Behind the white coat.

Prior to Louis Pasteur's discovery of microbes--an achievement considered by many to mark the dawn of modern medicine--hospitals were dangerous places in which patients were more likely to die of a contagion acquired there than if they had simply stayed home. Since then, the white coat of the physician has come to symbolize sterile technique and antisepsis, and to this day it is synonymous with the scientific basis of medicine.

In the more than a century since Pasteur's time, medical science has raced ahead with astonishing speed to close in on some of the fundamental mysteries of life. And yet, we are no closer today than we ever were to resolving the problem of troubled physicians who are a danger to the well-being or even the lives of their patients.

Physician training has been described as the longest rite of passage in the Western world, and yet the selection process of student physicians often selects for the wrong qualities, while medical school training often perversely instills the wrong attitudes in physicians. Once in practice, physicians are protected by a web of interlocking self interests; impaired physicians in whose hands lives are entrusted--and sometimes needlessly lost--are rarely fired.

College premedical studies are dominated by the Mount Everest of premed, organic chemistry; although no one seriously claims that physicians actually use it, the memorization of lengthy chemical reactions involving carbon has traditionally been used to sort out the winners in the med school admissions ordeal. A black market in old lab papers flourishes at most schools, and sabotaging the lab experiments of fellow students is common. The process selects for competitive individualism over teamwork and cooperation.

And it is a highly selective process. At one exclusive university, 450 of 1,200 entering students declared themselves to be "premed"; four years later, only 100 remained, of whom about half would ultimately secure admission to a medical school. Once there, hardly any drop out; the survivors have sacrificed too much to turn back.

Student physicians in med school are immersed in a culture in which patients are thought of primarily as biological systems that have illnesses unconnected to their emotional health or their spiritual well being. One of my most vivid memories of med school is of the Kaflkaesque internal medicine conferences in which white coat after white coat would solemnly file into the Faulkner amphitheater. A "presenter" would step to the lectern and, with out so much as a greeting, deliver a rapid fire rendition from memory of laboratory values and X-ray studies. The patient was not just anonymous but devoid of any hopes or fears, and never did the physicians express any emotional connection to the per son with the disease.

I remember especially one case of a female IV drug user who had developed an endocarditis (heart-valve infection) which, after multiple treatments with intravenous antibiotics, had become resistant to all known antimicrobial drugs. Although the physicians in the great amphitheater could discourse at length about the relative merits of multi-antibiotic regimens versus surgery, none suggested asking this young woman what pain she was going through that prompted her use of IV narcotics, again and again bringing her to the brink of death; nor did the thought of enrolling her in a drug abuse program seem to cross their minds.

If patients were devoid of human needs, so too were physicians and those of us who wanted to become one. At a seminar on women in medicine, a physician heavily involved in medical student teaching told us that, when she was a resident and had been unable to find a babysitter, she had locked her children in her car in the parking lot of the inner city hospital where she worked and had checked on them from time to time during her shift--a statement made not in the spirit of a confession but in advancing herself as a role model of appropriate self sacrifice.

Those outside the medical world tend to view medical school teachers as the creme de la creme of physicians, and it is certainly true that the academic superstars who publish studies in the New England Journal of Medicine work overwhelmingly in academic medical centers. Below that level, however, there are plenty of reasons other than clinical proficiency why some individuals teach in medical schools. Academic medicine pays less than private practice or even HMOs, and while the majority of physicians who accept the lower compensation are competent and idealistic individuals who enjoy teaching, others are less competent and, in fact, some studies have shown a higher rate of malpractice losses in academic centers than in community hospitals. Some medical school instructors lack the business sense or the interpersonal skills--or both--to survive in private practice. The rate of one physician in six impaired by alcohol or drugs is no less in academia than among their community physician counterparts.

In early 1990, the Journal of the American Medical Association published two studies in which graduating seniors were questioned anonymously about their med school experiences. Most of the women said they had been sexually harassed. About one student in four reported being so severely abused verbally that the abuse could never be forgotten. And roughly one medical student in six reported being physically assaulted by an instructor, but virtually none of them felt safe enough to report the assault.

While I didn't witness any physical assaults of medical students, two of my supervising residents were shoved against a wall and slapped around by their attending physician, a surgeon whose behavior was well known at our school but who was treated as a kind of inside joke. What struck me was not only that this psychopath was tolerated in a medical school but that the surgical residents defended his behavior. The residents had, after all, not known the answer to the question they had been asked, and now they would never forget this crucial data.

If the teaching and role models provided by the med-school "attendings" (senior supervising physicians) can be problematic, more alarming still is the use of residents or even first year interns as "instructors"--fresh med-school graduates who themselves are trainees. The blind lead the blind.

The examples set in medical schools are sometimes chilling. During my own training, I witnessed two avoidable deaths, both for the same reason: surgeons taking unstable patients to the operating room in defiance of the anesthesiologist's recommendation. One of the surgeons was a cocksure resident working without supervision; the other, a senior surgeon heavily involved in medical student teaching, who should have known better but was incapable of listening to advice. In both cases, the anesthesiologists' reports were destroyed, word was passed to shut up about what had happened, and the mistakes were buried.

As stressful as med school is, most physicians in training find residencies more stressful still. Nonsurgical residents average about ninety hours per week; surgical residents, because of the vast time they spend in operating rooms and the need to check on many post surgical patients twice a day, average about 120 hours per week. Some surgical programs are cutthroat pyramids in which half the trainees are slated "washout" before graduation, and some have an every second night call schedule (thirty six hours on duty, followed by twelve off, then on again for thirty six)--a punishment some surgical subspecialists endure until they are in their mid-thirties.

Some surgeons finish their training as veritable saints, having kept alive their idealism, caring, and compassion. Others, however, complete their years of sacrifice deeply angry. There is all too much truth in the stereotype of the wrathful surgeon hurling instruments across an operating room.

Residency also usually marks an end to any training in the human side of medicine. As odd as it must seem to those outside the medical world, internists almost never have any training in alcohol counseling, pulmonologists almost never have any training in smoking cessation, and endocrinologists are almost never taught how to get their diabetics to take their insulin and follow their diet.

By the time I reached my residency, I yearned for treating the patient as a whole human being, and I chose carefully and well. At the McGill Family Practice program in Montreal, Canada, residents are supervised--with the permission of the patients--from behind one way mirrors by a senior physician or a psychologist who can observe four residents at a time. I'm convinced now that interviewing skills--or "bedside manner"--can be taught, that active listening can be learned, that the "playback" of what patients have said to reassure them that they were truly understood can be mastered, that the connecting touch on the shoulder that has been known for centuries as the "laying on of the hands" is a skill within a realm of even the less demonstrative student physicians.

The McGill program videotapes residents' patient inter actions. I'll never forget watching myself miss the muttered expletive of a troubled patient that was a clue to his alcoholism--a comment made while I was too busy writing in the chart to catch it. Seeing myself as the patients saw me bans formed everything I did as a physician.

Graduation from residency marks the end for most physicians of the absurdly long hours of many training programs. It also marks the be ginning of stress of a different type: being utterly and completely responsible for patient care, in a "buck stops here" culture.

It has been estimated that there are 100,000 avoid able patient fatalities due to physician error each year in the United States--a statistic that works out to the crash of a fully loaded 747 jet each day with the loss of all aboard, or about one avoidable fatality per physician every six years. Although I've never had to deal with the guilt of an avoidable adverse outcome--fatal or otherwise--I've had enough close calls that I get emotional just thinking about the issue.

A few months ago I saw a patient in my emergency room, who had an apparently superficial wound infection where a benign brain tumor had been removed. The surgical infection was a trivial problem; the real issue was to rule out the possibility that it had crossed into the central nervous system and produced a meningitis. I telephoned the patient's neurosurgeon at his prestigious medical school.

"Did the patient have a fever?" he asked me. "Was his neck stiff?" No, and no. "Well, I think you can skip the lumbar puncture," he reassured me. "The operation was done in an extremely sterile environment."

I had no sooner informed the patient that his neurosurgeon had advised avoiding the painful spinal tap when I began to have nagging doubts; even if his neurosurgeon was being a bozo, the patient needed the test. I told the patient I had changed my mind, and that I'd have a hard time sleeping that night if I didn't thoroughly check him out. He reluctantly agreed. The lumbar puncture showed pus in the cerebrospinal fluid. By the time the helicopter landed to fly the patient back to his embarrassed neurosurgeon, he had a fever of 105 degrees and no longer knew his own name. Only massive doses of antibiotics kept him alive. It's gratifying to think that I saved his life, but in my heart I know that, if he had balked at the painful procedure, I would have let him go home to a certain death from a lethal and fast moving disease.

The stress of medicine produces alcoholism rates in physicians only slightly higher than the general public, but drug addiction rates many times higher, in part due to the easy availability of purloined narcotics. Depression is commonplace, suicide rates are much higher than in the general population, and among female medical students and physicians, the rates of anorexia and bulimia are above those of their counterparts outside the profession. Although the world at large views doctors as confident, even arrogant, in many cases that arrogance and the walls some of these physicians build around themselves cover up for the insecurities that seem to go with the turf.

The current process of selecting and training medical students and residents is so problematic that it is difficult to know where to start an overhaul, but a few key points consistently jump out at almost anyone who examines our medical training system.

First, the failure to do background checks on med school applicants is scandalous. The letter of recommendation and the interview have been shown again and again to be almost useless in making intelligent choices. In fact, an Ivy League medical school was recently embarrassed to discover that a new student had been previously convicted of manslaughter--a piece of information that it learned by reading about her in the newspaper. Pilots, FBI agents, Peace Corps workers, and many other critical professionals must undergo extensive back ground investigations. Medical school applicants should under go similar scrutiny to weed out those with drug and alcohol addictions, as well as the sexually troubled applicants who could go on to become the type of physician who cannot be trusted alone in an exam room with a patient.

Second, the dangerous and dehumanizing thirty six hour shifts in training must come to an end. Much has been writ ten recently about the extremes of sleep deprivation that physicians-in-training must endure. Unfortunately, the recent harsh cutbacks in Medicare and Medicaid have put even more pressure on teaching hospitals to exploit their residents.

Finally, the profession must put more emphasis on the human side of medicine and on the skills that separate the healers from the mere technicians. Even those medical problems not directly produced by the mind body connection will result in psychological sequelae--denial, anger, depression, assuming the "sick role" Additional training in psychology and in developing the interpersonal skills needed to be a good physician might also result in more self awareness in some of the problematic individuals who often seem to have extraordinarily little insight into their own behavior. Perhaps the corollary of "Physician, heal thyself" is "Physician, know thyself."

And yet, despite a selection process that often passes over those who would make the best physicians, a training system that seems bent on wringing out the idealism and empathy with which most medical students start, and a medical establishment that far too often covers up for those who should not be practicing, the medical profession endures. Perhaps the profession owes its longevity to the pride and satisfaction its physicians realize from seeing the years of hard training and sacrifice make a crucial difference or even save a life. For the obstetrician who performs an emergency caesarian section that results in the joyous birth of an infant who otherwise wouldn't have survived, for the pediatrician who recognizes the one child in a hundred who is in mortal danger and pulls that child back from the brink of death, for the psychiatrist who is the bridge over troubled waters for the schizophrenic tormented by inner voices, for the surgeon whose trained hands deftly reach into the chest of the hemorrhaging gunshot victim and cross clamp the aorta, the satisfaction is phenomenal.

When the chips are down, it's amazing how physicians rise to the occasion. When the doors of the emergency room slam open for the trauma patient being ventilated by frantic pare medics, and the walls are bathed in the eerie glow of an ambulance's flashing red light, the petty jealousies cease, a truce is declared in the doctor wars, and the dysfunctional family somehow pulls together as a team.

There is plenty about the medical profession that I find frustrating, and yet, when I'm away from my emergency room for any time, I miss it a lot. The moving stories I see every day of courage, love, and devotion, the memories I have of patients whose lives have touched mine and enriched me forever, keep me coming back to the endless fascination of the comedy and tragedy of the Shakespearean stage of life that is my ER--a drama in which among the leading players will always be the fallible human beings who are physicians.

Alan Bonsteel is a family physician from San Francisco who practices primarily emergency medicine. He is a graduate of Dartmouth Medical School.