Beyond the ER
The February 6 issue of The New York Review of Books carried Dr. Arnold Relman’s account of his own hospitalization at Massachusetts General Hospital (and elsewhere) under the title “On Breaking One’s Neck.” In a subsequent article, I said that the appearance of Dr. Arnold Relman as a patient at Massachusetts General Hospital, accompanied by his wife, Dr. Marcia Angell, was like the appearance of a royal couple: two former editors of the major journal, New England Journal of Medicine, physicians of the highest reputation and visibility, and senior mentor of many of the doctors on staff. (I have long admired Relman and Angell’s critical writings about the medical profession, and have read NEJM for many years in order to say in touch with medicine and the state of the profession.) After the ER, Relman moved to the Mass General Intensive Care Unit. There, the ninety-year old Relman died three times, only to be brought back to life by the vigorous efforts of the doctors. I noted that he had around him as supportive personal visitors during and after official visiting hours large numbers of doctors and lawyers, many of them relatives of Relman and/or Angell. It seemed clear to me that this distinguished liberal couple had put together (Angell used her editorial skills) a magnificent account of a benign and successful hospitalization, but an account which did not even come close to considering the haloing effect of professional courtesy for an eminent figure reduced to patienthood. I felt that this failure reflected a blind spot in the profession’s understanding of unequal access to medical care and that the lack of awareness of his own life-saving privilege tainted Relman’s larger analysis of the US medical system.
I sent my critique as a letter to the editor of The New York Review of Books, and heard nothing further. I published it on the New Politics Blog (January 22) as “How a Famous Ninety-Year Old Doctor Survived Hospitalization, But You Probably Won’t,” and then on Truthout (February 2). Now, some three months later, the May 8, 2014 New York Review carries a respectful letter from Dr. Manuel Martinez-Maldonado, who offers courteous praise for Relman’s article. But then, Martinez-Maldonado notes: Relman “provides a list of factors that he feels allowed him to remain alive, He forgets a very important one… One does not rapidly forget the editor of The New England Journal of Medicine. I’m sure that helped a lot with his care. I wonder … what would have been the experience of John Doe.” Having allowed himself this remark, Dr. Martinez-Maldonado then returns to his attitude of deference.
Relman then responds to Martinez-Maldonado, stating that his individual identity made no difference in the Emergency Room. But, he now acknowledges, the ICU was a different matter. The staff “allowed members of my family (particularly the physicians in my family) to stay at my bedside after visiting hours. I don’t think this would have been the case if I had been ‘John Doe,’ and I am quite convinced that this special treatment furthered my recovery.
We have to be grateful for small things. But Relman’s belated and very partial concession avoids confrontation with the role of privilege in access to life-saving medical care. Privilege is often invisible to those who have it. In fact a profession that claims to be above such things is riddled with systemic tribalisms which decide, often on a social basis, who lives and who dies. We sorely lack a critique of this from within the profession, and from patients, who must rise above the feudal deference built into the practice of medicine.
When doctors hear about, or experience, the horrors of contemporary medical care, they tend to miss the systemic quality and explain it with the medical equivalent of, “there’s a bad apple in every barrel”—an argument whose absurdity they may see when applied to police beatings of black youth, but whose absurdity they miss when applying it to medical care. In the implied argument of Relman’s earlier article—he received good care at Mass General because it is a “top-notch place”—he missed an important systemic consideration related to the place of hierarchy in the culture of the medical profession. The time is long past when we must realize that problems in medical care are not a case of individual bad apples, but are, rather, systemic and must be so described and opposed.
Stories like Relman’s update the Great American Success Story, a story which always oppresses those of us who do not share the success. He made it, came through the system fine, and just like us, had no special access. What about the rest of us, with our memories of horror and failure in our medical encounters? How do we explain our own bad medical experiences? If the system is a benign one, there must be some deficiency on our part, or at least the bad luck involved in encountering the bad apple. Success stories leave us blaming ourselves, rather than the system,