In medicine, as in any team sport, conflict — and remorse over how it was handled — is par for the course. Throughout my career, there have been instances where I’ve looked back and wondered: Could I have made an earlier diagnosis, adopted a different treatment, or spoken more gently to the family or to a colleague? I am certain I am not alone in these feelings of doubt and shame — in the fast pace of medicine, sometimes there is not enough time to behave in ways that make us proud or do our values justice.
For me, the most memorable conflict occurred in 1986, as a result of a disagreement with a colleague over the care of a patient, Mrs. B. Mrs. B suffered advanced dementia and was bed-bound and aphasic. Her husband Mr. B was the ultimate caregiver and would drive her to within a block of our building, scoff at a wheelchair, decline any help from a transport aide, and carry all 80 pounds of her in his arms up to my clinic. Despite her advanced state, Mrs. B had always been elegantly dressed by her husband, with lipstick in place and hair neatly done. She came in every three to four months for a blood pressure check and routine blood work, but it seemed like not much could be done for her — on her list of diagnoses was the trinity of “tabes dorsalis,” “neurosyphilis,” and, most alarming of all, “GPI.”
GPI (General Paresis of the Insane) is not a disease unto itself but a manifestation of the last or ‘tertiary’ stage of syphilis caused by the spirochete treponema pallidum. Its antiquated title carries much medical history on its back; no less a titan than Sir William Osler stated famously, “He who knows syphilis knows medicine.”
To understand Dr. Osler’s statement, let’s take a brief detour into the remarkable history of this disease. The association of GPI with advanced syphilis came about some 10-30 years after the initial canker sore of primary syphilis in the 1880s, and then finally Dr. Hideyo Noguchi of the Rockefeller Institute proved the linkage by identifying spirochetes in postmortem brains. At the time, approximately 10% of all admissions to psychiatric hospitals were neurosyphilis patients (per UpToDate) — which meant that syphilis was a serious public health problem. Though less so today, thanks to early recognition and aggressive public health efforts, syphilis and GPI are by no means extinct; when I did my geriatric fellowship in 1988, a serum VDRL or FTA was a standard part of the dementia workshop.
Though in some ways GPI is a typical illness — paralysis is common in many diseases — it is the paralysis combined with personality changes and ultimately dementia that sets GPI apart. In Mrs. B’s case, the late stage of her infection meant that she was bed-bound and endured increasing frailty and aphasia; as her clinician, I was tortured and often discussed with my clinic attending if a spinal tap or IV antibiotic treatment had ever been performed and if it could possibly help her.
One late evening, Mrs. B spiked a high fever at home and Mr. B brought her into the ER without calling ahead, their adult daughter by their side. Given the severity of the dementia and the lack of hospital beds, the ER wanted to discharge Mrs. B home with oral antibiotics. Mr. B and their daughter were unsettled and upset. I happened to be on inpatient floor duty that night and, thinking of no other recourse, the daughter asked her dad to try me at my after hours number. The operator transferred the “urgent” call to me. Mr. B explained what happened and was afraid she would die if sent back home. The ER and I discussed and in deference to me as her clinic doctor, agreed to admit her to my inpatient team for IV antibiotics and find her a bed “somewhere.”
My senior resident (who in those days ran the team) was shocked and grilled me the next morning on rounds. Didn’t I have an interest in geriatrics and palliative care? Who could justify aggressive care given Mrs. B’s high level of dementia and poor quality of life? The other wrinkle is that this senior resident had a reputation as a gun-slinger or cowboy and sometimes it got the better of us when we worked together. I would like to think that the patient’s diagnosis of GPI and syphilis conferred nothing judgmental on his side of the discussion, but nevertheless — I wondered.
After all, when a call is made that a patient should be admitted, it is the rare ER doctor that disagrees. We hope these decisions to admit are based purely on the medicine and the examination and labs. We know that if the chair of the department wants a patient admitted, or if the patient is a “VIP,” it will more than likely happen. Does the bad blood between teammates that might not see eye to eye, or have different worldviews or politics, interfere with such decisions? Did my senior resident look at this elderly woman with GPI and a different social and economic status from his own and allow some bias to set in? Did I see this woman as a member of my own clinic family and want to protect her from those biases? Was he ‘right’ or was I ‘right’ or was the truth somewhere in between?
At the time, something bubbled up in me and despite being only an intern, I voiced my opinion to the resident that Mrs. B still meant a lot to Mr. B and their daughter and who were we not to provide every chance to get her home improved and infection-free? In retrospect, with where my career has taken me in working with those at the end of life, I can’t imagine making that firm of a statement today. I wonder now, more than 35 years later, if I was taking a stand just to take a stand. Sure, there are many docs that could honestly have made the argument that quality of life is not a rigid yardstick and absent a DNR order or request for palliative care, Mrs. B deserved to recover in the hospital and get home. But I have never been one of those docs.
I can now see both sides of the equation and had I been the senior resident at that time, I might have questioned my intern the same way I was questioned. During residency, you become attached to your clinic patients; I can remember going to great lengths to get to know them and their families and advocate for their care. It was not unusual to receive cakes and family pictures and thank you cards in return. Maybe that was all it was? I was feeling ‘dissed’ by a clinician that had no knowledge of the family and their dynamics, how much Mrs. B meant to Mr. B and their daughter. I also remember feeling flattered, even honored that here I was, a measly first-year intern, and a family was entrusting care to me and even more, to plead their case against the ‘establishment.’ It’s possible that these contextual factors clouded my judgment. But for the personality clash, I might have advised the family to take her home instead of admitting her to the hospital.
Thirty-five years later, I wonder if that resident has ever thought back to that long night with Mr. and Mrs. B and the morning rounds during which we hammered things out. Are we naive to think these conflicts should not happen and therefore they don’t? Further, are we, as medical professionals, too averse to admitting to disagreement? I am sure that teams at investment houses and schools and startups have their own rivalries and tensions. Sometimes they work them out and sometimes they reshuffle the deck and move people around. I can’t ever recall a team of mine on the inpatient or outpatient side being reshuffled, but that was a different era.
Today, the question of personality clashes seem especially pertinent. Most trainees work in teams not just during their training, but also for the entirety of their careers; the lone wolf medical practitioner is verging on extinction. Perhaps this means that individual decision-making, and the tension this can cause, will be frowned upon. Alternatively, perhaps it’s the desire to make decisions and assert one’s own personality and preferences — and the insight that comes when reflecting after the fact — that’s crucial to our development as doctors.
Have you ever let personality clashes or ruptured work relationships on a team color your decisions regarding patients?
Dr. Schor is a geriatrician specializing in long-term and post-acute care. He was medical director and attending physician at Daughters of Israel for close to 30 years and is now a Senior Medical Director at Optum Health. He is a new grandfather, an avid birder, and lives in Millburn, NJ. Dr. Schor is a 2022–2023 Doximity Op-Med Fellow.
Names have been changed to protect patient privacy.
Image by DrAfter123 / GettyImages