Why Good Friends Don't Always Make Good Doctors *By KENT SEPKOWITZ, M.D.

* Published: November 30, 2004 "What would you do if it were your mother?" Patients ask me this simple question all the time. In fact, I have asked the very same question of doctors caring for my family. What better recommendation can there be? It's the medical equivalent of insider trading information. But is it the right question? Increasingly I wonder. In fact, I suspect it may be exactly the wrong question. A few months ago, I became involved in the care of a good friend who was hospitalized. For the most part, I served as a sort of kitchen cabinet adviser. But for a brief time, I entered the direct line of decision making. And I made a wrong decision. Antibiotics, my specialty, were being given and I thought that, given the discomfort and inconvenience of intravenous administration, the medication finally could be stopped. Wrong. Three days later, high fever returned and bacteria were again detected in the bloodstream. The situation was resolved by antibiotics, and little harm was done to my friend - or to the friendship. Making a mistake is always a miserable experience, and this one surely was more sickening than most. As I rethought the case I wondered why I had cut the antibiotic course short because, in retrospect, it seemed quite foolhardy. And then I realized the source of the problem: I had made the mistake because I liked the patient. And because of this, I didn't want to inflict more pain. The potentially distorted judgment of a physician caring for a loved one is well-worked territory. The traditional argument is that doctors may underestimate the severity of illnesses because they are unable to accept grim information about loved ones. Hippocrates, in fact, cautions against treating one's own family. My mistake, however, arose from a different, and much more modern circumstance. Medicine in the 21st century is a contact sport. It hurts. We have developed an assaultive, physical, even brutal approach to diagnosing illnesses and treating people: chemotherapy, surgery, biopsies, transplants. All for the better, most would argue, but literally a painful way to proceed. Once it was the awful taste of syrupy medicine; now it is the pain of a spinal tap. And this creates the following conundrum: Even when someone is quite ill, the doctor can't worry about hurting the person or the person's feelings. Sorry, but the next biopsy or the next surgery or the next awful test must be done. Trying to soften the blow in the name of friendship invites disaster. Stated another way, a better question to ask your doctor is: "What would you do if it were a total stranger?" This basic change in standard procedure for doctors and patients has largely gone unnoticed. Rather we remain attached to a Marcus Welby fantasy. Television's apocryphal Dr. Welby, who once diagnosed and treated worthy souls for an hour each week, held hands and frowned

thoughtfully, but he never did a bone marrow biopsy. The gentle 19th-century country doctor moved gracefully with his books and odd wooden equipment but did not catheterize your coronary arteries or fulgurate a polyp. And even the kind pediatrician of youth did not administer the modern menu of shots, shots and more shots - or else had the nurse do the dirty work. So where does this leave us? After all, the cool and aloof physician is the very model we had tried to mothball a generation ago. Entire medical school curricula were reformatted to teach students to be more sensitive. My class was among the first to be force-fed certain upbeat gestures, phrases and postures. We watched videos of actors playing concerned doctors. And we practiced how to nod our heads invitingly. Does the harshness of modern medicine mean we should return to the day of the shamelessly huffy doctor, consigning attempts at kindheartedness to the scrapheap? Surely not. Basic human decency remains the irreducible premise on which the entire health care enterprise is built. But the fact is that doctors do best when they preserve their crust, which may be mistaken for a lack of concern. It is simply too complicated to inflict physical pain on a friend no matter the long-term gain. Maintaining a stiff and formal distance, a professional arm's length, is the best way to assure intelligent, rational medical care. Perspective is thereby preserved, resulting in clarity rather than the fuzziness of sitting too close. Regrettably, the health care system works best when the doctor remains over there somewhere, off in the corner, friendly but never a friend. /Dr. Kent Sepkowitz is director of infection control at Memorial Sloan-Kettering Cancer Center./