Beethoven’s Gastroenterologist

Published in April, 2006

According to musicologists, Beethoven’s second symphony was written at a time when he was suffering from a severe gastrointestinal ailment. You will find in the fourth movement of this symphony a musical description of Beethoven’s abdominal symptoms. I am grateful that there were no gastroenterologists existent to treat his abdominal ailment. The severe discomfort of this medical condition provided the stimulus for the progressively radical, revolutionary, and immortal 3rd through 9th symphonies. Space is inadequate to detail the massive volume of string quartets, piano sonatas, and other compositions by Beethoven which redefined that “auditory stimulus” we call music. Beethoven demonstrates one of many instances where mankind has been more blessed by the absence than by the presence of physicians. Perhaps another one of those times could be right now.

It is unwise to ask physicians to go on strike to protest their multitude of grievances. Physicians  tend to care for patients even when inadequately reimbursed, threatened by massive personal inconveniences or lawsuits, and when un-thanked. Physicians are not requested, but demanded, to perform at 100%,  often working many 24-hour days straight, awakened many times through successive nights. Most of us can usually remain cheerful through this entire ordeal of exhaustion and sleep deprivation, and still act concerned about our patient’s welfare. This concerned behavior is usually because we actually do care about our patients.

The rules have slowly changed for physicians. Historically, patients were grateful for physicians, and accepted that things did not always work out. Medical care now has become a constitutional right. Medical care is now regulated and monitored, quality controlled and measured. Quality management has become the buzz-word across every specialty and across all 50 states. The tolerance for human error has reached zero. Safety is the summum bonum of medicine.

Other industries have observed that human performance tends to degenerate with exhaustion. Industrial scientists have identified that degeneration in performance tends to occur unnoticed by a person, especially when performing high stress and complex decision making tasks. There is good reason why the airline industry thought it best to severely restrict work hours for their pilots and flight attendants. Even the American Nursing Association is aware that nurses that work greater than 12 hour days tend to show severe degeneration in their performance and a greater incidence for mistakes, and has asked Congress for laws which severely restrict nursing work hours.

Oddly, physicians do not feel that their work performance degenerates with exhaustion and sleep deprivation. I recall instances in residency when my total sleep time for the week (Monday to Saturday morning)  contained less hours than the total fingers on one hand. I took great pride in my ability to perform surgery while totally asleep, not recalling a thing I did minutes after the completion of the procedure, yet noting that the patient got better and did well. Bravissimo! I protested loudly when the feds decided to regulate residency work hours at limits of 80 hour weeks and no more than 24 hours continuous duty at work. No more heroism in residency. No more tales of the “good ole’ days” when chief residents in surgery operated through the night, since it was then that they could operate independent of the attending.

Work-hour restrictions regulate the wrong doctor. The young and supple, healthy physician-in-training is most capable of loosing sleep and still performing well. The older doctor does less well at handling a long busy night on call preceded and followed by a full clinic day. Those late night decisions tend to be the most perilous. Specialties that have a low potential for disaster from poor decisions generally do not have to make those decisions at 2 am. If you use the wrong ointment to treat a skin rash, if you make an error in the refraction of an eyeball, if you wrongly advise an antidepressant when a good vacation might be more effective, the outcomes and treatment plans may easily be adjusted days or weeks later, sometimes to an unhappy, but rarely ever dead patient. A  2 am miscall on a ruptured appendix, myocardial infarction, or a delivery that is not going well, and you end up with the highly possible chance of performing in a theater of law defending your “thoughtless” actions which “caused” a poor outcome or death.

 The public desires to have matters two ways. First, they want no possibility of medical error. Secondly, they wish to have medical care immediate and on demand, paid for by somebody else. The public is currently receiving a close approximation of this ideal, but to the progressive bankruptcy of the system. Physicians are serving as the sacrificial lambs to make this short-term myth occur. We work progressively harder each year, yet are reimbursed continually less, while suffering from increasing taxes and overhead costs and oppressive state laws. This system is not sustainable—something is going to break. 

So, let’s deliver medical care with safety as its highest value. The public demands it–we should give it to them. Physicians should not work more than 60 hours a week (40 hours/week if you are greater than 50 years old and retirement mandatory at age 60), and nobody should work more than a 12-hour stretch in 24 hours, including time while being on call or on beeper. Our decisions and performances will be made when we are fresh, rested, and in optimal working conditions. Applying these regulations (which is still far more permissive than the airline industry regulation of pilots) will shut down the practice of medicine, but that is not our problem. Our problem is to deliver safe medicine. Lawyers may fill in for our absence at night.

Time for a little more Beethoven. Beethoven’s fifth symphony is a first instance of rhythm rather than melody defining a piece of music. Just say ba-ba-ba-baaaa in a monotone and everybody will know that it is Beethoven’s fifth.  Those immortal four beats are said to be fate knocking on the door. Soon, we’ll all be singing Beethoven’s fifth. It is not surprising that the best classical music today (eg., Goreki, Arvo Pärt) is coming from the old eastern block, where there is a serious shortage of physicians, and most non-life-threatening symptoms fail to receive a sympathetic ear.  Washington State just might find the absence of physicians a similar blessing in disguise. Just don’t take away our lawyers—you’ll need them for night call. Maybe they’ll be too tired to “serve” us in court the next day.