear out Dr. Richmond’s closet by tomorrow at the latest, because the new surgeon starts this week, and we need to get her things moved in.”


The three looked uncomfortably at each other for what felt like a long, awkward moment.


“What are we meant to go through?” asked Robert.


“Just the personal things your father kept locked in that large mahogany armoire. Here’s the key, and feel free to use the boxes I left for you.” Barry pointed to the stack of boxes as he moved toward the door. “I’m sorry about your dad, and I’m sorry that although I worked for him for so long, this is the first and probably the last time I will meet you. He was a great doctor. The patients really liked him. He sure put in long hours.”


Robert and Belinda looked around the rather large and barren office, with its massive wooden desk. Nothing was on it, not a single pen or paper clip. Nothing. The two nonwindowed walls were covered with photos that their dad had apparently taken over decades but with no one they recognized. Catching their looks of confusion, Barry explained that the photos were probably a combination of staff and grateful former patients. Then he vanished down the hall, leaving Dr. Richmond’s adult children somewhat chilled at the task before them. They could not help but notice the absence of family photos. Not a single photo of his son, his daughter, or his wife of more than 40 years. Their father, Dr. Paul Richmond, had died suddenly from a heart attack a few days before while he was preparing for a particularly challenging surgical case. His death had been a complete shock to everyone. No one had seen it coming, or so his family thought.


To let in more light, Belinda pulled the cord on the blinds, which brought down layers of dust. Evidently, they had not been opened in years, which seemed sad because once the blinds were opened, they could see a large park full of trees and walking paths across the parking lot.


“Let’s pack up whatever we find and get out of here. We can let Mom decide what she wants to do with his stuff when we drop it off at her house. There can’t really be much left here to go through.” Robert turned to the armoire and used the key to open the door. A few papers slipped out, landing at his feet. The chest was packed full of papers and cards in every drawer and shelf, literally hundreds of old letters and cards dating back over many years. Robert tossed a stack to Belinda as he opened a card. It had been written 20 years earlier and was from the wife of a patient for whom his father had cared. The wife was full of grief at the loss of her husband but thanked their dad for giving her husband the extra 5 years no one else thought he would have. She also thanked him for being available 7 days a week and for all his outstanding care. Robert leafed through some more of the letters at random.


“Looks like his patients really did like him. There are so many cards and letters describing Dad’s dedication, what a great doctor he was, and lots of comments about how much time he spent with them. So many write that Dad was always there for these people. That phrase keeps coming up. I should feel pride, but part of me is a little angry and sort of jealous.” The brother and sister looked sadly at each other before agreeing to go through a few letters but then just pack it all up and get out.


After an hour, Belinda sighed. “I don’t know the man whom all these people have written to. The way they describe him as so available, so warm, so caring—I guess it’s nice that they seem to have gotten so much from our dad, but I’m kind of sad that we didn’t have him around very much at home. He was home most nights, but usually too late to eat dinner with us, and he usually made morning rounds 7 days a week. With his job this may have been necessary, I guess, but most of his colleagues took turns making weekend rounds for each other so they had time off. I wonder why he didn’t do that?”


Instead of leaving rapidly as they had planned, both just sat and continued reading the many documents, fascinated and curious.


“It’s obvious he did a lot more than just treat patients,” said Robert another hour later, looking up from the photo album he was perusing and glancing thoughtfully toward Belinda. “I’ve been surprised at all the extra work he did that we didn’t know about. All the pressures on him over the course of his long career. It’s interesting going through his papers, even though it’s a rather strange experience being here without him. Dad’s office always seemed off limits to us. I wonder if that was just what we thought. I don’t recall him ever telling us we weren’t welcome to visit him here. It’s odd but sort of comforting to sit here, in his worn-out leather chair, peeking into chapters of his life we didn’t know about. Somehow, I don’t think he would mind, but I wish we had asked him about all of this when we had a chance. Reading these papers is giving me a completely different impression of Dad.”


Belinda took a deep breath and put down the letter she was reading. “I know what you mean. Take this letter, for example. It’s from a patient whom he seems to have operated on about 20 years ago. Dad was just so devoted to his patients, and it looks like they reciprocated. Let me read it to you.”



Dear Dr. Richmond,


I am writing to thank you for all the care you gave me and for saving my life not once, but three times. You were constantly available for me and must have almost lived in the hospital when I was your patient, especially when I had complication after complication. You were so concerned for me through my three emergency surgeries. I am sure that many of your patients must thank you for the extraordinary work that you do, and I am proud to be one of them. I know I wasn’t always easy to deal with.


Your nurses are wonderful and caring too. I bet you don’t know that they talk about you as though you walk on water. They talk about working on “RW,” by which they mean “Richmond Ward,” although I know the signs say Ward 3A. They always talk about you very respectfully, always calling you Dr. Richmond, although they have nicknames for some of the other doctors. I understand why they respect you so much. You are more than a great surgeon; you are simply kind and always there for your patients. Thank you for answering my long list of questions and letting me feel safe to ask you anything. Thank you for never making me feel rushed.



Thank you for all your expert care and attention. I don’t know how you manage to do it, but you do, and I appreciate it.


Sincerely,


Thelma Close


Belinda brushed a tear from her eye as she laid down the letter. She caught a glimpse of herself in the wall mirror; the university logo embroidered on her gray sweatshirt caught her eye, and she remembered her first day on campus when her parents dropped her off for her freshman year. The last item her dad had picked up for her at the bookstore checkout was that sweatshirt. She knew she hadn’t even thanked him. This was still her go-to sweatshirt after all these years. How she wished she had thanked him! Belinda’s thick blonde hair complemented her blue eyes. She had the same color hair and eyes as her dad. She looked at her reflection and was grateful that she still took her daily run, which kept her fit and healthy. She choked up a little, remembering a few times she had complained to her dad that he didn’t come run with her. She knew she had resented his not taking time to enjoy the fresh air and get in an early morning run, but she was beginning to understand why he hadn’t taken time for himself. He put his patients first.


“You know, it’s so hard reading all these letters. There are literally hundreds of them from patients and colleagues over the years. I think he must have kept almost everything that was ever written to or about him throughout his whole career. The dreadful irony is that he was the only one who knew about all of these wonderful letters and citations.” She paused. “And we are only seeing them because of his sudden death last week. Just 58 years of age. He kept all this stuff in this office, filed neatly away. I don’t think Mom knows anything about these letters and how his patients felt about him. It almost feels like we are breaking into a separate part of his life—the world where he worked. I feel like we’re intruders into a huge part of his life that he kept private from us. He must have known we would see this someday.”


Robert listened to all Belinda said. He was feeling distressed by the experience of going through their father’s office. Robert Richmond looked very much like his father had when he was 30—the same swept-back blonde hair, already beginning to show silver strands. His face was less worn and beaten than his father’s had been at this age, a result of being less sleep deprived than his dad had been. Robert’s chosen profession was economics; he was fast becoming well known for creating algorithms to explain the economic relationship between poverty and climate change. He had never regretted his career choice, although he knew his dad had been disappointed that he hadn’t gone to medical school.


He responded to Belinda. “Frankly, it’s weird—us finding out so much about him at this time. I must have read 20 other letters like that one. Part of me is proud that his patients adored him so, but part of me is just mad at him for what we went through. While he gave so much of himself to his patients, we had an absent father whom we are only really getting to know now that it’s too late. He’s gone. And to make the irony even worse, to die in his operating room just a few weeks before he was finally meant to slow down! He had been planning the perfect retirement, would finally spend more time with Mom doing all the things they have put off over the years because of his devotion to work. He’d worked hard to save enough to allow an early retirement. It’s all so confusing. I have had such mixed feelings about him for many years, and now my uncertainty is made worse by finding all this stuff, having to sort through all of his professional belongings. I have to say, Belinda, that I think we drew the short straw, having to do this job. I would rather be going over the finances or sorting out his clothes and other belongings at home with Mom. But someone has to do this, and I think it would be really hard on Mom right now.”


He sat back and looked out of the office window, then glanced at his father’s beautiful oak desk with the surgical society’s painted coat of arms carved into its base. Stylish glass mementos of conferences attended in India and Chile, embossed with his father’s name and the year they had been given, sat proudly on a shelf by the door. Robert looked around the room that had been so central to his father’s existence, where he had spent so much time and seen many of his patients. His father had not done much to decorate the office beyond the walls of photographs. Only a bare minimum of furniture occupied the space—the desk and his chair, plus three chairs for visitors. The armoire they were slowly emptying also contained numerous awards, transcripts, and membership certificates of his father’s many degrees and academic qualifications, along with some favorite historical surgical prints and photographs of various major professional events. It seemed sad and disappointing that he had hidden the evidence of his successful career. Their father had always been modest, but it was odd that these were not on display. Perhaps he had just never gotten around to having them framed and hung.


Robert realized that in a matter of days the documentation of his dad’s career would be gone, and a new surgeon would move into this office. He wondered what the point had been of his dad keeping all these mementos, letters, inscribed books, and photos. He was pretty sure that his father had not gone through them himself and that most were just filed away. So, what did they show, and what could they learn about their father’s life from them?


As Robert contemplated their father’s private study, Belinda continued to read through the files. Like her brother, she also had avoided going into a health profession, despite her parents’ quiet pressure to do so. She had gotten a master’s degree in business administration (MBA) and was now working for a startup business that created and sold a new line of easy-to-use garden hoses, and it was expanding rapidly. She turned to her brother and realized that, as usual, he was thinking deeply about their task and would tend to see most of the negatives involved in it. She knew her role, as the more outgoing of the Richmond siblings, was to keep him positive and not allow him to be too inwardly focused, an attribute she had also seen in their father. She looked across at Robert and tried to bring him out of his reverie.


“Don’t look so upset, Robert. We will get through all of this today, and whatever papers we can’t sort out here, we’ll just take to Mom’s house. Let’s make sure we learn as much about Dad as we can and take advantage of this opportunity. I’m glad we have this chance to find out so much about him. He never talked about work very much. In fact, he didn’t seem to talk about himself much at all. He was more interested in finding out how we were doing at school or whatever we were up to. You must admit, we were always loved and supported by him. We just didn’t seem to have much time to have fun with him. He made sure we could try any sport we wanted, even though he didn’t come see us compete. It’s too bad he didn’t take time for golf or tennis. He didn’t seem to take time for himself much.”


Robert nodded. “I was just thinking, what was the point of Dad keeping all this paraphernalia? It was only meaningful to him, and is much less important to us, and at the end of the day we’ll throw a lot of it away, unless Mom wants any of it. I don’t know what I expected to find here. Interestingly, most of the cards and letters are from many years ago. Maybe patients send thankful e-mails nowadays. But something did surprise me: that whole drawer of letters and correspondence he kept that concerned his contacts with the various hospitals, insurance companies, malpractice companies, and medical boards he was involved with over the years. Some of those letters are quite remarkable and show how much pressure he was under during his professional life. That was a real eye-opener to me.”



Belinda nodded. “He was under so much pressure during his career, and yet he was resilient and was able to push back. Some of the nonsense he had to put up with from these other groups amazes me. His ability to fight back on behalf of what he thought was right, and what seems to have usually been in the best interest of his patients, is a whole new part of Dad that I just didn’t know about. No wonder he used to sometimes complain about administrators not understanding the stress he was under. I can’t seem to find support from the people he worked with. He really had some huge pressures, and I feel guilty for not understanding that before.”


“Did you look at all the letters from his malpractice company about that lawsuit he mentioned to us at home a few times over the years?” Robert asked.


“Yes. Incredible, aren’t they? I haven’t read them in detail yet, but the simple volume of communications with all the lawyers is shocking.” Belinda paused. “There’s such a contrast between what he told us and what was actually happening. He minimized it totally at home and even made a joke of it at times. Do you remember how he used to say how he wished he had implanted the fishing nets we saw on vacations into his hernia patients rather than the artificial mesh implants he used that led to the lawsuit against him? I wonder if Mom knows what was really happening and how much time and effort it must have taken him to defend himself. Looking at the paperwork, it must have taken Dad hours and hours of time to respond over a decade of legal arguments and fights. It looks like you’ve read more of the details than I did; did you really work out why he was sued and what happened at the end in court, when he won the case? He may have won the lawsuit, but it seems like he paid a huge price for it with all the years of his time and money it took to finally win.”


“Yes, I have,” Robert answered. “But it’s hard to work out the details just from the paperwork. I wish Dad was still here so we could understand all this better, and how it affected him. As far as I can see, multiple lawsuits were filed against the artificial mesh manufacturers and against the doctors like Dad who had implanted them. And then there were some other suits against Dad from individual patients, separate from the class-action suits, for specific damages they believed they had personally suffered from the surgeries, especially for what seems to be called ‘pain and suffering.’ We’ll never understand what happened. We’re only seeing pieces.


“It’s actually the letters about some of those individual lawsuits that are the most interesting. Some of the patients seem to have been claiming really substantial disabilities, such as permanent severe abdominal pain that stopped them being able to sit comfortably, or chronic migraines and loss of employment. And they all claimed that he was negligent for using the hernia mesh in his clinical trials, even though it had been fully tested and approved by the federal authorities, and they had signed consents for him to use the implants. The letters I found most painful to read were the ones he wrote to his insurance company defending what he had done and responding to the individual patient claims, some of which just seemed so unlikely. He seemed to have been trying to walk a tightrope—defending himself and his clinical practice while at the same time not wanting to disrespect the claims of the patients. Did you see the claim from that patient who said that one of the nurses had given him an injection in the wrong place, which had led to chronic nerve pain in his leg? She was suing Dad for overseeing poor care after her operation, even though in that case the mesh implant seemed to have worked perfectly. I could sense Dad’s frustration at being sued for something he had no control over.”


Belinda began to realize the enormous burden her dad had carried for more than a decade. He had gone through it pretty much alone. No one in the family had known what he was dealing with. No one could help support him.


“He wrote letters about this for more than a decade,” she said. “And he finally had to go to court about 5 years ago. I think I finally understand why he became so cynical about research and why he stopped doing clinical trials in the last 10 years or so. Did you see that letter he wrote to the other implant manufacturer he worked with, withdrawing from doing any more clinical trials, despite having worked closely with them for many years? That really changed his life in the second part of his career, because it meant that he didn’t go to so many conferences to present his findings, and it took a great interest out of his professional life. I had never realized until now that these lawsuits most likely led him to withdraw from his research career. That must have been a great loss for him. I guess he decided that it was just not worth it. I’m going to sit Mom down when we get home tonight and try to find out how much she knew about all this. I wonder if he kept her in the dark most of the time, and if she didn’t know much more about it than we did. What was it that led him to keep so much to himself? I wish he could have shared some of this with us, if only to get it off his chest.”


“I agree,” said Robert. “At one level, talking to him was always frustrating because he would just minimize any problems and say everything was fine. If he didn’t want to talk about something, he simply was not going to. And the lawyers telling him not to talk to anyone about the cases would have made it worse. It was as though he had a coat of armor on the whole time that stopped anyone from trying to find out what was happening inside of him in his work and professional life. I wonder if he was a typical doctor in that respect. Are they all trained to keep their stresses inside? Maybe they think they can’t acknowledge any weaknesses because if they did, the metaphorical walls would fall down, and the whole castle of the medical culture would collapse?”


“I don’t know,” said Belinda. “Maybe that whole approach helped him survive the pressures of his profession. Whatever else, it is really remarkable how strong he seemed to be and how he coped with this sort of stress on top of all the pressures of his usual clinical practice, while at the same time not sharing his concerns with us, or likely with anyone except maybe his lawyer, from the look of some of his letters. Now it’s too late to help him. I feel torn, because we could have been there for him, but he shut us out. He probably thought he could manage and not lean on us, but his good intentions led to his becoming more isolated over the years. I saw a book on mindfulness in the armoire, but it doesn’t look as though he read it. It seems his whole life was dedicated to helping everyone except himself.”


She shook her head. “You know, this is getting a bit morbid. I miss Dad so much. I just wish I had spent more time with him and that he had carved out more time for us. All those weekends we could have done things. All the family holidays interrupted. His insistence that he had to go to the hospital and round on his patients at Christmas and Thanksgiving—taking so much longer than he would say. It always felt to me that our family celebrations inevitably took second place. I don’t remember anyone complaining to him about late dinners. Maybe he didn’t realize the toll it took on us.”


Robert looked over at his sister, lifting his head out of a file marked Resident Teaching. “You know, Belinda, I will always miss Dad and wish we had spent more time with him. I’ve been going through paper copies of his surgery lectures to his residents in this file. It was just so typical of him to always keep a hard copy of everything he did—he never really did trust computers. We both know that he had a really dry sense of humor, but we saw it so rarely. Looking at some of his lectures, I’m surprised to see how much humor he threaded quite well throughout them. He was really funny. He used lots of hilarious cartoons, especially those of The New Yorker style. I remember him telling me how proud he was that he had been given the residents award as ‘teacher of the year’ on three occasions in recent years, and I can see now how he did it. His lectures look like stories, only they are stories of patients and clinical settings, beautifully illustrated and both funny and thoughtful. It must have taken him ages to make up these PowerPoint presentations. Somehow, they remind me of the sort of surgeon he apparently was—careful, thoughtful, and sensitive to the needs of his patients and all who worked with him. You should definitely go through some of these lectures to look at how his personality shone through, even when discussing how to take out a gallbladder or repair a bowel.”


“Maybe, but I’m not sure I really want to see the detailed photos!” Belinda laughed. “Not my scene, and never will be. But that’s interesting to hear, because I really hadn’t realized how much teaching he was doing, especially recently. I know he used to have those Christmas parties each year at home for all the residents when we were kids, but I’ve always thought that was because we had a large house that was close to the hospital. Now that I have my own family, I realize what a commitment that was for both Dad and Mom, because a lot of work was involved in getting everything just right for the party, and I remember how proud Dad was of his barbecue skills. I haven’t ever really thought of Dad as a teacher. He really enjoyed having the residents over for the annual parties; I wonder why they stopped having them.”


Robert interjected. “One thing this reminds me of, and that I will never forget, is that amazing conference he took all of us to, the whole family, when he was president of the state surgical society, and he had to give the main conference keynote speech. He had us sit up in front with Mom in the reserved seats, and I was so proud when he came onto the stage. All the house lights were dimmed, and just a single flood light followed him on the stage. He looked wonderful in his pinstripe suit and that blue tie mom gave him. I remember being surprised by how great he looked, and how the entire audience clapped for him for so long. He just stood there before us giving his speech, taking his time, and smiling at us in the front row. I remember thinking ‘that’s my dad’—I almost couldn’t believe he was on that stage, with everyone anxious to hear him speak. In retrospect, that must have been one of the highlight events of his professional life. I’m sorry we didn’t think to celebrate with him that night. As I remember, you and I went out for pizza by ourselves. We didn’t think to invite Dad or Mom.” He paused. “Not many children get to see their fathers like that. We were so lucky having him as a dad in many ways. I wonder if he has any photos around here from that night? It seems odd there are no family photos here in his office.”


Belinda went back to the armoire, where she took out several thick files marked Hospital Administration. “I saw these files earlier and didn’t think they would be too exciting. How about I go through them quickly? We’ll probably be throwing most of them out.” She carried the files over to her father’s desk and spread them out so that she could review each of them separately. She moved the large metal wastebasket close to the edge of the desk so she could rapidly read, sort, and discard the voluminous papers. Robert remained sitting in one of the comfortable patient chairs, reading files of academic papers and correspondence to his father, discarding most of them. After a few minutes he looked up, because he noticed Belinda had stopped filling her wastebasket. To his surprise, she was reading papers from the first file in detail. She was frowning and staring intently at what she was reviewing. Her right hand was on her forehead, and she was concentrating deeply.


“What’s going on?” Robert said. “I thought these files would be quick and easy.”


“So did I,” said Belinda. “But they’re fascinating, and I’m learning so much more about the pressures on Dad, things he never told us about. It’s remarkable what he went through. Do you remember a few years ago, when he was chief of staff? I certainly didn’t appreciate how much he was responsible for managing. It seems he was in that position for 2 years, as well as being deputy chief for 2 years beforehand. Remember, he told us that it was just a part-time role that he did on a voluntary basis? It was so much more. That job ended up being something that almost took over his whole professional life for several years. You and I were both away at college, and we used to worry about how Mom was always home alone. Dad was at work so much. He would come home after 8 P.M. most nights and seemed to work most weekends. We were really worried about both of them. Dad was working crazy hours and telling us he was doing lots of extra surgeries because they were short of doctors, while Mom was just sad and lonely all the time. You have to read these files after me, because they explain exactly what was going on. I can’t believe he never even mentioned all of these issues, when it looks like they took over his life for a long time. How on Earth did he manage to cope with all the pressures?”


Robert looked puzzled. “What pressures? What was happening?”


“Well, I haven’t read everything yet, of course, but it looks like the hospital’s CEO1 and his financial officer were fired on the same day, with no notice. It seems that when Dad was chief of staff, he wanted to employ much-needed additional physicians and nurses because the hospital was constantly full to overflowing, but the CEO kept refusing, saying they couldn’t afford it. Dad didn’t believe the hospital was unable financially to manage hiring the staff he was requesting. The hospital was always so full. So Dad went through the accounts and discovered that hundreds of thousands of dollars seemed to be missing, and then he confronted the CEO.


“From the look of these letters, the CEO actually tried to fire Dad, calling him a ‘troublemaker’ in the letter I just read. Here’s Dad’s response.” She paused as she continued reading. “He refused to get upset about the name calling and also refused to resign, saying it was his role as chief of staff to help all the clinical staff, and if that meant fighting to increase their numbers as needed clinically, then he would continue to do that. At the end of the letter, he formally requested an independent external audit of the hospital finances over the previous decade. Dad sent copies to all members of the hospital board and the executive committee. That was gutsy of him. It must have been all-out war. I can’t believe we didn’t know anything about all of this, although I do now recall a couple of articles being written in the local newspaper about the eventual sudden resignation of the hospital CEO and CFO.2


“Would you pass me the letters you’ve already read?” asked Robert. “It sounds like Dad must have eventually won this battle, but what a nightmare! I can’t believe he was threatened with being fired. Dad was the most ethical and honest man I’ve ever known. That is one area I have always tried to copy. He would never do anything that he thought was wrong, so it must have been unbelievably painful for him to be in that position, essentially an internal whistleblower against someone in a more senior administrative position. And it doesn’t sound like he had a lot of support, at least initially. I suddenly understand why he was never at home and why he and mom were constantly worried that his job was at risk. If Dad had ever been fired, it would have been total humiliation for him, whatever the reasons and the situation. He lived his life to be a highly respected doctor. Thank goodness he managed to survive such an awful situation. I guess we’ll never really know what sort of long-term toll these events took on him.”


“You’re right,” said Belinda, “although it does explain one of the attitudes he had in the later years of his career. I had a long talk with him a few years ago about leadership when I was applying for a new job. He was very interesting on the topic. I argued that I could easily move from one industry to another if I had good generic leadership skills, and at that stage I was thinking of doing just that. A great job had opened up at a major software company, and as you know, I am not great with computers. He had a very different view. He told me he believed that if a high level of technical knowledge was required in the industry I was moving into, then I should get that knowledge first. Interestingly, he used health care as an example. He said there had been a move in the past 20 or 30 years for nonphysicians with MBAs to increasingly take up CEO and other health care leadership positions, and he felt that his generation of doctors had let control of the health system slip away from them. He made it clear to me that he felt strongly that leaders in an industry as complicated as health care should have been clinicians of some sort at one time, so that they truly understood the pressures of clinical practice. I guess that explains why the new CEO of the medical center, whom Dad was involved in appointing, was a physician administrator. And it probably at least partly explained why Dad was prepared to take on the role of chief of staff. He would have seen it as being his duty and the right thing to do.”


Robert agreed. “Yes, Dad was always ruled by his sense of duty. If he had a problem, his answer was just to work harder until he succeeded. It’s fascinating finding out all these extra things about his work life, and it’s amazing how he coped with the pressures on top of his patient load. But there was a cost for dad, as we both know. While you were reading all the legal papers about the fraud case, I found a plain file in the bottom drawer of his desk. It’s not marked on the outside in any way, and knowing Dad, it’s really rather sad. It’s full of old holiday brochures that he had read and notated. They go back about 20 years, brochures from countries all over the world, and quite a few are about adventure tours for couples, like safaris, hiking, boating, and cycling. You know how he was going to retire in a few months, and he and mom have been planning a number of trips that they would take once he had stopped work. Well, it looks to me like he’d been thinking of these trips for many years. It’s such a shame that he worked so hard and so selflessly all his life and didn’t get to take those trips. He and Mom have always taken annual holidays, but usually around the family. It looks like he had a whole lot of other plans or ideas that never happened.”


“I wonder if he ever even discussed these vacation plans with Mom,” Belinda responded. “I still can’t believe he died just before he retired. He spent his entire life taking care of others, but he didn’t take time for himself, let alone Mom. And now he’s gone, so suddenly, and with no warning.”



Over the next hour, Robert and Belinda continued looking through their father’s files, throwing out most items. They were exhausted and had become subdued, talking less and less as the day dragged on. They seemed to be getting near to the end, with only a few files left to review, when Belinda suddenly sat up, holding a letter in her hand and staring at it with her eyes wide open. She clenched the paper tightly, as though she could not believe what she was reading, and looked at Robert, who was regarding her in surprise. She burst into tears.


“Oh, Robert, I don’t believe this.” She forced the words out in a faltering voice. “It looks like Dad had heart problems for years and did nothing about them. Look at this letter! It’s dated a month before his death. Come here and take a look; tell me I’m wrong. I think his death could have been prevented!” She sank down into the desk chair again as the impact of the letter hit home. “This letter makes it pretty clear that Dad was not taking any heed of longstanding cardiac symptoms. He seems to have known he was at risk, but he just put off seeking the care he needed. Why didn’t he seek help himself?”


Robert slowly got up from his chair, looking suddenly pale and troubled. He moved to the desk to read the letter Belinda was holding and had to pry it from her hands. The letterhead was that of a long-term friend and colleague of his father’s.



Dear Paul,


I decided to write to you personally after our discussions over the past several months and years, because I am most concerned about your health. I feel it necessary to document my concerns in the hope that you will follow up with my recommendations, which you have to this point refused to do. You are not physically invulnerable, and I believe you are in danger of having a heart attack or a stroke. I am aware that you do not have a primary care provider and have ordered all your own tests yourself, coming to see me only for a second opinion on your self-diagnosis. I would normally have written this letter to your primary care physician, copied to you, in the hope that they could persuade you to receive treatment.


I confirm that I have examined you on two occasions recently and that I agreed with your impression that the tight chest pain you have been getting for several years was most likely mild angina, getting worse over time. Your electrocardiograms have shown increasingly marked ischemic changes suggesting likely coronary artery obstruction by significant plaques in your left anterior descending artery, and possibly in other coronary arteries. Your lab work looks normal.


I informed you at our most recent consultation a month ago that you should be receiving medication treatment, including aspirin and beta-blockers, and that you should have an urgent angiogram, which could possibly lead to coronary stenting or coronary bypass surgery. You told me that you would think about this but made it clear that you also were busy, with lots of surgeries booked, and that you thought you would be fine until you retired next June as long as you took things slowly. You will recall that I asked if I could phone your wife about your condition, and you refused me permission.


Since that time, my nurses have tried numerous times to schedule your angiogram, and I have personally spoken to you twice on the phone to entreat you to seek urgent treatment to avoid a possible heart attack or stroke. This letter is the only approach beyond speaking to you that I can think of to try and get you to agree to what I believe is essential testing and treatment. Please do follow up with me urgently so that we can arrange these investigations and start you on appropriate treatment.


Yours truly,


Benjamin Scott, M.D.


Cardiologist


Commentary


The story of Paul Richmond, a widely respected and dedicated surgeon who gave his all, is not atypical of the stories of many highly successful and professional physicians over the past century. Dr. Richmond was, from the outside and from the perspective of his patients and colleagues, almost the stereotype of a wonderful, caring physician: always available, always caring, always professional—and seemingly invulnerable, able to cope with all sorts of stresses and pressures with apparently no substantial impact on himself. A picture of medical resiliency. This is just the type of picture that many physicians, not surprisingly, want to project to their patients, their families, and their communities, and most physicians can manage this act successfully, because to a great extent it is an act that has required a lot of training to develop and much concentration to maintain. So, let us now turn to the unintended consequences of professionalism in the context of the culture of medicine.


One of the interesting aspects of medicine is the implicit set of beliefs, ethics, values, and moral underpinnings associated with the culture of medicine. Dr. Joan Anzia, M.D., a psychiatrist from Northwestern University who has examined these in detail, presented her findings at the conference of the American College of Psychiatrists in February 2019. She described the following implicit beliefs as characterizing the culture of medicine (Anzia 2019):




  • I can do without sleep.



  • I don’t have time to exercise.



  • I eat and drink when I can.



  • I can always do more. I can get it done.



  • I have to do it perfectly or it’s a personal failure.



  • I can’t tell anyone if and when I have doubts or vulnerabilities.



  • If I ask for help, my colleagues won’t trust or respect me.



  • I’ll just work even harder and keep everything under control. It’ll be okay. I can’t say no.


Dr. Anzia contrasted these beliefs with the needs of a culture of resilience and wellness, which she noted includes




  • Getting adequate sleep, exercise, nutrition, and hydration



  • Accepting that doing everything is not possible but that the most important and essential things should be done



  • Understanding that, while doing your best, we are all humans, and perfection is impossible



  • Isolating oneself from friends and colleagues is bad, and asking for help and advice is good



  • Trying to have everything under rigid control is not good for anyone


Challenging these implicit beliefs is vitally important, and it needs to occur as early as possible, certainly through medical school. Unfortunately, many of these beliefs are hardwired into physicians trained over the past 30 years and are going to take a long time to change. They are driven by what Gabbard (1985) described as the “compulsive triad” of the doctor’s personality—doubt, guilt, and an exaggerated sense of responsibility, working synergistically with the ethical obligations of the Hippocratic Oath, which, while covering many positive aspects, contains nothing about self-care or the care of other physicians.


It is self-evident how this culture of medicine, driven by implicit beliefs, promotes a sense of perfectionism such that any discovery of burnout, or any deficit in professional behavior, is met with shame and denial by both the suffering physician and medical leaders. Dr. Anzia suggested that it may help to reconfigure the ethical principles on which all doctors depend. She recommended multiple changes to core ethical principles, many of which are included in the Hippocratic Oath doctors take at the end of medical school. A current-day version of the Hippocratic Oath as sworn by today’s medical students at their commencement ceremony, taken from the University of California, Davis School of Medicine student handbook, is as follows (Health Professions Advising 2018):



I swear to fulfill, to the best of my ability and judgment, this covenant:


I will respect the hard-won scientific gains of those physicians in whose steps I walk, and gladly share such knowledge as is mine with those who are to follow.


I will apply, for the benefit of the sick, all measures which are required, avoiding those twin traps of overtreatment and therapeutic nihilism.


I will remember that there is art to medicine as well as science, and that warmth, sympathy, and understanding may outweigh the surgeon’s knife or the chemist’s drug.


I will not be ashamed to say “I know not,” nor will I fail to call in my colleagues when the skills of another are needed for a patient’s recovery.


I will respect the privacy of my patients, for their problems are not disclosed to me that the world may know. Most especially must I tread with care in matters of life and death. If it is given me to save a life, all thanks. But it may also be within my power to take a life; this awesome responsibility must be faced with great humbleness and awareness of my own frailty. Above all, I must not play at God.


I will remember that I do not treat a fever chart, a cancerous growth, but a sick human being, whose illness may affect the person’s family and economic stability. My responsibility includes these related problems, if I am to care adequately for the sick.


I will prevent disease whenever I can, for prevention is preferable to cure.


I will remember that I remain a member of society, with special obligations to all my fellow human beings, those sound of mind and body as well as the infirm.


If I do not violate this oath, may I enjoy life and art, respected while I live and remembered with affection thereafter. May I always act so as to preserve the finest traditions of my calling and may I long experience the joy of healing those who seek my help.


What changes does Dr. Anzia suggest? She focuses on the ethical principles identified in the Oath and suggests changes as follows:




  • Beneficence should include the principle that physicians must take care of their own bodies, minds, and spirits, and those of their colleagues and trainees, in order to do good for others.



  • Hope and optimism: These principles have traditionally been interpreted as “for the patient” but could be fostered throughout medical training and practice as a value to help physicians.



  • Practice within the limits of competence could be expanded to include the need for physicians to monitor themselves and their colleagues in a team environment, looking for external or internal stressors that need changing.



  • Nonmaleficence should be not only for patients but also for our colleagues and ourselves. Individual physicians and physician leadership should speak out when they see adverse impacts from, for example, the workplace environment.



  • Justice: Physicians need adequate resources and time to look after themselves and their colleagues so that they can continue to perform at the top of their licenses.



  • Veracity means speaking honestly about needed changes in our work.



  • Fidelity means being faithful to oneself and one’s own moral attitudes in order to practice effectively. Interestingly, some are trying to redefine burnout as a “moral injury” and have a good point about it at this deeply personal level.


The unintended consequences of the culture of medicine for Dr. Richmond were personal, in terms of his absence from home and distancing from his family and friends, his loss of time for lifestyle interests and passions outside of medicine, and his tragic, untimely, and potentially preventable death just before he was to retire and fulfill his long-held plans to travel with his wife. The long hours of work that physicians are trained to accept needs to be questioned, and this is a recurring theme throughout this book. What other profession in the twenty-first century could think that limiting resident work to a maximum of 80 hours per week could be seen as rational? The effects of overwork in junior doctors are brilliantly described in Kay’s (2017) heartbreaking bestselling book detailing his work as a resident, which should be mandatory reading for all training directors and those involved in supporting inhumane hours of work for trainee physicians. In what other professions are incumbents proud of their often 7-day accessibility and of their capacity to perform physically arduous and demanding technical work such as surgery for shifts of more than 12 hours at a time? It is hardly surprising that physicians get used to working long hours, when so many go through an absurd baptism of fire otherwise called a residency program. The results of these unintended consequences for Dr. Richmond’s wife and family were perhaps even greater than for him, as seen in Robert and Belinda’s conversation: he was, to them and their mother, a lifelong physically—and often psychologically—absent father and husband. The only people not adversely affected by his professionalism and work practices were his patients, so it is not surprising they placed him on a psychological pedestal. This, of course, is part of the reward that many doctors seek, either consciously or unconsciously, and that keeps them working excessively throughout their careers.


The need to change the culture of medicine is also a major topic in my previous book, which focused on physician suicide. Several discussions focus on the ethical principles underpinning medicine and how these drive much of medical practice (Yellowlees 2018). Much of the current book is about how physicians, as inherently very resilient individuals, can overcome, avoid, or prevent these unintended consequences. My argument, however, is that although being resilient is very important for all physicians, and that resilience techniques can be successfully taught, it is not generally possible to “resilience yourself” out of highly stressful situations. Organizational, systemic, and culture change usually is required in many environments where physician stress or burnout is highly prevalent, as described in a comprehensive NEJM Catalyst (2018) collection of papers published in late 2018. Many approaches to reduce the impact of the more than 70 individual and external factors adversely affecting clinician well-being are also described by the impressive work of the National Academy of Medicine (2019), and the first change that has to happen is for physicians as a profession to learn that it is not necessary to sacrifice oneself on the altar of wildly excessive hours of work.


Another important theme in this scenario is the psychological defenses typically used by doctors—denial and intellectualization—as well as the issue of delayed gratification, putting off fun or joyful events, such as Dr. Richmond’s travel, in deference to immediate work priorities, as described in Yellowlees (2018). These defenses are also sensitively discussed by Elton (2018), who has written a fascinating book focused on the inner lives of doctors that describes the psychological dynamics of many physicians whom she has treated in her psychological practice.


Dr. Richmond also experienced other major sources of stress common for many doctors, including being sued, which in some specialties such as obstetrics-gynecology is almost inevitable during the course of the average career, and interacting with nonclinical health care leaders who may have differing priorities or experiences and a much stronger focus on financial rather than clinical outcomes. The issue of health care leadership itself is very important for most doctors, but it also creates tremendous ambivalence in many potentially excellent medical leaders because it often requires gradual, almost complete cessation of clinical practice, something most doctors find very difficult to accept. This is discussed in more detail in Chapter 2. The final tragic topic in Dr. Richmond’s scenario is how he treated himself, and did so inadequately, rather than putting himself in the role of patient and seeing a doctor for his own medical problems. About one-third of doctors are like Dr. Richmond and do not have a primary care physician, so they are unable to receive the regular medical care throughout their lives that all patients are advised to seek.


What, then, is the stereotype of the ideal doctor, and what do many pre-medical students fantasize that they will eventually become? The first point to make about this is that the topic is very popular and that perceptions of idealized physicians vary enormously. When I put “physician stereotypes” into Google, the search returned more than two million results, with the top pages primarily focused on humor or Hollywood’s perceptions of doctors as seen through many popular television shows and movies that are now part of our culture. Although Grey’s Anatomy, Scrubs, and House, all featuring doctors with various personal and interpersonal problems, have taken over from Marcus Welby, James Kildare, and Hawkeye Pierce, it is fair to say that most doctors, certainly those of Dr. Richmond’s vintage, were more influenced by the physician representations of the twentieth century and see these as being their idealizations. These older, more professional versions of physicians are certainly what the bulk of today’s medical profession would prefer as models for future physicians. It will be interesting to see if public perceptions of doctors change over time because of the influence of the current generation of TV doctors. Tanenbaum (2011) wrote an interesting article tracing the “25 Most Memorable TV Doctors,” for those who wish to review the changing media perceptions of physicians.


What, then, are the professional attributes expected from physicians that Dr. Richmond demonstrated? And what is the nature of professionalism as it relates to the medical profession? These are core questions of interest to the Alpha Omega Alpha Honor Medical Society, which, with more than 40,000 active physician and medical student members, has recently published a comprehensive monograph on professionalism best practices in the modern era (Byyny et al. 2017). They noted that the practice of medicine is, at its core, dependent on a “covenant of trust,” which is a contract that medical professionals have with patients and society that “determines medicine’s values and responsibilities in the care of the patient and improving public health.” They described the physician’s side of the contract as follows:




It starts with physicians understanding their obligations and commitments to serve and care for people, especially those who are suffering. Physicians must put patients first and subordinate their own interests to those of others. They should also adhere to high ethical and moral standards and a set of medical professional values. These values start with the precept of “do no harm.” They include a simple code of conduct that explicitly states: no lying, no stealing, no cheating, and no tolerance for those who do. The Golden Rule, or ethic of reciprocity, common to many cultures throughout the world—“one should treat others as one would like others to treat oneself”—should be the ethical code or moral basis for how we treat each other. (Byyny et al. 2017, p. ix)


Dr. Richmond clearly upheld his side of this contract, even if he subordinated his own interests too much, something many physicians do. Changing this practice is something physicians need to consider in order to gain more balance in their lives in a way that does not disrupt patient care. Dr. Richmond certainly met the standard for professionalism described succinctly by the Royal College of Physicians and Surgeons of Canada in 2000, who defined the professional requirements of physicians as being the delivery of “the highest quality of care with integrity, honesty and compassion.” They also noted that physicians “should be committed to the health and well-being of individuals and society through ethical practice, professionally led regulation, and high personal standards of behavior” (Royal College of Physicians and Surgeons of Canada 2016).


Along similar lines, the American College of Physicians in 2002 developed a physician charter that had three core principles (ABIM Foundation et al. 2002), namely




  1. The primacy of patient welfare, or dedication to serving the interest of the patient, and the importance of altruism and trust



  2. Patient autonomy, including honesty and respect for the patients’ desire to make decisions about their care



  3. Social justice, to eliminate discrimination in health care for any reason


In reviewing many of these issues, the Alpha Omega Alpha monograph described the professional core values that are typically included within the physician’s oath all new doctors take and that underlie the professional behavior of most physicians throughout their professional lives, including the commitment to (Byyny et al. 2017, p. xi)





  • Adhere to high ethical and moral standards—do right, avoid wrong, and do no harm.



  • Subordinate personal interests to those of the patient.



  • Avoid business, financial, and organizational conflicts of interest.



  • Honor the social contract with patients and communities.



  • Understand the nonbiological determinants of poor health, and the economic, psychological, social, and cultural factors that contribute to health and illness—the social determinants of health.



  • Care for all patients regardless of their ability to pay, and advocate for the medically underserved.



  • Be accountable, both ethically and financially.



  • Be thoughtful, compassionate, and collegial.



  • Continue to learn, and strive for excellence.



  • Work to advance the field of medicine, and share knowledge for the benefit of others.



  • Reflect dispassionately on your actions, behaviors, and decisions to improve knowledge, skills, judgment, decision making, accountability, and professionalism.

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Mar 29, 2020 | Posted by in PSYCHIATRY | Comments Off on “Our Dedicated Dad”

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