The Fourth Wall
Andrew Bomback

In medical school, during my surgery rotation, I was expected to report for service rounds at 5 AM. All of the patients on the floors needed to be rounded on prior to the OR cases, which began at 7 AM. Therefore, to pre-round on my patients, I arrived at the hospital at 4 AM. I figured this was a good time to experiment with growing out my hair and not shaving. Midway through the rotation, a cardiothoracic surgeon suggested I get a haircut and shave. He did this in private; it was not a rebuke, rather a suggestion. He advised, “Your patients want you to look and act like the doctors on television.” Indeed, he looked and acted like a doctor on television. For the most part, I’ve followed his advice to this day. Every once in a while, I break the fourth wall (to borrow a term from television) and let the patients know that I am as frustrated and disappointed with the medical system as they are. Usually, this is when they see me on the phone with an insurance company or witness my struggle in trying to obtain their medical records from another hospital.

My father, who just turned seventy, is a doctor through and through. He defines himself as a doctor. He’s been a pediatrician for over forty years; many of his patients are the children of his former patients, and some now are even the grandchildren of his former patients. When kids dress up as a doctor for Halloween, my father is the kind of doctor they are imitating. Indeed, a number of children have specifically dressed up as Dr. Bomback for Halloween. A local magazine, which included him among the best doctors in the county, asked him to pose for the cover of that issue. He and one of his patients re-created a Norman Rockwell painting, my father cast as the reliable family doctor about to give a shot into a boy’s rear end. It’s a morbid but entirely true thought: his obituary will mention his doctoring in the first sentence.

I haven’t quite figured out my feelings about my father’s inevitable, upcoming retirement from medicine. I should say that he hasn’t decided to retire. He claims he doesn’t want to retire, he just turned seventy and always pictured himself practicing until his eighties, but the moment of reckoning is fast approaching. He is virtually computer illiterate. He is completely lost with the electronic medical record. Two or three times a year, he asks me to help him complete a mandatory online training course required by the hospital. “I can’t do this,” he says dejectedly. Because his quick, illegible handwritten notes are now considered insufficient documentation, he’s had to cut down his daily panel almost in half. He’s never had to think about billing, about collecting, about the financial part of his practice, but his junior partners are obsessed with this aspect, to the point that they sold their practice this past year. He was the only partner not involved in the negotiation. “I waste so much time on the computer,” he says, with the subtext that he’s spending less time with patients and their parents. He used to brag, when he’d come home at night, about how many children he’d seen that day, sometimes fifty, sometimes sixty. He used to take pride in how he could see four children in the time a junior colleague could see one. He will be miserable when he retires, because he has always taken tremendous satisfaction from his job, but he is miserable now, because that satisfaction is slowly being taken away from him as he realizes that he is unequipped to do the job. His doctoring skills—his ability to diagnose, treat, counsel, etc.—remain unparalleled, but he has no skill in navigating what doctors of my generation call “the system.” This, I surmise, is because there was no system when he started practicing. He will be relieved when he no longer has to force his outstanding but antiquated method of medicine into the modern dance of being a doctor.

Suburban Physician, who tweets anonymously at @BurbDoc, has become a cult hero for a growing (7000+ followers) bunch of physicians who (based on virtually all of his tweets being favorited or retweeted) agree with him when he tweets, “Remember, folks, it’s not that I don’t care, it’s just that I dislike certain patients.” Or when he tweets, “Local specialist is very LOUD about his Christian faith. Called him up abt a poss charity case, simple fix, on an uninsured pt. Said no thx.” Or when he tweets, “Now when I get past med records from prior docs, it’s a tome bigger than Moby Dick’s dick. Seriously. NYC’s Yellow Pages is smaller.” If my father, who is probably going to have to surrender to retirement because the onslaught of electronic medical records has completely undermined his efficiency as a physician, ever learned how to use Twitter, he could favorite or retweet, “Clicking stupid fucking boxes isn’t about best care. It’s about datamining our charts so some higher up fuckwad can demand more salary.”

The older generation of doctors—the ones my father’s age—are much more confident in their abilities than my generation, and I don’t think this is entirely due to experience. They began their careers in an era when doctors were held in much higher esteem than they are now, and I think they bought into the collective philosophy of doctor knows best. My generation of doctors has doubts and realistic expectations. We were explicitly trained to avoid paternalism with our patients. It is exceedingly rare to find an ultra-cocky, young doctor in my hospital (although the type still appears on television or movie screens). He or she sticks out like a sore thumb and is roundly criticized as “over-confident,” “reckless,” or a “cowboy.” Over-confident is a buzzword in our evaluations of the residents and fellows, a way to signal that this doctor is capable of hurting a patient.

My father doesn’t need to work from a financial standpoint, but he is struggling with the idea of life as a non-practicing physician. His only hobby is exercising at the gym, but he mostly goes to keep my mother company. On vacation, he brings medical journals as his pleasure reading. For as long as I can remember, the magazine rack in his bathroom has been stuffed with my mother’s New York magazines and his latest copy of Pediatric Infectious Diseases. My section chief, who’s just a couple of years younger than my father, once told me he skims medical journals on his drive to work, sneaking in the reading at red lights. A retired medical school librarian, whom I cared for in the hospital, asked me if I was related to my father after I introduced myself. She told me she used to hold tapes of medical textbooks for him at the circulation desk. I remember these tapes in his car. He listened to them driving to and from work. “Your father used to thank me so much for holding the tapes for him,” the librarian said, “and I didn’t have the heart to tell him that no one ever checked them out except him.”

From Harvard Business Review: “[The] Mayo [Clinic] also understands that the way employees present themselves sends a signal to patients. Patients don’t encounter doctors in casual attire or white coats. Instead, the more than 2,800 staff physicians wear business attire, unless they are in surgical scrubs, to convey professionalism and expertise. It’s a dress code that some outside Mayo have called ‘pretentious,’ yet we’d argue that it’s no more pretentious than, say, the dress code for airline pilots. Airline passengers don’t want to see their pilot in a polo shirt, and patients feel the same way about doctors. In effect, Mayo Clinic doctors—just like service workers in many other industries—work in a uniform; it’s a visible clue that communicates respect to patients and their families.”

My father’s consultation office is filled with pictures of his children and grandchildren. My wife and I take our kids to his practice for their check-ups, and often she’ll breastfeed in his office after the visit. We sit in the office and go through all the photos, much the way, I suspect, his patients do when they are waiting for him. I have no pictures of my family in my office, and I try to deflect any questions patients ask about my children. I will co-lament with some of my patients about how badly the Mets, Jets, and Knicks are playing, but that is as close as I allow myself to being anything more than their doctor.

Tom Cruise plays a doctor in Eyes Wide Shut. I saw this movie while in medical school, and I was intrigued by how Cruise’s character flashes his medical license the way cops whip out their badges. His ability to prove that he’s a doctor gets him out of jams, gets him invited inside, gains trust from others, makes him sexier to women, etc. I’ve never seen any doctor do that—in life or in other movies—but for a while I carried my medical license in my wallet. On a plane, once, a passenger was short of breath, and the flight attendants asked if there were any doctors on board who could assist. I volunteered and flashed my medical license to an unimpressed stewardess, who didn’t even glance at the document.

My father even reads throwaway journals. These are low-quality journals that review literature published in other, higher-quality journals. Throwaway journals are sent, free, to all members of a society or association (e.g., I receive Renal and Urology News because I am a member of the American Society of Nephrology), who in turn throw them away as soon as they arrive.

At the end of a phone call with a pulmonologist, after we’d discussed the very poor prognosis of our shared patient, she said, “I used to take my kids to your father, and I’m getting such a flashback hearing your voice. You sound so much like him on the phone; I’m remembering the times I’d call him with questions about my sons. I love your dad.”

Jordan Grumet, an internal medicine physician who also writes poetry (his chapbook is entitled Primary Care), performed an “autopsy” of the medical profession in a blog post entitled, “Are We Witnessing the Death of the Modern-Day Physician?” Grumet eulogizes the dying profession—“While some physicians are committing suicide or becoming addicted to drugs, others are leaving in less-devastating but still consequential manners: early retirement and nonclinical career paths”—and then searches for “intrinsic” and “extrinsic” causes of this death. The extrinsic factors are the predictable complaints: higher cost of education, lower salaries, less respect in the community, mountains of paperwork in a system that favors compliance over competence. I am more interested in what he calls the intrinsic cause, which is essentially the practice of medicine itself not living up to the expectations of medical students and residents. “The highs are much less common, and the lows are part of our moment-to-moment experience. Unlike most sitcoms, our patients die frequently. Diseases rarely follow patterns and rules. We lose many more battles than we win.” Perhaps it was because I grew up with my father, and my idea of a doctor wasn’t based on someone on television or in a movie, but I have never felt betrayed by medicine. I’ve never felt that the field promised one thing and then delivered something else.

A survey of patients asked what bothered them most in a doctor’s appearance. Answer choices included earrings and long hair on men, nose rings and crew cuts on women, tattoos, bad teeth, obesity, and body odor, but the winner (or loser, I should say) was sneakers. Patients did not want their doctors wearing sneakers. When I started residency, a friend who was one year ahead of me advised, “Find a pen that you really like, because you’ll be doing a lot of note-taking, and buy the most comfortable pair of shoes you can find.”

A Google image search for “doctor” reveals essentially the same picture: a doctor wearing a white coat with a stethoscope draped, scarf-like, around the neck. The only difference between the images is the doctor—white man, black woman, Asian man, black man, white woman, white man, Indian woman. They all wear the exact same uniform of brilliantly white, crisply ironed coats adorned by a stethoscope sitting on the neck. The stethoscope is a fashion accessory. I never saw doctors wear their stethoscopes like this until shows like ER and Scrubs. The older doctors in my hospital, like my father, never wear their stethoscopes like this. They have the ear pieces meet at the back of the neck, like the clasps of a necklace. They project the notion that they were just using the stethoscope and can use it again at a moment’s notice. The “doctor” images that Google returns with the stethoscope worn in this fashion are almost exclusively cartoons, and the cartoon doctor is an old, white man, like my father.

Many of the attending physicians who trained me as a medical student, who seemed old at that time, are still working more than a decade later. Now we are colleagues—peers, so to speak. They walk slowly through the hospital, often assisted by canes. Quite a few have hunches in their backs. None seem particularly happy. My younger colleagues and I sneer at them in hushed conversations: “I’ll never work when I’m that old.” I don’t think any of these doctors are working out of financial necessity (it is conceivable that their retirement savings were affected by the market crash a few years ago, but these doctors don’t seem like the types to be cavalier in their investments, and their money probably was secured in the least risky types of accounts). I think they are working because, as my brothers and I say about my father, whose gait is not as steady as it once was and whose back is not as straight as it once was, either, “What else is he going to do?”

My most obvious example of breaking the fourth wall is with my patient Lillian, who has a rare form of kidney disease, fibrillary glomerulonephritis, about which we know very little. Because we know so little about its etiology, we subsequently know very little about effective treatments. She presented with moderate kidney failure and, in the first year of treating her, she advanced to severe kidney failure. We had tried the only therapy that had been shown, in case reports, to work for her disease—a monoclonal antibody called rituximab—although the rationale for why this drug would work for this specific disease was at best speculative. She broke down in my office in near hysterics. Two visiting nephrology fellows from Spain were shadowing me that day, and her crying was clearly making them uncomfortable. I handed Lillian a box of tissues and told her we would re-dose the rituximab and that I thought a second round of therapy would help. I said, “You will get better,” which was not an outright lie, because if her kidneys failed, she’d get a transplant, in which case she would technically get better. Lillian stopped crying. “You really think so?” she said. “Yes,” I said, with my most television-doctor certainty. Later, when Lillian left the office, the Spanish nephrology fellows asked me if I really thought she’d get better. “No,” I said, “but she needs to have some hope right now.” They laughed, but Lillian did get better. After it was clear that her recovery was going to be sustained, when she was stable and healthy and no longer suffering from kidney failure for over two years, I reminded Lillian about that episode in my office, about her crying and my saying she would get better. She remembered it as clearly as I did. “I was bluffing,” I confessed with an awkward smile, but also in a way that a television doctor might say the line. So, I suppose I didn’t entirely break the fourth wall.

My father called me late on a Friday night. He was in a panic about an online training course required by the hospital. He couldn’t get the course started. “The computer is saying something about cookies,” he said timidly. “And it needs to know what version of Internet Explorer I’m using. How do I do this?” I answered, “Maybe you should retire.” The exchange felt like something on television.



Andrew Bomback is a physician and writer in New York. His essays have recently appeared in The Los Angeles Review of BooksThe MillionsEntropy, HobartThe Harlequin, and Ohio Edit.