51

The Powwow

"Two great physicians first My loving husband tried

To ease my paiii-iii N~aiii. At last he got a third

And then I died." Epitaph in Cheltenham clitii-cliN-ai-(l

The consultation, a convocation of medicine men, takes place when the patient's family has doubts. They worry that their own ai-igtir may have misinterpreted the omens. They worry that his brew lacks potency. They decide that their own death-wishes ("I wish Mama would get better or something") must be overcome by multiplication of magic. Two beads are better than one, they figure, even as shrunken ornaments.

Doctors are well aware of how families feel. The patient is a secondary consideration. The families pay the bills. If the patient dies, the family must have no regrets that they have not done enough. If he lives, they must be able to congratulate themselves on their foresight in having a consultation. So virtue is made out of necessity. "In the interest of the patient" consultations are called. No families object. They are pleased that their doctor (in whom they say they have the greatest confidence) is asking anotl-ier doctor to give his opinion. They have two levels of thinking: on one they know that two doctors seldom disagree and that whatever changes in regimen will be made will be done solely to justify the consultation fee. On the other they klio%\- that a doctor one hundred pei- cent sure of him

!f %%-oiild never think of asking another doctor to see

T ~o -:iiiiiier in which consultations are conducted lm clia.-, --, (I on-er the years. It used to be that the doctor in %koiil(l tell the family that he wanted a coiistiltatio:-, If(- %%-oiild then call his consultant, meet him at the ()f the patient and send the familv outside the rOOTli Tli(~ c,)iistiltaiit would listen to the doctor's recotilltiT)Z of tlit, 1)atieiit's history and then would examine the patit,rit. -kfter\~-ards, both doctors would go into a huddle fir front family or patient, in another room if possible, or at least iii the I)athroom. Both doctors would then meet the fri,,Iiteiied family. The attending doctor would state the consultant's opin-

 ioii while the lattei- iio(l(iecl in al(ri-eciiieiit. The feNN, questions fi-oiii the f'ztiiiiln- \Noti](I I)e (leftl,,- ~iiisNN,ei-eci ii) double-talk, lea\-iii,-, tileiii c-()iifiis(,(]. The coiistilt~ijit would accept his fee ~iii(I (1(,I)zii-t. Tlieii the faiiiiIN, would ask the atteii(iii)(-r (loctoi-, "\N-liat (ii(i lie saN~'-)" aitcl listen to the iiitei-pi-t~t~ttioii of the oi-~ictilai- opii)ioii.

That's cliaii(,cci iio\N-. The patient sick- ciioti(,I) to iiee(i a consultant is iistiill\- iii ~t liospit~il. The ~itteii(Iiii(, doctor, alert to the iiiixi(,ties of the kinfolk, tells them that he is liax~iii(, a coiisiilt~itioii. The coiistiltztiit c~oiiies iiiiannounced aii(I iiiiatteii(led, reads the hospital cliart, examines the I)ziti(,iit aii(i xn,i-ites his opiiiioii on the cliart. That ol)iiiioii is tiieii retailed to the faiiiiln- I)N ~the doctor iii c-li~ti-(,e, \\-Iici)eN-er lie ~,,,ets around to it, Preseiit-(Ia,,- pi-oc,ecitire is less foriii~il tliiii pi-c\-iotisl,,, but just as effecti\ c. The amenities are ol)sci-\ (,(I.

NN'hen are coiistiltatioiis called? The .1()iiit ('()iiiiiiitt(~e

on Hospital Acci-c,(Iitatioii reqtiii-es tli(,iii  (',IC

sareaii sectioii is to be doi)e for the fii~,,t tiiii(~, \\Iieii a therapeutic abortion is advised ~iii(I  ()I)c,i-~itioiis

designed to cause sterility (iiiltle ()i- Lti-c coii

templated. In addition, coiistilt~itioii,, ti(, i-c(ltlii-ecl when the patient is not a ,oocl tlii~, plii-~ise is explained latei- on), wlieii the i-,, ol)sciii-e and when doubt exists as to the 1)(,st ti-(,~itiiieiit to be titilized.

It is ratioiial to require a coiistiltitioii \N,-Iieii a woman is to be subjected to the (laii(~c,i-s of it (,~iesai-eaii sectioil, for the operation is daii,,ei-oiis, ~is the statistics slio\~,~. Butwlio's the coiistiltziiit iii such c~ises? Usti~tll,,~ the obstetrician who is (,oiii(, to do, oiassist at, the operation, or one \vlio \N-ill expect art equal favor when iie needs a consultation foi- tl)e siiiiie purpose. Is it not too much to expect of iiioi-t~il iii~iii that the\, will not stretch the indications foi- the operation, which pavs ii-tore than another tvpe of cleli\-er,,-" Especiallv if t~ie patient is wealtliy-else how account for the number of Cae
52

sareans done on the wives of tycoons? They surely cannot all have contracted pelves, high breech positions or uterine inertia.

Consultation is necessary when the attending physician NN,aiits to do a therapeutic abortion. It is necessary for the doctor's protection against the powers of the state, against possible charges of malpractice and agaii)st his liecoming known as a too-willing complier with the NN,islies of the women wanting to get rid of their iiiixn,elcome passengers. Therapeutic abortion is a borderline euphemism. Therapeutic for whom? It can't be for the fetus in utero. It can be only for the pbysical or mental health of the mother, when the contii-iuatioii of the pregnancy is likely to harm her. In other ),%-oi-ds, her health in potentia, non in esse. Doctors in such cases do not hesitate to don the mantle of the prophet. For the record, I am not a Roman Catholic.

(The liberalized abortion laws in some states are too iie%%- for comment. As yet there are no complete statistics on morbidity or mortality.)

The reason for consultation in sterilization proce(lures varies. In some states it is contrary to public polic%- except on strong medical indications. In all it is absolutely necessary lest the tinsterilized spouse sue the doctor for an unwarranted attack on his or her right to have a family.

"The interest of the patient" is presumably the rationale for mandatory consultation in the vast majority of cases. A consultation is required "when the patient is not a good risk," or as one hospital I know of put it, 11 when there is a possibility that the patient may die." That last sentence gives one pause. Until men learn to read the future, who can foretell the date, the hour and the maiiner of death? "Not a good risk" means that the patient is very old, very sick or both. Here the consultation is mostly to prevent suits for malpractice or to satisfy the family. It is in the nature of calling the pi-iest, with less likelihood of advantage from the secular sacrament.

 The other reasons for consultation seem more justifi~tl)le. NN'lieii the diagnosis is obscure or when the type of tre~itiiieiit is in question, certainly another doctor should I)e called in to help the attending doctor make tip his mind. The consultant, no matter how elevated his position, I)ears in mind that all doctors are equal, except that lie is a bit more equal than the one who called Iiiii-i in for an opinion. He is tactful, and careful about his reputation. His tact arises out of his fear of offending the referring doctor, thus drying up a source of income. He gives his opinion, hedging it about with

The Medicine Men

a dozen qualifications so that he is covered in case of any untoward event such as a quick recovery or sudden death. The family, informed secondhand about the results of the consultation, can be pleased only that in this case the doctors do not disagree.

How is a consultant chosen? The same way a barber or a hairdresser is. Becai-ise the referring doctor likes him, because be is of the same ethnic group, because his office is in the same building, because be's a good golf partner, because be reciprocates by sending patients to the referrer. Of course, he has to be competent, more or less. Who would go to a barber who used dull scissors? But given the sharpness of the scissors, any of the above becomes the prime desideratum. Somewhere along the line "the interest of the patient" has become lost.

Not that it actually makes much difference. If it did, the great and rich of this world would never leave it. Think of the number of physicians in attendance on the late Pope John, oi-i Winston Churchill, on Humphrey Bogart, on Stalin. (Stalin was suspicious of doctors, especially of Jewish doctors. He died of a cerebral bemorrbage, possibly the victim of his own lack of faith. None of the physicians in attendance dared to treat him lest he survive and they be accused of plotting against the state.) By taking thought the consulting doctors added neither cubits to their stature nor years to their patients' lives.

The consultation, a necessary evil, looks for the most part like a magnification of the mummery that goes with the practice of medicine.