Book Excerpts: Student Rotations Shape Interest in Ethics

A description of the latest book by Barron Lerner’86, “The Good Doctor: A Father, a Son, and the Evolution of Medical Ethics,” was included in the Spring 2014 issue’s Alumni in Print. The paperback version of the book was published in May 2015.

In the book, Dr. Lerner compares his own experiences as a physician with those of his father, an infectious diseases specialist.

Below are a few excerpts from the chapter, “The Second Dr. Lerner.” The excerpts describe moments from his P&S obstetrics & gynecology and pediatrics rotations that informed his later work in medical ethics. His memories were aided by notes he kept in a diary.

Some students, particularly those who were very proficient or intended to become surgeons, had few qualms about learning on patients. The rest of us and some of the residents joked about our flubs and successes. But no one discussed the ethics of the situation. Did students, indeed, have a right to do these procedures? How many times was it acceptable to try before giving up? And were you obligated to tell patients that you were doing a particular procedure—possibly even something as invasive as a spinal tap—for the first or second time? Not surprisingly, I chose an ethics topic for a presentation I needed to do for the rotation: the treatment of severely disabled neonates. For decades, paternalistic physicians had quietly left such babies to die, not necessarily even telling parents they could possibly be saved, albeit with major physical and mental deficits. Such lives, these doctors believed, were not worth living. But in an era of patient autonomy, parents were being given the option to pursue aggressive treatment. I applauded this development, although as a medical student, I had admittedly not seen any such children.

The ob/gyn rotation was an enormous learning experience for me in other ways. I was on call every fourth night. Sleeping, which took place in a tiny, overheated room while the student was wearing paper scrubs, was technically allowed but not exactly encouraged. Deliveries almost always seemed to happen in the middle of the night, and if you were in the call room, no one was going to come and find you. And the residents liked having students around to do the trivial tasks—known as scut work—for them. Some of my fellow students simply said no to scut. Some had the ability to lie down in bed and fall asleep immediately. I could do neither. One day I wrote that things seemed “somewhat out of control” because I had slept for only 45 minutes the previous night and was still trying to function more than 30 hours after I had arrived at the hospital. If anything, the house staff worked even harder and longer than I did.

The constant workload was difficult for me for two other reasons. First, there was very little time to read about the diseases that I was encountering. Given the choice between reading and sleeping, I preferred to sleep. Second, an 80- to 100-hour workweek was cramping my style. I had prided myself on maintaining a diversity of interests during the first two years of medical school. But now there was very little time to read the New York Times, much less jog, go to the gym, eat out, or engage in political activities. What did it mean that, this early in my career, I was fighting what I called a “maniacal devotion to medicine”? But how could I become a patient-centered physician like my father and his generation of doctors without completely focusing on my work?

In contrast to obstetrics, with its unpredictability and fast turnover of patients, inpatient pediatrics featured a large number of ongoing, devastating cases. Not surprisingly, I was drawn to the family dynamics and the ethical issues raised by such sad stories.

Once again, I struggled with my role. My resident had made me the official blood drawer for one of the boys. Although I was able to obtain the blood, he cringed and screamed whenever I came into the room, making it difficult for me to develop any type of relationship with him. His mother told me that he was starting kindergarten in the fall, but we both knew he would never finish school. Fortunately, many of the pediatric residents and attendings prided themselves on dealing with such profoundly challenging cases. The pediatricians’ egos, I wrote, were smaller than those of other physicians. I learned a great deal from their ease at interacting with both the sick children and their parents.