Autonomy Makes the Best Medicine

75-year-old cancer surgeon John Stehlin’s story captures the uniqueness of the doctor/patient relationship, fully explored in The Best Medicine: Doctors, Patients and the Covenant of Caring, (St. Martin’s Press, 221 pages, $23.95):

“There was this one woman, Peggy, who was in the hospital and doing quite poorly,” he recalls. “Usually, she was very upbeat. She had a wig because her hair had all fallen out, and she always dressed in a nice nightgown and wore her makeup. Anyway, one day, I went in and she had had a bad night. She was very disheveled. No makeup. Her hair piece was half on. She wasn’t dressed nicely. She looked like she didn’t care. Well, I told her, ‘I can’t work with this crap. Look at you. I won’t have you giving up.’ And I walked out.  A little while later the nurses came to me and said ‘Peggy wants to see you.’ I went back in and she was changed. Her hair piece was on straight, she had her makeup on and she had changed her clothes. She looked me right in the eye and said, ‘F___ you, John Stehlin.’ I stepped back and applauded her.”

By stripping bare the doctor/patient relationship in The Best Medicine, authors Mike Magee, MD and Michael D’Antonio remind the reader that the best medicine is an exchange of values; it’s a living trust. Magee, a former professor of surgery, and D’Antonio, a feature writer, let the men and women who perform the work and those who use their work speak for themselves. Their stories, arranged in chapters on scientists, healers, mentors, teachers, and friends, are often inspiring.

First, the patients tell their tales. By the time they have finished, the reader knows the outcome of the story and, therefore, knows the physician primarily from the patient’s perspective. The emphasis on what has happened to the patient prepares the reader for the story of the physician, who is no longer a faceless authority in a lab coat. Knowing what the doctor does sparks a deeper interest in how he does it.

Neither a dry, clinical patient history nor a series of feel good tales—though the weakest chapter promotes New Age mysticism—each story is presented as an end in itself. The sick men and women of The Best Medicine, and their doctors, by explaining their approaches, provide crucial clues to finding and keeping the best doctor.

Choice of physicians—and absolute autonomy for the physician—is a recurrent theme. “When I went to the hospital for my operation,” remembers one patient with a brain tumor, “I noticed that almost everything on the top of my chart—my name, age, address—was wrong. It sort of upset me. If they couldn’t get that right, then how could I be sure they would take care of me right? I said, ‘I’m going home.’ No sooner did I say that then [my doctor] comes marching down the hall as mad as a bat. He said to me, ‘You pick the hospital. I’ll send you there and we’ll do the operation.’ I picked another hospital and he did just what he said.”

Another patient, a seven-year-old girl suffering from painful urination, was sent to a primary care physician who prescribed a baking soda bath and, after a year of the same affliction, refused to refer her to a gynecologist. Finally, the managed care doctor sent the girl to a urologist, who told the girl’s frustrated mother that the problem was in the girl’s head and sent her to a psychiatrist, who walked out when the mother broke down in tears. Eventually, the mother learned her daughter, Ashley, had a rare yeast infection. She learned it from a gynecologist, the specialist she’d sought in the first place.

What a difference. “I couldn’t believe it,” she says. “Here was a doctor who wasn’t even in my network, getting right on the phone to hear the story and ask all these questions. Then she asked me if I could get Ashley to her office right away...she figured out what was wrong that day and in two or three days Ashley was feeling much better. She’s been better ever since.”

The gynecologist, Shelley Giebel, 36, uses only cloth gowns, including large sizes for big women, different sizes of speculum, which are specially designed so women don’t have to shift all over the table, soft covers on the stirrups and cloth sheets--not that roll of paper—on the examining table. Everything is warmed before it is used.

Like Dr. Giebel, nearly every doctor in The Best Medicine puts the patient’s treatment first and one suspects that these doctors prefer private, fee for service medicine over managed care, which raises the question of how these magnificent doctors manage to survive in today’s profession and how patients are able to afford their services. The most striking examples of quality health care are delivered by doctors whose judgment is apparently untethered to the bureaucracy of an HMO, PPO or Medicare.

The best doctors have something else in common: they love their work for its own sake. While each recognizes that the patient’s improved health is rewarding, they are not motivated by altruism; they are moved by the quest for knowledge. One physician says, “I believe there are scientific answers to every question. We may not have all the answers yet, but they are waiting to be discovered.”

Whether treating a soldier in Vietnam for an unexploded grenade lodged in an eye socket, or performing cosmetic surgery—among the several accounts presented here—each physician and each patient acknowledges the supremacy of clinical knowledge.

For those whose lives have been touched by illness and death and those who are in good health, The Best Medicine offers a glimpse of medicine as it can and should be practiced. The concrete-bound stories don’t provide a deep analysis of quality health care, and three is a political correctness throughout—the only gay patient has AIDS, of course—and some stories are generic. But The Best Medicine is a reminder that American health care delivery, though not through managed health care, is the best in the world.

Life does end and, when it does, Magee and D’Antonio demonstrate that—even when dying—one’s doctor can improve one’s life. “People want to die with no pain, no tubes and no loneliness, and the fact is, most do,” says one gerontologist. “[W]hen it comes to other issues, like breathing tubes, everyone makes their own choices. It boils down to what that individual believes makes life valuable.”

“I had one patient who was dying of Lou Gehrig’s disease. He was 63. He decided he had enough. He wanted the tube out. He set up a whole schedule. His family came in to be with him. At three o’clock the tube came out. He died twenty minutes later. It was consistent with how he had lived: engaged, in control. I hope that having me as a doctor helped make that possible.”

This 2000 article was published in the Philadelphia Inquirer and in Los Angeles Times' local newspapers.

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