1 Boring Old Man

I spent several years as a kid with an illness that now doesn’t exist, chronic tonsillitis that kept me from eating. It was in the 1940s before antibiotics, and there was a terror about tonsillectomy. It predisposed kids to polio. So I spent a couple of winters in bed sick, being fed on cokes and soft-boiled eggs, waiting to be old enough for a safe operation. In the interim, the treatment was frequent "painting" of my tonsils with Mercurochrome. And while I dreaded those treatments, the doctors that attended me as a child were indelibly imprinted on my mind. Whatever I saw in them must’ve been pretty important, because years later when it dawned on me that I was going to have to be an adult, I decided to go to medical school "out of the blue." At the time, I had no idea where that decision came from, but I now know it was driven by something I saw in those doctors as a young child. I was also left with an aversion to undercooked eggs.

I don’t know if painting tonsils, or postponing curative surgery, or the later restrictions to prevent polio even mattered medically. The coming of antibiotics and polio immunizations made those questions irrelevant – ideas long forgotten. But I do know now [as I knew then] that my caretakers believed those things were important, and their motives were only to take good care of me. I’m absolutely sure that my doctors had no stock in a Mercurochrome company. Whatever you call those motives, that’s the thing that ultimately attracted me to medicine. I call it Integrity.

Mercurochrome was toxic to germs and people, so the "painting" was a compromise in one direction. Postponing surgery was a compromise in the other direction – restraint. And keeping me from swimming in public pools or the wonderful nearby lake was a social compromise that weighed heavily on a six year old. They didn’t get those recommendations from their own experience. They were told those things by other doctors – the 1940s version of Key Opinion Leaders [who also didn’t have stock in Mercurochrome, connections with Operating Room revenues, or anything to do with the local swimming pool economy].

That’s how medical practice works. It’s an applied science. The questions are bottom-up – they come from sick people. The answers are top-down – they come from academic medicine, research, or specialists who limit themselves to a particular condition. Practicing clinicians are in the middle, where personal experience is heavily informed by the recommendations from above – thus the requirement for Continuing Medical Education whether by formal or individual routes. In medicine, almost everything is a compromise, and this flow of information is the way of finding right compromises [known as best practices].

It’s number 3. above that comes closest to the root meaning of Integrity – wholeness or completeness – like the word Integer [a whole number]. The Integrity of Medicine includes the integrity [as in wholeness] of the system, not just the personal integrity of individual physicians. The things that I’ve been writing about – the Pharmaceutical Industry’s invasion of Academic Medicine, the ghostwritten journal articles, the corruption of Continuing Medical Education, and the commercialization of KOLs – destroys the Integrity of System Medicine at every level. To use a worn movie metaphor, it’s a disturbance in the force that pushes us over to the dark side. But it is not melodrama to say that these things threaten the whole enterprise.