William A. Nolen’s father was a lawyer. “Billy,” his son quotes him as saying, “if you’re smart, when you grow up you’ll be a doctor. Those bastards have it made.” Billy did grow up, and did become a doctor, and does have it made, at least according to most of the criteria of our society—money, of course, but more importantly status and power. Now Dr. Nolen, practicing general surgery at the Litchfield Clinic in Minnesota, Chief of Surgery at the Meeker County Hospital, and a part-time clinical instructor at a university-affiliated medical center, has attempted to describe the “tedious, painstaking, laborious and time-consuming process” by which he became what his father hoped so earnestly he would become. He has produced (“written” seems almost too generous a term) a dismal book, which, nevertheless, if closely read, reveals much about contemporary medical education and practice.
The Making of a Surgeon is an account, episodic and roughly chronological, of the author’s five years of training in Cornell’s surgical division at Bellevue Hospital in New York City. Those years of internship and residency are, as Dr. Nolen correctly notes in his Introduction, the critical apprenticeship period in which a young doctor is transformed “from a helpless, frightened medical school graduate into, hopefully, a capable confident surgeon.” The transition is indeed fascinating, almost magical; in the operating room it can be measured by subtle details that may, under stressful circumstances, mean the success or failure of one phase of an operation: the speed with which a knot is tied (tight enough to hold the tissue, not so tight as to destroy it); the ease with which an elusive “bleeder” is located and clamped; the dexterity with which a vessel is “stripped” or a segment of small bowel sutured.
Dr. Nolen has, disappointingly, passed over most of these details. How are such skills gained? What is the relation between acquiring them and learning how to “manage” a surgical patient? What is the relation between the science of surgery and its art (for the distinction here is real, however misused)? These questions he has been unwilling, or unable, to answer. Instead the reader is given such homilies as “The man that suffers through it will never forget it. I never have.” Or: “But when it’s all over and the new surgeon is turned loose to practice his art, somehow he’s ready. He has to be.”
Dr. Nolen’s failure to describe the evolution of surgical skills (his own or anyone else’s) is paralleled by his failure to describe another critical aspect of the discipline, though a much neglected one—its aesthetics. After even a week “on” a surgical service one understands how much a craft surgery can be—intricate and immensely satisfying, at times beautiful, even sensuous. Yet for this the author expresses no feeling, which suggests a larger and much more serious deficiency of the book and of its author. Dr. Nolen, at least as he reveals himself here—as he embarrassingly does—is insensitive not merely to the art of surgery, but to its object: to people, to their pain and suffering. His book is surprisingly desolate, suffused with the author’s tendency to turn people into something less than they are. He extracts from people what he can use: they are the subjects of the anecdotes that make up much of his book. He also does not hesitate to deride them, especially if they happen to be patients.
“Toni wasn’t a bad sort,” Dr. Nolen writes of a heroin addict:
She was actually very pleasant. There wasn’t any point in trying to go into the history of how she had got hooked (the stories were never reliable), but I think she truly wished she could break the habit….
Toni was, of course, a hooker. Every female addict I knew, at least any who had even a remote chance of getting a customer, was a prostitute…. Where was a girl like Toni, uneducated and unskilled, going to earn thirty dollars a day except as a prostitute? And when her looks and figure went to pot so far that she could no longer hustle for a living, she’d turn shoplifter or petty thief. They all did.
Dr. Nolen reveals himself to be, in fact, an enthusiastic amateur sociologist, undaunted by even the most apparent self-contradictions. For example, he writes that for his Bellevue patients “vitamins were a luxury” not because they couldn’t afford them, but because “they couldn’t afford to concern themselves” with them. On the one hand he seems to believe that his patients were so ignorant that they “had no idea of what a balanced diet was like” and that, if free annual medical exams had been offered them, they “would rarely have the time or inclination to take advantage of it.” On the other hand he is convinced that the “vagrants and petty criminals” he treated were so cunning that they were able to make use of the most obscure hospital rules, for example the rule that requires the admission of anyone who has even momentarily been knocked unconscious.
The Bowery denizens [a favorite expression] knew this, of course, so any time they got anything resembling a rap on the noggin, anything that left them with a lump or laceration that we couldn’t deny existed, they showed up in the admitting office and claimed they had been knocked out, and the admitting physician would have to let them in…. Usually the patient was drunk and most of the time he was belligerent. After a five minute examination I’d know there really wasn’t a hell of a lot the matter with him. Many of them were on the bum…. They were dirty, infested with lice, chronically undernourished and malingering. To them, admission to Bellevue was a godsend. True, they had to take a bath, which didn’t appeal to them, but once that was over they’d have a warm, clean bed and three meals a day…. Bellevue represented the height of luxury.
The combination of callousness and prejudice in this passage infects the entire book. In one chapter, modestly called “All About Nurses,” Dr. Nolen suggests that a good nurse is a woman who works harder than she is required to do, manipulates patients so that the doctor’s job is more pleasant and his mistakes are covered up, never complains, and gives her favorite intern a present at the end of the year (“I damn near cried,” the grateful doctor reports). Of one nurses’ aide Dr. Nolen remarks, “She was a Puerto Rican…but she knew how to work,” and of male hospital workers (excluding doctors) “I’d say 90 percent, conservatively, were homosexual.”
Consistently, it is the patient who suffers. “Goddamn you, Larry,” Nolen recalls having told one of the apparently countless men he suspected of malingering, “why the hell can’t you take care of yourself?” Nolen ignored the patient’s complaints until one of his superiors suggested he get an X-ray, because “maybe that will shut him up.” The film revealed a broken hip. “If he had been smarter,” Nolen writes, “he probably would have sued the whole stubborn bunch of us.”
Smarter? Clearly the surgeon’s ability to disguise his negligence derived not from the patient’s lack of “intelligence,” but from his powerlessness in the hospital—a quality shared by patients everywhere, and by all classes and races (though the poor and non-white indisputably suffer most). Indeed, one virtue of this depressing book is its naked expression of the hospital patient’s, and to a lesser degree every patient’s, status as nigger. It also serves to tell us something about the mind of a doctor who enjoys the grandeur of his position as much as any other aspect of surgical practice.
Dr. Nolen likes to use images of power, control, and domination. An operation, he explains, “like a battle, is a cooperative venture. The surgeon is the boss.” And although “A surgeon can no more operate on a patient by himself then [sic] can a general fight a war alone,” it becomes evident that, more than anything else, Nolen wanted to be appointed supreme commander, i.e., Chief Resident. At first disgusted and depressed by Bellevue’s physical appearance, Nolen chose to intern there because “Bellevue was like Everest…. I was young and fresh and idealistic. I wanted to join Dr. Stevens, Sharon and Jerry and take a crack at conquering Everest.”
Yet from the evidence of the rest of the book it becomes clear that what Nolen wanted to climb and conquer was neither Everest nor Bellevue but the rigid surgical hierarchy that held so much promise for the man who, according to his father, had it made. There is evidence enough in the headings of his chapters: “Assistant Resident: One Step Up” and “First Resident: Next to the Top” and “Chief Resident: Final Responsibility.” On the eve of assuming his position as chief, Nolen “jokes” to his assistants: ” ‘None of that now,’ I said, ‘rank has its privileges. Get smart and I’ll farm you out to a dog lab for the next six months…. I’ll have you in Podunk Hospital before you know it.’ ”
The book ends with Dr. Nolen attaining at last what he has coveted so hard and for so long: “The day that Dr. Stevens called me into his office and told me I was to be the next chief resident ranks with the day I received my acceptance at medical school, and if my wife will excuse me, my wedding day, in my personal list of great moments…I felt ten feet tall.” And he adds: “I wasn’t God by a long shot, but as far as power was concerned, I was closer to Him than anyone else at hand.”
This disturbing document of Dr. Nolen’s professional ascent should not however be dismissed. It is well worth studying closely. Unattractive as the portrait of Dr. Nolen may be, it can most valuably be seen as the product of a particular system of medical training and practice, of a particular set of professional (and even cultural) values. The serious deficiencies of the organization and delivery of health services are becoming increasingly apparent, and proposals of all sorts have been advanced to meet the widely acknowledged medical crisis of this wealthy, yet profoundly unhealthy, nation. However, essential questions about doctors themselves, are rarely, if ever, asked. So a book like Dr. Nolen’s is useful, in that it raises, if only by indirection, the question of what we want from doctors and what we think of them, of what doctors think of themselves and of their patients.
In a chapter called “Pathology: Six Months in the Death House,” Dr. Nolen touches upon what is perhaps the central concern of American medical practitioners. “Autopsies,” he writes, “remind us of our fallibility. Doctors are supposed to keep patients alive. Every time we let a patient die we’ve failed to do our job.” Nolen here is reflecting an attitude not limited to the profession but shared by most of us: we all perceive doctors as, above all, preservers of life, the determined enemies of death. Yet how radically different our idea of doctors was one hundred, or even fifty, years ago.
Until very recently doctors did not need to be reminded of their fallibility; it was everywhere evident. Before sulfa drugs and antibiotics, before antiseptic surgery and intravenous fluid therapy, most doctors and patients would have been amused by the notion that doctors were “supposed to keep patients alive.” It was not until 1912, according to the medical sociologist Lawrence Henderson, that “for the first time in human history, a random patient with a random disease consulting a doctor chosen at random stood better than a 50-50 chance of benefiting from the encounter.” Doctors would do what they could, of course—set broken bones, drain abcesses, certify births and deaths, prescribe harmless or harmful potions, induce diarrhea or vomiting, and act, by and large, as friend, adviser, comforter to patient and family. But doctors couldn’t do much, as everyone including the doctors themselves knew.
But during the first half of the twentieth century medicine was attached to science and technology. Suddenly—and the suddenness of this change can hardly be overemphasized—medical practitioners could do something for people, something measurable and dramatic and physiologic, could on occasion actually cure them. The impact of this transition was as much social and psychological as it was epidemiological. We need only recall the way in which antibiotics were at once given the name “magic bullets,” or cortisone that of “wonder drug,” to understand how much we all marveled at medicine’s new capabilities. The public response to organ transplants, especially cardiac, is a more recent example. Doctors today are not merely tradesmen; they are experts. They do not merely comfort the sick and alleviate pain; they battle with death, and even redefine it to suit their purposes.
This change has invested our physicians and surgeons with an aura of omnipotence vastly out of proportion to their capacities and with a sense of omniscience which serves to diminish their understanding. Dr. Nolen’s tendency to compare a surgeon to God, the ease with which he presumes to know what drug addicts are all about, and homosexuals, and nurses, indeed his own facile assertion that this country does not need more doctors, are only a few cases in point. At one moment Nolen wonders whether he might be “just an arrogant ass whose ego had grown out of proportion to his skill.” The answer to that question matters only because our society has placed men like Dr. Nolen in a position which makes them unaccountable to the rest of us, and which confers upon them an immense capacity to hurt other people, however unintentionally. “Damn it,” he shouts at one patient, “if you won’t let me do this job you can bleed to death! I’m sick of your bellyaching.”
But here one must sympathize not only with the patient but with Dr. Nolen himself. He and his colleagues are the products of an arduous education and training which are not merely narrow, but narrowing. Largely as a consequence of the recent changes in medical science and technology, with their increasing emphasis on the doctor as a miracle worker, the modern physician-in-training is systematically taught to think of his patients not as human beings, but as examples of one or another disease process, as “clinical material.”
A student today is fashionably encouraged by his teachers to think of the “whole patient,” but he surely knows that what is really expected of him is that he be at his hospital “rounds” on time, and that he be familiar with the most recent article in The New England Journal of Medicine on, say, “Elevated Histaminase Activity in Medullary Carcinoma of the Thyroid Gland.” The rites du passage of medical training stipulate that healers must suffer more than other men and women if they are to be certified. Indeed, Dr. Nolen remembers one of his professors saying, “I don’t give a damn about the intern who got straight A’s; give me the one who will get out of bed at night!”
Dr. Nolen did get out of bed at night, and must have suffered for his patients. At one point he is provoked by one of them, whom he had told to “be nice or get the hell out of here,” to feel a closer bond with them:
Before I could say another word I felt his hand close around my wrist like a vise.
“Listen, Mr. Big Shot,” he said, “just because you’ve got a nice white suit you think you can talk down your nose to guys like me. We’re just trash for you to practice on. Well, I’m not going to take it. Get me my clothes—I’m getting out of here.”
The thing was. he was right. I had been looking at him not as a patient who needed compassion and care, a human being with a problem, but as just another bum who was going to keep me from getting to bed that night. I picked myself up, swallowed my pride, walked back to the stretcher and apologized….
Ambivalence toward the patient was a constant characteristic of the entire house staff, but particularly of the interns. We were at Bellevue to learn, and we needed those patients just as much as they needed us. But at the same time, we were overworked and chronically tired. Sure, it was nice to have a patient with a perforated ulcer under your care, but god-damn it, why did he have to come in at two o’clock in the morning and keep you up all night? We wouldn’t have been human if it hadn’t bothered us. We tried not to give vent to our resentment, as I had on this occasion, but once in a while it was inevitable and, I think, excusable.
In one sense, certainly, Dr. Nolen’s crude resentment was “excusable.” The style which is imposed upon physicians-in-training in this country is neither instructive, as some medical educators would have us believe, nor glamorous, as the popular image would imply; it is, rather, destructive, and hated by those who must endure it. But is it reasonable for Dr. Nolen to vent his resentment upon his patients, whose suffering is at least as real as his, and not nearly so temporary and lucrative? And is this double-edged suffering really inevitable, as Dr. Nolen says it is? Only until such time, I would suggest, as Dr. Nolen and his colleagues, and all of us who have been or will someday be patients, come to see how we all share in it will we be able to identify its source—the intolerable shortage of medical personnel; the rigid and dehumanizing hierarchy of medical education and care; the cultural and economic and racial and sexual gulfs between doctor and patient; the archaic and senseless rites of initiation; the obsession with fighting death which prevents decent concern for the quality of that life which is deemed so precious; and of course the idea that health is a commodity to be bought or sold.
A new movement toward better and more democratic health care is emerging in this country, an alliance of radical professionals and consumer and community groups which is struggling to attain, in addition to specific structural and economic changes in the health care system, basic changes of definition. Patients are refusing, as Dr. Nolen’s patient did, to be treated as niggers. Young professionals are refusing to make it in the rigid medical hierarchy or to regard their patients as less than people, or themselves as more. Communities are demanding the right to control health facilities in their neighborhoods. Hospital workers (“menials,” as Dr. Nolen calls them) are beginning to organize into strong unions. Women, blacks, Puerto Ricans, Mexican-Americans, and Indians are demanding admission to professional schools. All of this, ironically, so that the relationship between doctor and patient can again become what the American Medical Association is fond of saying it is: a sacred trust.
Such efforts are only beginning. (The hospital workers, for instance, have not as yet taken strong positions on the question of health care.) But as they succeed, they will bypass doctors like Nolen, who will continue to regard themselves—as The Making of a Surgeon demonstrates they do—less as people than as characters in a soap opera. These doctors will doubtless remain as absorbed as Dr. Nolen is by “to put it in the vernacular, the ass-kissing” that getting to the top of the surgical pyramid requires. They will still be able to slice a patient’s leg with an electric saw while removing a plaster cast, tell the patient his pain is imagined, and then discovering it is real, say, as Nolen does, “It took some talking but I managed to convince Mr. Swanson that the cuts were his doing; he had jumped too much.” They will continue to scare patients out of the hospital with the threat of an unnecessary spinal tap or proctoscopic exam because the patients are making their demands known. And, if they can get away with it, they will still lie to families in order to get them to donate blood.
There were some very original and devious tales told. “Your father must have blood immediately,” one of my co-interns once said to a big family. “If you don’t all donate we’ll just have to give him dog blood, and that doesn’t always work so well.” Needless to say the family moved en masse to the blood bank.
A more subtle approach was to simply stand at the foot of the bed, shaking one’s head in dismay, watching the clear sugar-water infusion running into the patient’s veins and muttering, “If only it were blood!”—just loud enough for the family to hear. Usually the discussion that resulted from this approach was good for at least one pint.
Dr. Nolen’s confession is a best-seller. Eighty thousand copies are in print; it has been condensed in the Reader’s Digest; it is a selection of the Literary Guild; the publishers have allocated a large advertising budget for it, promising, in Publishers’ Weekly, that the author’s face will become “as familiar as your family doctor’s” (however familiar that is). Now Dr. Nolen has it made beyond the dreams of his father, to whose memory this book is dedicated. Indeed the popular acceptance of this book suggests the extent to which we are his accomplices. (At its last annual convention the AMA presented an award to Robert Young, of the television show “Marcus Welby, M.D.,” for epitomizing the values of the American physician.)
Dr. Nolen himself has moved to Minnesota, where he is now at work on a sequel to this volume, In Practice. Perhaps Bellevue, although it is a very important hospital which serves millions of sick, sometimes desperately sick, people, is no longer the Everest it once was. Or perhaps Dr. Nolen is simply no longer as “young and fresh and idealistic” as he once was. All he has to say on the subject, as the book closes, is “I didn’t need Bellevue anymore—some other would-be surgeon did.” He has left to teach those who aspire to become what he is how to do it and, as he says, “to do something for others with what I’ve learned”; while the rest of us may well wonder why his Bellevue patients could not qualify as those “others,” or why so few of us have the courage of the patient who gripped the wrist of Dr. Nolen and asked him just who he thought he was.
February 25, 1971