Two Doctors, Two Generations: Q&A with Dr. Barron Lerner

June 23, 2014 at 12:11 pm

On May 6, 2014, Barron Lerner, MD, PhD, kicked off the Lerner Lectureship series with a talk that explored the evolution of medical ethics through the lens of his father's and his own practice of medicine. Dr. Lerner's father, Phillip I. Lerner, MD, was "a revered clinician, teacher and researcher who always put his patients first, but also a physician willing to 'play God,' opposing the very revolution in patients' rights that his son was studying and teaching to his own medical students." The talk built upon Dr. Lerner's new book, The Good Doctor, which touches on issues of patients' rights, autonomy, generational friction, and the remarkable bond between father and son.

Below, Dr. Lerner discusses some of his father's unique stories and what it means to be a "good doctor."

The Lerner Lectureship is generously supported by Sam Miller, a grateful patient of Dr. Phillip Lerner.

Why did you write The Good Doctor?
There are several reasons. First, when someone is a historian of medicine and had a father who kept copious journals about his career as a physician, it is hard not to imagine fashioning this information into a book. Second, including medical school, I have now been in medicine for thirty years. To the degree that I have achieved some wisdom, I figured it was the time to reveal it. Third, my agent, Robert Shepard, has been trying to get me to write a trade book forever. So I finally succeeded. Fourth, and most important, the book is a tribute to my father, who I believe exemplified what it means to be a "good doctor." It is a taller task these days, but one I think that those of us in medicine should try to embrace.

What did you learn about your father from his journals and your other research?
The main "finding" about my dad's career was how he felt it was his duty, having mastered the scientific literature and learned as much as possible about his patients' lives and values, to make the right clinical decisions for them. This made him an unabashed paternalist and someone who, in certain circumstances, was even willing to mislead patients to get them to do the "right thing." As his career progressed, and bioethics and patients' rights emerged, he begrudgingly began to incorporate some of the new dogma about informed consent into his practice. But he remained strongly opposed to the reflexive use of algorithms and the practice of giving patients menus of diagnostic or therapeutic options. He believed that these approaches were not congruent with the true practice of medicine.

What were some of the most interesting stories you discovered?
Well, I guess you could say there were good and bad ones. One of my favorites was the time that my father got an elderly Orthodox Jewish woman to agree to an open lung biopsy by getting one of his infectious diseases buddies, who was a devout Catholic, to do a consultation on the patient. When this doctor took out his rosary to pray for the woman, she could not say no. In another case, my dad not only diagnosed meningococcemia, a severe bacterial blood disease, at a patient's home, but deduced that she had recently been playing tennis by the fact that the rash was worst in the area of her right forearm.
On the flip side, there is the story that starts the book in which my father placed his body over a recently-deceased patient to prevent his colleagues from resuscitating her. As the patient did not have a DNR order, this violated both the legal and ethical standards of the day. He also tried to get doctors and nurses to give both of my extremely-ill grandmothers enough morphine to get them to stop breathing. But even in these instances, my dad was acting according to his fervent beliefs about what it meant to be a compassionate doctor. After preventing the CPR, he wrote that he had acted based on his "30+ years as a physician responsible for caring and relieving the pain of my patients who can't be cured."

What lessons do your dad's and your medical careers reveal for future physicians and health care reform?
I would first point out that there is no going back to the paternalism of my dad's era. Patients' rights are here to stay. Plus, modern doctors do not have the time to practice the intensive, patient-centered care that my father did. But there are ways in our modern system to replicate some of what my dad did and stood for. There is a bit of a backlash against patient autonomy, for example. Patients may be quite willing to take advice from physicians that they know and trust, even about end-of-life issues. And although office visits may be only 15-20 minutes, it is still possible to spend a few minutes discussing what is going on in a patient's life. I like to write down what we discuss in my notes and bring it up at the next visit. And the doctor-patient relationship does not only have to occur via face-to-face encounters. Innovative programs are using phone calls, Skyping and e-mailing to allow busy physicians to stay in better touch with their patients.

The Social Construction of Cancer - Part 3

November 27, 2012 at 11:22 am

Editor's Note: This is the third of four installments from guest blogger Dwai Banerjee, a doctoral candidate in NYU’s department of social anthropology. Images illustrated by Amy Potter, courtesy of Cansupport.

Part III

In a later visit with the homecare teams, I met Rajesh - a 29-year-old man who has been battling cancer since his teenage years. The walls of his room in a dense middle-class neighborhood were bare but for two pictures - one of a Hindu deity and another of his parents who had passed away in an accident when he was still young. Rajesh had contracted cancer while working in a chemical factory in his late teens. The cost of his treatment led him to lose the little property that his parents had left him when they had died. The relatives that he lived with now took him in, but refused to extend any form of empathy or care. The stigma of the diagnosis of 'cancer' along with fears of its communicability saw to his isolation in the small verandah of the house. Yet, Rajesh's will to live was strong; on his own, he would travel to the All India Institute for Medical Sciences (AIIMS) early in the morning, negotiate the intricacies of the bureaucratic processes and make himself available for treatment.

As it stands, effective public health insurance is by and large absent in the Indian health scenario. In its place, the only financial respite for the poor comes in the form of subsidized treatment at government facilities. The bureaucratic procedures involved in procuring these government grants are daunting at best; very few cancer patients are able to transact the opaque bureaucratic process within the time allowed by rapidly progressive malignancies. Fortunately in Rajesh's case, where kinship had failed, a local network of knowledge and care stepped in. Cansupport and a sympathetic AIIMS doctor collaborated together to procure both a part-time nurse to care for Rajesh, while also taking him through the process of applying for a set of government grants.

In my conversations with Rajesh, it became clear that the years battling both the disease and the public health system and spent him. Time and again, his upbeat demeanor would collapse; at the end of one of our conversations as I made to leave, he stated baldly that if the disease returned he would not fight it again. It had deprived him of years of income and left him at the mercy of a family that had not cared for him at his most vulnerable. He had become the errand boy of the locality, earning his room's monthly rent by doing chores for his family and neighbors. His resentment towards his family was something that he had been forced to learn to hide; working for them allowed him to transact the complicated business of 'living on' with the disease. Over the next few weeks, Cansupport would try and work with its funders to set Rajesh up with a food-cart, to gain him the monetary security and independence he needed. While the biology of the disease was now in remission, the collapse of the infectious life of cancer had spread outside the body, jeopardizing his will and ability to carry on.

Dwaipayan Banerjee is a doctoral candidate at the department of social anthropology at New York University. Prior to his doctoral candidacy at NYU, he graduated with an M.A. and an M.Phil in sociology from the Delhi School of Economics, India. He has recently completed ethnographic work concerning the experience of cancer, pain and end-of-life care in India. His research follows the circulations of these experiences across different registers - language, medicine, law and politics. His broader interests includes working at the intersection of philosophy and anthropology, as well producing and studying ethnographic film and media.