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John Livingston

The Parrot on the Shoulder of Medicine

I was blessed to practice surgery and medicine for 44 years. Almost half of that time was in the Navy, the other half in Boise. Twenty-five years ago, I was asked to help rebuild the trauma center at St. Al’s and I was lucky enough to recruit four outstanding surgeons from three outstanding medical schools. One of them called me up this morning from Colorado after operating on a difficult case for ten hours. He related to me the difficult surgical conundrum that confronted him last night and then how during the operation he had asked several surgical subspecialists into the operating room to see if they had any ideas about how to “skin this particular surgical cat”. They all had opinions about what to do, but all were reluctant to get involved because the chances for a good outcome were slim. For most of my career in and out of the Navy surgeons had to present their difficult cases before their peers at a Morbidity and Mortality (M&M) conference. These were difficult meetings and opinionated surgeons could be hypercritical of their colleagues. On one occasion a surgeon was critical about what another surgeon had done, and the very next month he made the exact same decision during a complicated case and the roles at M&M were switched. What both realized late into the second discussion was that during the light of day they each would have reacted differently than during the heat of the operation. They both made the same intraoperative decision and they both would have made a different choice in retrospect.

There is a lot to unpack in that discussion, but what concerned me most was that at this major Academic Institution, Medical School, and Trauma Center there was a reluctance of surgical teammates to get involved—for the good of the patient. I asked my friend if this was about legal liability and his response surprised me. He said that certainly played into it, but there were other issues. No longer are their (M&M) conferences where surgeons evaluate each other, but rather there are institutional administrative reviews—these used to go under the name of “utilization review” and “risk management review”. The cases are reviewed by administrators and lawyers and many times by physicians who aren’t surgeons themselves. There is always the underlying theme of “appropriate use of resources and personnel”. Choosing not to operate on a difficult patient and having a bad outcome or death is never reviewed. The only cases reviewed are bad surgical outcomes. Surgeons are incentivized not to operate on difficult cases.

My friend and I share a passion for the writings of C. S. Lewis and in describing the conflict in his soul minutes after the operation described above, he said this: “It is like doctors have an ore on a Galley slave ship and they row because the slave master has a whip”. I asked if the slave master was a metaphor for a hospital administrator, a hospital or plaintiff attorney, or a government bureaucrat; but for him it represented his conscience—his duty to do what was best for his patient. He also related that many of his fellow physicians have “gotten beyond duty” and are accepting of the fact that they are a “means of production without a conscience”. I recommended that he reconsider his thoughts and mostly his emotions after some rest. He said that the “spirit of service” has been sucked out of the souls of many physicians and nurses. For years they have been treated not as professionals but rather as highly paid technicians. “Now we see ourselves the way others looked at us.”

In the SCREW TAPE LETTERS there is a parrot that represents sin that sits on the shoulder of one of the main characters. The parrot is a dear friend of this character trying to move from purgatory towards heaven, but God won’t let the person in unless he removes the parrot from his shoulder. The character over and again chooses the parrot “sin” over Heaven. ” In my friend’s case the situation is quite different. Like so many doctors and nurses the parrot sitting on their shoulders is “duty”. They are being asked to remove the parrot in exchange for being complicit in an activity that is never looking at the wellbeing of the patient, but rather the efficiency of a process—an economic calculous and not a desired clinical result. The end—cost justifies the means—efficiency. The real cost is to the souls of providers who understand exactly what is happening, they don’t like it, they are conflicted by it, and they have nowhere to turn if they want to continue in their professional careers.

During the pandemic, the Crises Standards of Care (CSC) and the resulting emergency protocols that provided cover for medical facilities to practice below a previously prescribed standard of care without liability, has tortured providers in ways that should have been predictable. In a Medscape Survey, nurses were asked the reasons that so many were leaving the profession. It wasn’t because of long hours or the burdens and responsibilities of taking care of very sick patients. The main reason was a lack of respect for their professional ethics and their personal moral codes. They knew they could do more and that they could do better, and their patients could have been better served. Clinical decision making and the primacy of the patient, was replaced with a public health ethos of “herd” and communal wellbeing.

As the “After Action Reports” and “Out Briefs” are published by a less than inquisitive media, and as politicians take victory laps over what they perceive as a successful two years of Covid mitigation strategy—self-awareness is in short supply these days especially in an election year, the truth will slowly emerge. Mistakes are going to occur when new and unusual conundrums present themselves, but “the experts” were wrong more often than they needed to be. Mistakes were made, many times not because of a lack of information or data, but because of not understanding the limitations of expertise. Experts can try to identify risk, but they cannot define an individual’s or family’s tolerance or acceptance of risk. We need an honest review by honest people with a fresh perspective, but a review by people who actually “played in the game” doctors, clinicians, nurses, and not lobbyists, representatives of special interests, or government bureaucrats from the CDC, NIH, or the Idaho Department of Health and Welfare (IDHW). Pandemics and Natural Disasters will happen again. We must do better next time around. We can do better. We must be willing to confront our mistakes and learn from them. Time to bring back M&Ms.

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