Q: What Scares Doctors? A: Being the Patient

What insiders know about our health-care system that the rest of us need to learn

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Imagine the dilemma of a physician trying to watch over a loved one when things are going badly. Sherwin Nuland is a celebrity doctor; he was a surgeon for 30 years, teaches surgery and gastroenterology at Yale and is author of How We Die, which won a National Book Award. Last fall his daughter, 21, faced a crisis. She had been born with hydrocephalus--fluid on the brain. A shunt was put in, which worked fine for 21 years until it closed down. "She needed a total of four operations to get this straightened out," Nuland says. The experience tested his self-control. "It helped that I knew what [her doctors] were going through as these complications occurred--how badly it was affecting them emotionally. Because she was the daughter of a senior member of their faculty." But in an emergency, emotion is not an antidote for much of anything. However much we long for Marcus Welby, it is less important to know and love your doctor than to trust and respect him. And your prospects may benefit from his treating you with the cool commitment of a professional rather than the comforting warmth of a friend.


Finding the right doctor is important: but so is choosing the right hospital. There are all kinds of guides that can tell you what percentage of heart-attack patients were prescribed beta blockers upon arrival or sell you a report about your particular doctor. The problem is that it takes a doctorate in statistics to sort out the data. "The world's best orthopedic surgeon will be sent everyone's disaster cases," says Wachter. "He may be spectacular and still have worse outcomes than the crummy surgeon across the street who has better outcomes because he gets the slam dunks." Almost every knee replacement results in few days of post-op fever. It's normal--but it can still be cited in a report on the "high rate of postoperative infection."

The most basic challenge facing every patient is knowing when to go to the local community hospital and when to seek out the major teaching center. For all their fame and all-star doctors, teaching hospitals carry risks of their own. The sickest patients often have compromised immune systems and may need to be treated with broad-spectrum antibiotics--which increases the chance that antibiotic-resistant strains of staph and other bacteria will make the rounds of the intensive-care unit. As a rule, doctors decide where to go based on how sick they are. For fairly routine care--a hip replacement, a hernia operation--they will often opt for the convenience and comfort of a community hospital. But if there is any mystery about the symptoms, the rule is Get Thee to a Teaching Hospital. The meals will probably be worse, the beds may not get made on time, a spirit of competent chaos may abide; but for complicated surgeries, the mortality rate is typically lower because the volume of cases is higher and the surgeons are more experienced. Plus, the presence of all those interns and residents has a way of keeping doctors on their toes.

There is, however, at least one exception to the rule.


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