Friday Reflection #40: Power

JD is a 67-year-old man admitted with a community acquired pneumonia and a small parapneumonic effusion. The medical team admits him and performs a diagnostic thoracentesis, the results of which reveal a complicated parapneumonic effusion (pH = 7.11). A thoracic surgery consultation is called for a chest tube to be placed.  

Guided by the 99% Invisible podcast, four colleagues and I are making our way through Robert Caro’s 1974 epic biography, The Power Broker: Robert Moses and the Fall of New York. While reading a 120-page section for one of the monthly meetings, two of us highlighted the same sentence: 

“Regard for power implies disregard for those without power…”  

Although written with regard to the routing of Long Island’s Northern State Parkway in the 1920s, our discussion ventured into the applicability of this quotation to medicine.  

For me, what makes medicine a wonderful job is that our priority is to work collaboratively for someone else's benefit. In this age of cynicism, when so many have lost their trust in doctors (or science, or public health) or believe that the corporate contamination of healthcare has irreparably corrupted the field, I am sure it is hard for some to believe that this is true. Yet, I have rarely witnessed anything other to be the case. 

This is not to say that I always agree with the process or outcomes of medical decision-making. Second guessing, also called post-call quarterbacking, is alive and well in medicine and, when done thoughtfully, can be a great way to teach and learn. Let’s take one of my most common aggravations and consider what might be behind poor decision-making.  

A 65-year-old man goes to the ER after a syncopal episode. As part of his evaluation, a doppler ultrasound of his carotid arteries is ordered.  

Syncope (fainting) is a common problem, responsible for 1-3.5% percent of ER visits and 6% of hospital admissions in the US. Carotid dopplers are often done even though the test is definitively unnecessary in almost all cases. So why is it done? What might interfere with a patient’s welfare being the ultimate goal? I can think of four reasons: greed, sloth, ignorance, and fear. 

Greed 

Although money is the root of all evil, or talks, or makes the world go around or some other cliché, I think it has very little effect on the behavior of practicing physicians. At most academic medical centers, doctors are salaried. There is no financial incentive for doing another test or procedure or making another referral. I know that in other settings financial incentives exist for one more biopsy or one more consultation, but my experience in multiple practice settings, with multiple reimbursement designs, tells me that money has at most a small effect on medical decision making.¹

Sloth 

If greed is not the cause of bad decisions, might sloth be? If you are not salaried to do more, might laziness make you do less? I do not think doctors forgo necessary procedures because of laziness, but I do think it sometimes leads to extra interventions. When people don’t think, don’t look things up, don’t dig up old charts and old echocardiograms, they end up doing things those records would have shown to be unnecessary.  

Ignorance 

Ignorance certainly underlies some bad decisions. Given the current accessibility of knowledge, ignorance of facts in medicine today is just sloth. When you consider higher level reasoning and decision making, however, ignorance might truly lead to poor choices.  

Fear 

I do think that fear drives some poor decision making. Though some will equate practice driven by fear with the defensive medicine said to be practiced to avoid malpractice suits, I think more fear-driven practice stems from the fear of harming patients: the belief that it is better to err on the side of action to inaction, a problem with diagnostic calibration.  

So how does this all relate to power? In a collaborative environment, when some doctors are affected by greed, sloth, ignorance, or fear, and others by different types of bias and situativity, there will be disagreements regarding clinical management. Some of these disagreements will be critical: what drug needs to be given, does this person need to go the operating room, does JD need a chest tube? Other decisions will be important but not immediately critical: does this patient’s problem warrant overbooking her today? 

How are these disagreements resolved? Ideally, there is a discussion of the pros and cons of an intervention or a scheduling decision. Teams discuss the medicine and come to a consensus. This is one of my favorite parts of the job. We exchange ideas, cite literature, peer into our crystal balls. In the end everybody has learned and the patient has gotten the best possible care. 

And then there are the times that decisions are made by the person with the most power -- and “regard for power implies disregard for those without power.” When things run well, the person with the power has it for a reason. Power often comes with seniority and with seniority often comes wisdom.  

But not always. 

There was an incident during my internship when a patient of mine had the placement of a gastric feeding tube delayed for days because of a powerplay between me (a 26-year-old intern) and a senior surgeon.  

I recall a surgeon taking a patient of mine to the operating room. It was a difficult decision, discussed over the course of two days, both of us realizing that either an operative or non-operative approach would likely end with the patient’s death. The surgeon operated on the patient, I believe, not just because it was best for the family but because of the power I wielded in the situation. 

I was convinced that JD needed a chest tube. The literature at the time certainly supported my reasoning. What did not support my decision was the thoracic surgeon and my youth. I was overruled. The patient did well. 

In all three cases, a power dynamic dictated the decision that was made. There was also a disregard for those without power. In the first case, the surgeon disregarded my knowledge and the patient’s well-being. In the second case, the power I and the family held won out over the surgeon and, perhaps, the patient herself. In the third case, my knowledge was ignored.  

What is complicated is that, in all the cases, the counterfactual is not clear. I do not know how the patients would have done had the alternate decisions been made. Was power always working in favor of the patient? 

What I thought about first when I read Caro’s line is a situation common in my “mature” practice. A patient, who sees herself as powerful, asks that I use my power to help her navigate the system – usually jumping to the front of the line with an earlier appointment. I can get patients into clinics that I could not have 20 years ago – I have power that comes with seniority, with having trained many of the physicians in the institution. I am aware that helping my patient might delay care for a patient who does not think he has the power to ask for an earlier appointment -- or has a doctor without the power to secure one.  

I hope I usually navigate these rough seas of healthcare disparities safely and ethically. 

Sometimes medical decision making is simple, a doctor and a patient make the correct decision as equal partners. Sometimes, when collaboration is necessary, a team reaches consensus, avoiding the impact of greed, sloth, ignorance, and fear. Sometimes the decision is dictated by power, which implies disregard for those without power – a doctor or a patient. Ideally, power dynamics align with the best interests of the patient, with power in the hands of the doctor who will make the wisest decision. 

Photo by C.M. Stieglitz, World Telegram staff photographer

1. I have read and respected our readers comments on Sensible Medicine for long enough that you now live in my brain rent-free. I can hear the howls of laughter from some of you at this sentence.