THE DOCTOR IN LITERATURE Volume 3. Career Choices Picture (Doctor and the Doll, Rockwell) SOLOMON POSEN i Contents Introduction 1 1. Why Medicine? 8 Family pressures 8 Money 13 Status and power 15 The mysterious element 18 Dreams of innocence 19 True altruism 23 Role models. Books 23 Late starters 25 The interview for admission 31 Unachieved medical ambitions 33 Summary 35 References – Chapter 1 36 2. What kind of medicine? 48 Fact and Fiction 48 City and country 49 Hospital versus office practice 49 Gender considerations 50 Consistency and capriciousness 51 Financial and Life-Style Considerations 52 General practice versus specialization 53 Unspoken considerations 54 Summary 55 References – Chapter 2 55 3. Surgery and the Surgeon 60 Historical 60 “Aristocrats of the profession” 61 Hero worship 61 Physical appearance, military bearing, stamina 63 Undesirable traits: Attitude to “casualties” 64 Bullying; sexual harassment 66 Insensitive behavior 68 Surgeons as miserable teachers 72 High tech cave men 73 Surgeons and other doctors 76 Academic surgeons 81 Rituals of the operating room 82 Sadistic surgeons 83 Atypical surgeons; dropouts 85 Aggression as an asset 93 ii Summary 94 References - Chapter 3 94 4. Psychiatry and the psychiatrist 107 The one track mind 107 A meaningless hocus pocus 108 The “mad” psychiatrist 110 The “alien” psychiatrist 110 “Psychiatrists aren’t proper doctors” 111 “Psychiatrists have no morals” 115 Summary 117 References - Chapter 4 117 5. Specialists; general practitioners; fringe practitioners 123 Internists 123 Internal medicine – subspecialties 132 Neurology and neurologists 132 Oncology 134 Dermatology 136 Obstetrics/gynecology 138 Ophthalmology 141 Otolaryngology 143 Orthopedics 143 Pediatrics 145 General practice 148 “Ancillary” doctors 153 Pathology and pathologists 153 Anesthetics and anesthetists 157 Radiology 161 Marginalized doctors 162 Summary 164 References – Chapter 5 165 6. Researchers and academics. 183 Historical background 183 Solitary researchers 184 Part-time researchers 188 The research lab as a sheltered workshop 193 Cruel and useless research 194 Inside and outside the ivory tower 200 Scientific fraud and misconduct 204 Realistic accounts 206 Why research? 206 Summary 207 References – Chapter 6 208 iii 6. Abortions and abortionists 217 Historical 217 Unmentionable activities; cleaning up the mess 219 “Virtuous” refusals 220 Repulsive abortionists 225 Physically clean but ethically dirty 229 A series of abortionists 232 Amateurs: Disasters 235 Rights and wrongs of termination 240 Legal abortions 242 Why do they do it? 248 Summary 249 References – Chapter 7. 249 8. Euthanasia and physician-assisted suicide 259 A conspiracy of silence 260 Doctors or nurses? 261 Historical considerations 262 Officiously keeping alive; doing something. 264 Personality of the physician 265 The double standard 271 I can’t stand it any longer 275 The decision-making process 277 For, against and in-between 279 Special cases 285 Summary 287 References – Chapter 8 287 9. The Doctor and Politics 296 “Successful” and “unsuccessful” medical politicians 296 Incompatibility of the two activities 297 Political doctors: medical administrators 299 Non-political doctors 302 Lack of political skills as a source of weakness 307 Contrasts between “genuine” and “political” doctors 310 Protégés and victims 315 Politics and patient management 320 The loss of innocence 321 Compromisers 324 Summary 326 References – Chapter 9 326 Conclusions 336 Bibliography 338 Primary sources 338 iv Selected secondary sources 363 Name index 370 Subject index 388 Cover Design: Doctor and the Doll (Norman Rockwell, 1929). This typr of activity attracts some potential recruits to general practice. Picture reproduced by courtesy of … 1 Introduction This book is the third of four volumes in the series The Doctor in Literature. Like the first two,1, 2 it is intended to serve as an indexed, annotated anthology and to bring together a total of some 1500 extracts from approximately 600 works of fiction where medical doctors appear as major or minor characters. The citations in volume 3 relate to the choice of medicine as a career, and the doctor’s decision to confine his activities to specific areas. This volume also concerns itself with the perceptions (positive or negative) of different specialties among other members of the profession and among the general public. The question whether such perceptions might play a role in the choice of particular specialties is discussed in Chapters 3 - 6. Readers of this book and the other volumes in the series are likely to have some familiarity with medical terminology, so that a special glossary explaining anatomical and physiological terms is considered unnecessary. It is assumed that most readers will be familiar with the vocabulary describing the roles of medical staff (especially in hospitals) so that they will be aware of the difference between an “interne “ and an “internist.” A knowledge of historical and geographical variations in job descriptions is also taken for granted. For instance, in some countries “residents” are still called “registrars.” Senior nurses were given the title “Sister” in Great Britain and Australia for most of the twentieth century. A doctor’s office is called a “surgery” in British Commonwealth countries to this day. These terminological differences are considered of relatively minor significance, and are commented upon only when they affect the attitudes of the participants in a particular plot. Throughout this work, extracts from the literature are grouped acording to themes rather than individual books. Characters from major medical novels like Arrowsmith,3 The Last Adam,4 Love in the Time of Cholera5 and Saturday6 may therefore appear in several places, illustrating various aspects of medical career choices. As Osler points out, 7 medical behavior patterns transcend national boundaries and, accordingly, no attempt was made to group the relevant citations in geographical order. On the other hand, in this volume, several issues had to be analyzed within their historical context. Some specialties and subspecialties such as radiology and anesthesiology, which did not exist at all in the nineteenth 2 century, evolved as “ancillary” serrvices during the twentieth century and, in recent decades, assumed “interventionist” roles (see p. 153). Psychiatry ceased to be part of “Nervous and Mental Disorders” when Charcot and Freud parted company.8 It was then equated with psychoanalysis, but, in the late twentieth century, it outgrew this relationship and most psychiatrists now attempt to practice evidence-based medicine. Similarly, historical changes in disease patterns had to be taken into account in an analysis of fictional descriptions of career choices. Typhoid,4, 9 pulmonary tuberculosis10, 11 and pneumococcal pneumonia,12, 13 which figured prominently in works dating from the nineteenth and early twentieth centuries, were replaced in the second half of the twentieth century by diseases associated with peptic ulcers and their complications.14, 15 With the disappearance of peptic ulcer patients from hospital wards, the focus has shifted to coronary artery surgery,16 malignancies,17 Alzheimer’s disease6,18 and other afflictions of old age.19 Dementia is no longer deemed the result of insobriety or illicit sexual activities. Some of these changes in epidemiology and medical thinking are reflected in the disappearance of particular specialties (like venereology), the evolution of others (oncology, geriatrics, obesity surgery) with new options for career choices in real life and fiction. Novels portraying doctors as the main characters3-6 are not treated separately from those in which doctors appear briefly and as ancillary figures. For instance, Fontane’s Dr Rummschüttel20 plays a relatively minor part in the plot of Effi Briest, but in a few lines he provides an important insight into one aspect of medical behavior: Competent doctors are not deceived by malingering patients.21 Because of the number of works involved, the citations in The Doctor in Literature had to be kept brief. For readers in search of lengthy quotations from well-known authors, several conventional anthologies are available,20-27 some of them containing excellent selections. When citations in this volume came from works used in the previous two volumes, the editions, as far as possible, were the same as those previously employed. A notable exception was the 404 page edition of Ravin’s M.D.,30 which is no longer available and had to be replaced by the 372 page edition.31 When the cumulative index is completed, the references to all four volumes of this work will be standardized. 3 The inclusion and exclusion criteria for this book are similar to those employed in the first two volumes.1,2 It was found impossible to restrict the source material to works of solid literary merit, because some topics, such as the behavior of the surgeon in the operating room (see Chapter 3) or contemporary attitudes towards women doctors (see Book 4) are to be found only in popular fiction. Some illustrative passages therefore had to come from books that constitute neither literary nor commercial success stories. Works not available in English are, with few exceptions, not included. Medical clowns such as those portrayed in Elizabethan plays32 are not discussed. Medical murderers, deliberate inducers of diseases, salespersons of organs for transplantation and other sinister characters such as appear in clinical conspiracy novels,33,34