The Trap of Overspecialization

What follows is an excerpt from “Medical Catastrophe: Confessions of an Anesthesiologist,” written by Ronald W. Dworkin, MD. In addition to his work as an anesthesiologist, Dr. Dworkin teaches political philosophy in the George Washington University Honors Program and has written essays on medicine, culture and politics for a variety of publications, including The Wall Street Journal and National Affairs. His work can be found at RonaldWDworkin.com.

I called the number on the screen. It was the emergency room. The doctor on the other end of the line said that a patient was having difficulty breathing and might need to be intubated.

I went to evaluate her. The woman was in her twenties, thin, and wearing a party dress. She had asked her friend to take her home because she was feeling feverish and her throat hurt. While in the car she grew short of breath, so her friend made a quick detour to the hospital. When I met her she was sitting bolt upright in a tripod position, her head leaning forward and her arms extended in front of her, her fists bracing against the gurney. All her energy was focused on getting air into her lungs; even her saliva was ignored, as she let it drool down the sides of her mouth. Her eyes were unmoved, unseeing, and inexpressive. When I introduced myself a look of helpless bewilderment passed over her face in a sort of anxious spasm, making her sentient for an instant, only to return again to that look of dumb amazement.

When I went upstairs and told Dr. C about the case, he turned pale and looked at his watch. It was five o’clock in the morning. Perhaps the case might be delayed until seven, when the regular day would start and more staff would be around, he wondered out loud. I rolled my eyes. Then he pulled himself together and announced the plan: Acute epiglottitis is usually a pediatric problem, he noted. Therefore we would apply the strategy that pediatric anesthesiologists use in such cases. We would breathe the woman down with anesthetic gas; when she was deep enough, we would intubate her. To be safe, we would have an ENT surgeon around, ready to open a hole in her neck in case the airway closed off altogether before the tube could be inserted.

A modest plan, but in retrospect it was not realizable. Again, Dr. C’s error was to copy pediatric anesthesiologists at all points and not dare to stray. Our patient exhibited stridor, meaning she made a vibrating noise with each inhalation because her airway had narrowed. Because a child’s airway is already narrow it takes only slight additional narrowing to cause stridor; hence the endotracheal tube size needed in a stridorous child may be only slightly less than that needed in a healthy child. Moreover, the alternative to intubation—placing a hole in the windpipe directly through the neck, a procedure called tracheostomy—is fraught with post-operative complications in children. This is why pediatric anesthesiologists prefer to intubate children suffering from acute epiglottitis. Stridor in an adult, however, indicates a high degree of narrowing. The normal adult airway is fifteen to twenty millimeters in diameter, but an adult will not exhibit stridor until his or her airway is less than five millimeters in diameter—a large drop in cross-sectional area. Only a tiny breathing tube relative to normal size can pass through a stridorous adult’s narrowed airway, leaving the adult with the impossible task of breathing through a thin straw. Much safer to let a surgeon carefully and methodically place a wide-bore tracheostomy in an adult’s neck while the adult is still awake, especially since adults suffer fewer postoperative complications from tracheostomies than children do.

But Dr. C wasn’t thinking that way. He was a pseudo-technician trying to mimic a real technician. He was a monkey on the wrong stage.

Although he had a plan, Dr. C showed signs of uneasiness. Instead of waiting calmly for the moment to strike, he did his utmost to avoid it, to put it off and to keep it at a distance from him. When the ward clerk asked him if she should send for the patient, Dr. C said he needed more time to set up the operating room. When the nurse finished sterilizing the instruments, he told her to run them through the autoclave again, to be safe. He was trying to run out the clock; he was trying to get to 7 AM. His instinct for self-preservation was strong. It is the same instinct that fills a man sentenced to death with hopes that are not destined not be fulfilled. Dr. C kept looking anxiously at his watch, as if expecting it to save him. He seemed to know that his expectations were in vain, but he waited all the same.

The patient arrived. The ENT resident arrived a minute later. He was a good-looking young man with that look of self-satisfaction and conceit that senior residents are often more likely to exhibit than to deserve. He stood near the operating room table with a bored air. When Dr. C asked him whether he was ready to place a tracheostomy quickly, he replied, “Of course. No problem.” I detected something of the patronizing attitude of the expert standing above the rest of humanity in the tone of his reply, which was jarring, since he was a resident, as was I, but Dr. C either failed to notice it or simply overlooked it.

It was Dr. C’s second mistake—again, the mistake of the craftsman, not the artist. Dr. C was obsessed with technique and ignorant of what life experience should have been screaming to him about this young man: how this young man had yet to lose the freewheeling habits of his student days; how he had retained the urge to brag, to feign omniscience, and to conceal with casual aloofness any personal doubts about his abilities; how this young man proudly felt he was not like other young men. I recognized the personality from my college years: mental laziness combined with a rapscallion’s hope that “something always turns up, not to worry.” The young man could not be taken at his word! But Dr. C failed to take his measure and wrongly put his trust in him.

We put the woman at a forty-five degree angle on the operating room table. She made a long and melancholy cry with each inspiration. The sound seemed to arise from the very depths of her being. As the nurse prepped the neck, the woman fixed her eyes on the operating room light overhead, as if thinking here was the center, the focus around which the world gravitated. She was oblivious to the activities going on around her. She seemed to know only that something strong and bright, but less bright than sunny warmth, swept her face, and that she needed more air.

I placed the mask on her face and turned up the gas. Gradually, the anesthetic tugged at her consciousness, inducing forgetfulness, lassitude. Then came darkness, deep and impenetrable, weighing heavily on her brain. I thought she would be resigned to the darkness, to be almost grateful for it. But she was not resigned. There was some instinct in her that desperately craved freedom from the blackness. Although unconscious, she snapped her head from side to side. She reached for the mask with an arm I had forgotten to tie down. She defiantly withheld her breath.

Finally, she settled down. Then I looked inside her mouth with my laryngoscope. I saw only red, angry-looking tissue. I could not find the hole where I needed to insert my tube. I asked Dr. C to bang on the woman’s chest to send a small air bubble out of her windpipe, to act as a beacon. I confidently placed my tube at what I thought was the exit point. But my monitors quickly told me that my tube had gone into the esophagus and not the trachea. Dr. C furiously pushed me aside. His eyes darted back and forth, disturbed and restless. He tried to intubate the patient but failed. He tried a second time and failed again. Three attempts at intubation had irritated the woman’s already inflamed epiglottis, further narrowing the hole she had to breathe through. Nevertheless, air still squeaked through.

This is when the catastrophe occurred—a catastrophe that followed directly from Dr. C’s misunderstanding of what a doctor is. Professional medicine says a doctor is a craftsman, a technical expert. Therefore, Dr. C assumed, a good doctor must be a good craftsman who can perform a craftsman’s technical tasks. It would be a failure of doctoring not to do so, he believed. It was on such thinking that one more attempt at intubation hinged. Dr. C could have ordered the ENT resident to start work on a tracheostomy now, while the woman was still breathing. That way the resident could have taken his time. But Dr. C was tempted to try one more time to intubate, to prove to the whole world he was a doctor.

I have watched this mind-set operate in other venues. Anesthesiologists, for example, are keenly conscious of who is superior in the art of spinal and epidural anesthesia. When an anesthesiologist successfully places a spinal needle in a patient after another anesthesiologist has failed, the failed anesthesiologist feels like a man unable to consummate his marriage. He feels impotent, he can’t penetrate, he can’t get the thing in, and another man must do it for him. He endures a serious challenge to his manhood, and although he appreciates the other anesthesiologist’s help, he also hates him for succeeding.

This mind-set is especially dangerous when it involves intubations. The egos of some anesthesiologists are tied up with being technical wizards. Because they associate being a doctor with performing a procedure, they will jam a breathing tube inside a patient’s airway again and again, determined to get the tube in, causing so much throat swelling that the patient suffocates. I am familiar with several such patient deaths around the country.

It was on this mind-set that our patient’s life hinged. Already shamed by his lack of pediatric anesthesia expertise, Dr. C was determined to salvage his reputation by accomplishing a more difficult trick: intubating a patient with acute epiglottitis. “There was a man!” he imagined the crowd would roar. In fact, there was a monkey. He placed the breathing tube in the woman’s throat a fourth time. When the monitors proved again that the tube was in the wrong place, he quickly removed it and put the mask over the woman’s face to let her breathe oxygen and anesthetic gas, but now she was completely obstructed. Instead of her chest rising when she tried to breathe, it sank. Within seconds her color grew dusky.

All of us knew instinctively that death was close. Dr. C barked at the ENT resident, “Do the trach!”

The resident’s face grew white as a sheet. “Okay, but you know, I actually haven’t done this before . . .” he pleaded.

Slowly, as if trying to remember the illustrations in a textbook, the resident cut the delicate throat with a scalpel. The more layers he penetrated, the more blood flowed from the small wound and poured over the sides onto the mottled neck. The patient’s anatomy was deranged, he declared, to justify his slow pace. After a minute, no real progress had been made. The resident began to poke aimlessly in search of hard cartilaginous rings. The patient was turning blue. Her heart rate dropped into the forties.

Drops of sweat chilled my back. I looked at Dr. C. His nervous eyes had a hint of madness in them as he gazed back at me. “Perhaps we can give her some Atropine?” he panted with agitation. She didn’t need Atropine; she needed oxygen. But Dr. C injected the drug through the woman’s intravenous all the same.

The ENT resident dug deeper into the mashed blue-blood tissues, the blood clots themselves impersonating vital structures, with light barely able to penetrate the dark incision. A drop of brow sweat fell into his right eye. He blinked furiously to regain his vision. In the background we heard the patient’s heart rate rise on the EKG monitor. False hope: the Atropine Dr. C had given had artificially boosted the rate, although the underlying cause—lack of air—remained uncorrected. Irrational, deluding himself into thinking he had time when he actually had none, the ENT resident began poking about the neck with less urgency and with a clarity of mind that was useful but undeserved.

Things were going nowhere. I grabbed an intravenous catheter and went to the side opposite of where the resident was working. My plan was to pierce the small cricothyroid membrane that covers the windpipe low in the neck, and to hook the catheter up to a high-pressure jet ventilator. That way I could force air into the lungs, although how air would then escape the lungs I wasn’t quite sure. I was counting on the resident carving a hole in the trachea by that time. My needle hovered over the patient’s neck below the site where the resident was working.

Suddenly a man in street clothes darted into the room. He shoved the resident aside, grabbed a knife, and started cutting on the woman’s neck. It was the ENT attending who had been paged to come in from home. When he had heard what was happening he skipped changing into scrubs. Probably he had a more sober and accurate view of the ENT resident’s character than Dr. C did, adding to his sense of urgency. Within twenty seconds the windpipe rose out of the wound. The surgeon cut horizontally between two rings. He snatched a hook to spread the incision apart and then inserted a tracheostomy tube into the hole. I connected the tube to the anesthesia circuit and forced pure oxygen into the patient’s lungs. Everyone fell back for a few moments and gazed at the patient’s face, once blue, now reassuringly pale white—a mask that perhaps concealed some deeper damage within.

We brought the patient to the recovery room. She had yet to regain consciousness. Dr. C looked around skittishly to see if any eyes accused him.

I stood staring at the woman, girlishly pretty even in her critical state. She still wore her party dress. The arm that had reached up for the mask during the anesthetic induction lay on the gurney, its hand clenched tight. In all the swirling activity we had missed it, and I peeled back the fingers to reveal a tiny locket with a young man’s picture in it. Evidently she had clutched the locket before arriving in the emergency room.

“Who—who were you dreaming of in your hour of doom? Your boyfriend? Your brother?” I asked myself, my heart fluttering with uneasy curiosity.

I looked at her again. Life was seething, surging, pulsating inside her. Her organs were healthy and fresh. Her brain was sunk in wearisome sleep, waiting, hoping to be awakened, but the many minutes without oxygen might prevent that from happening. Nausea welled up inside me. I closed the woman’s hand around the locket, deciding it was right for the locket and the woman not to be separated.

We were in the realm of the indefinite, without certainty. I was uncomfortable— and yet discomfort captures the essence of what had gone wrong. When doctors become craftsmen, they narrow down their minds to materially determined magnitudes and formulas. To be certain about what they do know, they shrink down what they have to know. But a doctor-craftsman is dangerous, as the craftsman, unlike the monkey, has an ego that needs to be stroked; the craftsman may persist in an activity long after the monkey has abandoned it. When the craftsman’s work depends on knowing people, the situation grows especially dire, as people exemplify the indefinite more than anything else. The craftsman is not an artist; he or she has little understanding of other people’s lives; he or she has much perfect knowledge but little imperfect knowledge; he or she is uncomfortable with the indefinite. Doctors are sometimes called “craftsmen who love humanity,” but what good comes from loving humanity without knowing people? Far safer for a doctor to despise humanity but know well the people around him.

Professional medicine largely ignores the problem of subspecialists suddenly thrust onto the general stage. Doctors confess their concerns to each other privately but rarely publicly. Most medical boards today issue time-limited certifications, requiring doctors to stay abreast of their fields and keep a hand in general practice, thereby giving lip service to the problem while covering themselves at the same time. The method is useless.

I am a living example. Before anesthesiology trainees start their residencies they take the board certification exam, which they must pass three years later to become board-certified. The test at this stage is only practice; they aren’t expected to pass. But I did pass. People called it a fluke. But I had read all the anesthesia textbooks the year before. It was no fluke. Nevertheless, the notion that I was a fully functioning anesthesiologist at this juncture was ridiculous. I had book knowledge but no experience in giving anesthesia. And I certainly didn’t understand people. I was unsafe. In the same way, Dr. C had book knowledge about pediatric anesthesia but no experience in giving it. And he didn’t know people. He could have passed a pediatric anesthesia certification test, but it would have meant nothing.

Sometimes subspecialization in medicine goes so far that instead of fearing what they no longer know, doctors cease to know that they no longer know. They grow so removed from general medicine that they no longer take other fields seriously. This also causes catastrophes. I am familiar with several cases in outpatient surgery centers where gastroenterologists or plastic surgeons supervised nurse anesthetists, having assumed the role of anesthesiologist (which they are legally allowed to do, since they are MDs), resulting in a patient death. They watch the nurse anesthetists perform their technical tasks; the whole thing looks so easy, and pushing the anesthesiologist out of the picture saves money, so, these physicians think to themselves, why not take over the supervisory role? Then a catastrophe occurs. In one case, a patient’s surgery was performed in the prone position under deep sedation, which most anesthesiologists would have avoided because of the patient’s large size. In another case the drug succinylcholine was not available to treat a patient’s laryngospasm when her vocal cords were touched under anesthesia, causing her to suffocate. Again, the gastroenterologist was supervising the nurse anesthetist; no anesthesiologist was immediately present. Very few anesthesiologists would have performed such a case without having succinylcholine in the room. But in this case it was the gastroenterologist’s call.

Fortunately, my patient finally woke up in the recovery room, her mind intact. Catastrophe had been averted. At 8 AM we all went home.

Dr. C learned nothing from the experience, except to be wilier in the future when ducking hard cases. His most trusted method came to be “discovering” a small thyroid nodule in a patient that he didn’t want to put to sleep, and then demanding a full workup, thereby punting the case to another doctor at a future date. Another method of his was to hide the patient’s chart before surgery to run out the clock. The nurse would waste time looking for the chart; the patient could not be brought into the operating room without it; with every minute of delay, Dr. C was that much closer to being relieved by another doctor.

I went the other way. I learned to keep a familiarity with general anesthesia practice and never to allow myself to become an exclusive sub-subspecialist. A doctor is not a craftsman, and a good doctor is more than just a good craftsman.

From “Medical Catastrophe: Confessions of an Anesthesiologist,” by Ronald W. Dworkin.