A novel by Robin Cook is a great read with a medical theme. It brings up some serious questions about quality control and medical education.
Today is a holiday in the U.S. It is a day to give and receive, to enjoy family and friends, a day of selflessness and giving joy to others. In that spirit, I will recommend a book that brought me joy but was not my usual fare. It was a thriller with a medical theme, a page turner, a “junk food book”, an “airplane book,” escapist fiction, “trash reading,” call it by whatever pejorative epithet you want. I have read most of the classics and all of Shakespeare; I even read Don Quixote in the original Spanish. I thoroughly enjoyed them, but I have also enjoyed comic books. Sometimes you want a filet mignon, sometimes you just crave a Big Mac. I enjoy both. I refuse to feel guilty for indulging in guilty pleasures. This book had the added value of educating the reader about the inner workings of a teaching hospital, and it brought up some serious questions about the need for reforms in medical education.
The book is Charlatans, by medical doctor and best-selling author Robin Cook. Dr. Noah Rothauser is in his last year of training as chief surgical resident at a major teaching hospital. Dr. Ava London is a staff anesthesiologist with great credentials and an impeccable record. When a healthy patient dies on the operating table during a routine procedure, Noah is responsible for the Morbidity and Mortality (M&M) conference to determine whether any errors had occurred. He suspects the egotistical, vindictive surgeon, Dr. William Mason, is to blame, but the surgeon blames Ava. Much soul-searching, legal maneuvers, personality clashes, and hospital politics ensue. The plot thickens when more patients unexpectedly die under anesthesia. Noah discovers duplicate medical records, alterations to records, poor communication, omissions in medical histories, patients who lie, and other problems. It is a fascinating story replete with details about surgery and anesthesia. Near the end, there is an amazing surprise: a twist that no one could have foreseen.
I am going to divulge the surprise. If you want to get the full enjoyment out of reading the book, stop now and come back after you have read it.
Really. Stop reading this. The secret will be divulged. It will spoil the suspense of the story for you.
OK, you were warned. Proceed at your own risk.
It turns out that despite her phenomenal test scores and many years of exemplary performance, Ava never actually did an anesthesia residency. In fact, she never went to medical school! She didn’t even go to college. And she isn’t even Ava London; she appropriated that name from a high school classmate who committed suicide. She started out working for a dentist who let her do anesthesia on his patients; she figured, that’s not so hard. Unwilling to jump through all the usual hoops, she found an easier way.
How is such a thing possible? Well, it’s improbable, but it’s not impossible. She was highly intelligent, had a phenomenal memory, and was a skilled computer hacker. She was in the right place at the right time. She knew how to fabricate the necessary records, test scores, lists of patients, letters of recommendation, and everything needed to create the perfect paper trail. She had access to state-of-the-art simulation labs at a new medical school, so she could practice procedures. It’s not unheard of for a layman to get away with impersonating a doctor, as in the reality-based film The Great Imposter. In the modern cyberworld, identity theft, photoshopping, and bogus information are widespread. In this “post-truth” era of “fake news” any document can be questioned, and anything is conceivably possible. It’s a chilling thought: are your surgeon and your anesthesiologist really who you think they are? How could you know for sure? I hope you don’t have surgery scheduled while you’re reading this book.
Re-thinking medical education
Do doctors really need to go through four years of college, four years of medical school, and several years of residency training? Nurse practitioners and physician assistants do a creditable job of patient care with much less training. Enlisted corpsmen in the military do an excellent job. A 23-year-old Pharmacist’s Mate First Class successfully performed an appendectomy on board a submarine in enemy waters in 1942.
I can attest to many wasted hours during my education and training. On the advice of my pre-med advisor, I studied calculus for a year; I never used it. I enjoyed my classes in music appreciation and 20thcentury Spanish poetry, but did they make me a better doctor? If someone is going to be an ophthalmologist or a psychiatrist, is there any point in delivering babies or scrubbing in on heart transplants in medical school? When trainees spend endless hours drawing blood, starting IV’s, changing dressings, and doing other scut work, is that really necessary? Ancillary personnel will do all that for them in the future. Is the exercise educational, or is it abusive? It benefits the hospital, but does it benefit the student doctors?
Long hours and lack of sleep are traditional for residents. Older staff physicians say, “We had to suffer through it, so they should too.” Even though new regulations limit hours, it’s possible for doctors to voluntarily spend extra hours in the hospital for patient continuity, even fudging records to make it look like they’re compliant. Am I a better doctor because I worked from 8 AM Saturday morning to 5 PM Monday afternoon without sleep and was only able to lie down and rest for a few minutes? I don’t think so, and I don’t think I was doing my best for my patients by Monday afternoon.
It is common for top surgeons to schedule two or even three operations in different operating rooms at once, relying on their subordinates to open and close and to do routine parts of the procedures. Usually all goes well, but what if two unexpected emergencies developed simultaneously in two rooms? The surgeon can only be in one place at a time, and the patient in the other room would likely suffer.
As Dr. House famously said, “Everybody lies.” In the novel, a healthy man thinks he is going to have spinal anesthesia for his routine hernia operation, so he disregards the order to eat nothing after midnight and lies about it repeatedly. Several personnel ask him about it and he repeatedly denies eating because he is convinced it doesn’t matter. An unexpected complication requires the anesthesiologist to convert from spinal to general anesthesia; and during the intubation, he vomits up his large breakfast, obstructing his airway and leading to his death.
In the novel, a patient had two medical records. One described an old neck injury that was a contraindication to intubation, the other failed to mention it. The anesthesiologist got the second record and had no idea what to expect. Intubation failed, and the patient died. Other crucial facts were missing from patient histories. In one case the checklist required a resident to do a physical on the morning of surgery; the checklist was not followed because the patient arrived late, and the resident was busy elsewhere, and the surgeon’s colleague had previously done a physical that was thought to be adequate but turned out to have been done incompetently.
Miscommunications were rampant. The surgeon’s secretary told anesthesia the surgeon wanted his patient to have spinal anesthesia, but the surgeon thought the decision of spinal vs. general was to be left up to the anesthesiologist.
In a side story, Ava has gotten rich consulting and lobbying for the dietary supplement industry. She disapproves of dietary supplements but lends her experience and prestige to influence legislators not to repeal the DSHEA. She thinks by being part of the industry she can discourage the worst practices of the more unscrupulous companies. I question whether that is realistic. In the event, her employers use a security company to protect her, not realizing that it hires criminals; kidnapping, murder, and mayhem ensue.
Conclusion: a thrilling read and much food for thought
I don’t know how realistic Charlatans is, but it was fun to read. I hope there are no Ava Londons in my hospital. We all know mainstream medicine is far from perfect, and the novel prompts us to look at it even more carefully. Quality control is a big concern, and it is already being addressed with checklists and other measures. I don’t presume to know if or how medical education should be changed, but the first step is to think about the possibility of changing it. And of course, changes could be instituted stepwise and monitored at each stage with controlled studies.
Watch out for charlatans. But all things considered, it’s usually safe to trust your doctor.
This article was originally published in the Science-Based Medicine Blog on December 25, 2018.