The Tragic Case Of The Anguished Physician


By Richard Gunderman, MD, PhD & James Lynch, MD

In his “Nicomachean Ethics,” the ancient Greek philosopher Aristotle points out that anger is not always a moral failure. To be sure, it is usually wrong to give in to it, but situations can arise when a good person naturally experiences a sense of moral indignation. The human mission is not always to hold anger at bay but sometimes to feel it appropriately – why, with whom, when, where, and how a good person would do.

Consider a real-life case that illustrates both the appropriate and inappropriate sides of medical anger. One day in clinic, a physician experienced a crisis. By his own admission, he had cursed, screamed, kicked a wall, and even cried. A complaint was filed. Among the infractions it cited were “unprofessional communication,” “disruptive behavior,” and the “unsettled” state of colleagues who were left “concerned for their safety.”

The institutional emergency response system was activated. The physician was placed on immediate administrative leave, ordered to stay away from the medical center, given a mandatory referral to the employee assistance program, and required to attend a program for distressed physicians. As the official letter made clear, these responses were not intended as discipline and were not to be construed as such. However, they would be recorded in the physician’s permanent file.

To the physician’s surprise, the investigation did not include speaking to him. On the contrary, he was ordered to report to a room in the executive suite, where he sat alone across a table from a collection of leaders. One, from human resources, he had never seen before or since. Two others were medical colleagues who had known him for many years, whose look of genuine concern was unmistakable. None asked him what he thought would help.

Instead, they delivered a conditional sentence. He was told that he must submit to each item on a list of “non-disciplinary” actions, under threat of discipline. They were acting as men and women of system, and they believed in their physician repair protocols as surely as they believed in their patient care system. Everything unfolded exactly according to the policy and procedure manual, spelled out with the utmost attention to propriety. Yet it seemed to the physician to miss the mark.

Despite the physician’s attempts to offer insights on what had dismayed him, the system acknowledged no responsibility, a stance that it has maintained to this day. Instead, it focused on following its own policies and procedures. All protocols and decision trees had been followed to a T. Established policies having been observed, not one of those present at the meeting ever reached out to him afterward to see how he is doing.

What might he have said if he had been encouraged to explain what happened, the series of events that led to his crisis? Suppose, for example, a committee member had asked him, “Can we, as health care system representatives, learn anything about the system that might help us improve it? Might we discover something about the etiology, pathophysiology, and treatment of physician distress that would allow us to prevent or at least improve our responses to such unfortunate situations?”

Here is what the physician would have said. More than once likened to the Obi-Wan of the hospital medical staff and medical school faculty, just the person to whom colleagues would turn in times of distress, he now finds himself feeling “like a cellist in a marching band,” or “a cellist playing a dirge in the ruins.” He wonders if he can ever feel at home in a system that evinces no interest in institutional soul searching.

The institution sees him as the pathogen and itself as the cure. Either the distressed physician must be repaired and reintegrated into the system, or he must be permanently extirpated, to prevent him from wreaking any more damage. Happily, in the meantime, the physician has returned to full-time work. After four months passed, he completed the required three-day course that some of his colleagues refer to as the “angry doctor class.”

So what happened? Months before the incident, his oncology partner announced his departure. Knowing that half their patients would be left medically homeless, the physician tried to assume their care. A younger version of himself would have been able to shoulder this load, but he was no longer young. He felt like someone carrying too many paper bags in the rain. The moistened bottoms give way, and the contents spill out.

Then a patient presented with a large mediastinal mass. The physician knew that urgent treatment was necessary, or the patient would wind up in the intensive care unit on a ventilator. With urgency in his voice, he argued as much, pleading for prior authorization. But the system’s wheels turn slowly, and a whole week passed before authorization was received, by which point the patient had already required intubation. The family was grateful that the patient’s life had been saved, but the physician knew better.

The insurer could have saved a great deal of money by keeping the patient out of the intensive care unit. The institution could have kept one of its ICU beds free for a patient whose placement there was inescapable. The physician could have avoided deep frustration and anguish and instead experienced a sense of fulfillment that his patient had been well cared for. And the patient could have been spared the anxiety, risks, and costs of a prolonged stay in the ICU.

The crisis occurred the next day, when during clinic the physician saw a distressed colleague, just beginning to cope with a frightening new diagnosis. Later that day, the physician was scheduled to host a wedding rehearsal dinner. Family members texted him, reminding him to be sure to arrive on time. Just as he was preparing to leave, he received a text about another patient experiencing delayed care. An insurance clerk told him that his prescribed treatment regimen was not on the “approved list.”

Knowing that he had his patient’s best interests at heart, the physician protested. He was invited to a “peer-to-peer” phone consultation to present his case, not to a clerk but to another physician. Later, the physician on the other end would turn out to be a long-retired member of a different medical specialty who knew little about the care of patients with this disease. Yet even before the physician could find this out, his call went to voice mail. This is when the situation became too much to bear.

The complaint filed by the clinic staff mentioned his cursing, screaming, and kicking the wall. It labeled his conduct as “unprofessional.” It accused him of making colleagues fearful. What it did not mention, however, was this: the physician had watched his patients, innocent and frightened human beings who assume that health professionals are doing everything possible on their behalf, fall victim to a system that did not and could not know them.

In his defense, the physician had never exhibited such behavior in the past. And even before the emergency response system was activated, he apologized to everyone present, later sending personal handwritten cards asking forgiveness. Yet the system did not see this. What the system saw was its own success. First, it had ensured that no patient was treated without promise of payment. And second, it had dealt with unprofessional conduct in a way that limited its own risks to the fullest extent possible.

Largely because employee assistance programs are often designed by people who have no direct role in patient care (attorneys and administrators), it does not see when a patient suffers needlessly. The system does not feel any sense of responsibility, in part because its policies were followed, but even more so because it is incapable of feeling. Too often, money trumps patient need, especially when there is no one to advocate. But in this case, there had been an advocate, and the system had come for him.

On the evening of the tribunal, the physician attended a banquet to celebrate the professional excellence of outstanding medical students, residents, and faculty physicians by an organization of which he is a long-time leader. On the drive home from the event, he received an automated message from human resources. It wished him a happy birthday in a tone of merriment that rang especially hollow. The system, it seems, was blind to the bitter irony of its well wishes.

Aristotle was right. The physician should not have acted out, but he had good reason to be angry, perhaps even to think disruptively. The system was letting his patients down, forcing him to delay therapy that his 31 years of professional experience demanded. It was not only imprudent to delay such care. It was also morally wrong. Every physician’s ultimate professional mission is not to follow policy but to advocate for patients. Now and then, a little anger may be just what the doctor ordered.

Richard Gunderman is Chancellor’s Professor, Schools of Medicine, Liberal Arts, and Philanthropy, Indiana University, Indianapolis, IN. James Lynch is dean of admissions, University of Florida College of Medicine, Gainesville, FL.


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    • Editor-in Chief:
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