The Good Doctor

1. The First Dr. Lerner: Paternalism and Patient Devotion

Being a doctor, he believed, meant knowing every last detail of their medical histories and their lives.

A product of his time. Phillip I. Lerner, born into a working-class Jewish family in Cleveland in 1932, chose medicine partly as a path to the middle class and partly out of a sense of gratitude for escaping the fate of European Jews. His training at Western Reserve emphasized a humanistic, patient-centered approach, reinforced by mentors like Louis Weinstein and the legacy of William Osler.

All-consuming dedication. Dr. Lerner practiced an intense, all-consuming type of medicine. He was fiercely devoted to his patients, often going the extra mile to understand their lives, not just their diseases. This included:

• Spending hours writing detailed scientific papers on cases.
• Maintaining intense relationships with patients and families.
• Making house calls and visiting patients on weekends.
• Personally performing lab tests like Gram stains.

Doctor knows best. Rooted in the era's norms, his approach was deeply paternalistic. He believed his extensive training and dedication entitled him to make decisions he felt were in the patient's best interest, even if it meant concealing information or overruling others.

2. The Golden Age of Medicine and Scientific Triumph

Other than surgery, there were few interventions in medicine that could so drastically improve the condition of a patient with a serious disease.

Era of breakthroughs. Dr. Lerner entered medicine during a "golden age," witnessing miraculous cures thanks to new antibiotics and medical technologies. This fostered immense optimism and a belief in the power of scientific research.

Infectious diseases pioneer. Specializing in infectious diseases, he was at the forefront of applying scientific findings to patient care. His work, particularly on endocarditis, demonstrated the dramatic impact of antibiotics on previously fatal conditions.

Clinical acumen valued. While research was crucial, the era also highly valued clinical judgment and experience. Doctors like Dr. Lerner and his mentor, Louis Weinstein, could make life-saving diagnoses based on subtle signs and deep personal knowledge of diseases and patients.

3. Illness Hits Home: A Turning Point for Father and Son

That year, 1977, was a very bad year.

A one-two punch. The unexpected death of his father, Meyer, from a pulmonary embolism after routine surgery, followed two months later by his wife's (the author's mother's) breast cancer diagnosis, profoundly impacted Dr. Lerner. These events shattered his sense of control over medical outcomes.

Disillusionment begins. Witnessing his father's preventable death and his wife's suffering despite aggressive treatment led to a growing sense of powerlessness and disenchantment with medicine. His journals reveal this shift, questioning the limits of intervention and the randomness of illness.

Shaping the next generation. Paradoxically, these same events, particularly his mother's illness and his father's response, fostered the author's interest in medicine. He saw firsthand the human impact of disease and the potential for a doctor to make a difference, even amidst tragedy.

4. The Second Dr. Lerner: Entering Medicine with Bioethics in Mind

So it was that I first openly expressed my fears that my mother was going to die in an interview room at Columbia.

A different motivation. Unlike his father, the author pursued medicine not out of economic necessity or survivor's guilt, but from a desire to help others, influenced by his parents' ethical modeling. His interest in history and humanities shaped his perspective.

Introduction to bioethics. At Columbia, he encountered the nascent field of bioethics, which emerged in response to medical scandals and patient activism. Courses highlighted issues like:

• Truth-telling to cancer patients.
• Rationing of scarce resources (e.g., dialysis).
• Human experimentation without consent (e.g., Tuskegee, Willowbrook).
• The "right to die" movement.

Questioning authority. This training instilled a critical perspective on the medical profession's historical paternalism and a strong belief in patient autonomy and informed consent, setting the stage for future disagreements with his father.

5. Training in a Changing World: Exhaustion and Ethical Dilemmas

"It doesn't matter if you are napping, about to undergo surgery, or whatever," I wrote. "You will be exposed and examined whenever a mass of white coats congregates at your bedside."

The rigors of training. Medical school and residency were intense, demanding periods marked by long hours and exhaustion. This environment, while fostering clinical skills, also presented ethical challenges, such as:

• Balancing patient dignity with the need for students to learn procedures.
• Witnessing dehumanizing language or attitudes towards patients (e.g., "GOMERs").
• The pressure to prioritize efficiency over patient interaction.

Impact of fatigue. The constant workload and sleep deprivation made it difficult to maintain a humanistic approach and reflect on ethical issues in real-time. The author struggled to balance his desire for patient-centered care with the demands of training.

Emergence of new diseases. The AIDS epidemic and the resurgence of tuberculosis during his training highlighted the unpredictable nature of infectious diseases and tested the limits of medical knowledge and compassion, particularly in intensive care settings.

6. Clash of Eras: Paternalism vs. Patient Autonomy

"You can’t do that!" the shocked son cried.

Differing ethical frameworks. The author's training in bioethics, emphasizing patient autonomy and transparency, directly conflicted with his father's ingrained paternalism, where the doctor's benevolent judgment was paramount. This led to significant tension.

Controversial actions. Dr. Lerner's willingness to take matters into his own hands, such as physically obstructing CPR on a dying patient without a DNR order, exemplified the older model. He saw it as a merciful act based on his clinical knowledge and the patient's suffering.

Son's perspective. The author, grounded in modern ethical norms, was horrified by such actions, viewing them as a blatant violation of patient rights and hospital protocol. Their debates highlighted the generational shift in medical ethics.

7. The Futility Debate: When Doctors Believe They Know Best

"I know in my heart," he unabashedly declared, "when certain patients are ready to go."

Questioning aggressive care. As Dr. Lerner encountered more terminally ill patients, he became a fierce advocate against what he saw as the inappropriate use of technology to prolong suffering. He believed physicians were not obligated to provide "futile" care that offered no meaningful benefit.

Challenging autonomy. This stance put him at odds with the growing emphasis on patient and family autonomy, particularly regarding end-of-life decisions like CPR and feeding tubes. He felt patients and families sometimes made choices that were medically unreasonable.

"A Criminal Act". He viewed attempts to resuscitate terminally ill patients without clear directives as "criminal," arguing it robbed them of dignity. His actions, like the CPR obstruction, were based on his conviction that he knew the "right" thing to do based on his experience and the patient's condition.

8. Caring for Family: A Doctor's Deeply Conflicted Role

"So both mothers were spared suffering at the ends of their lives because their ‘sons’ were doctors who ‘acted.’"

Blurring boundaries. Dr. Lerner increasingly took on the role of primary physician for aging relatives, including his grandmothers. While providing excellent, personalized care, this violated modern ethical guidelines against treating family members due to potential conflicts of interest and lack of objectivity.

Orchestrating death. His involvement became most pronounced at the end of his relatives' lives. Believing he knew their wishes and that prolonged suffering was unacceptable, he sometimes took steps to hasten death, such as ensuring sufficient pain medication that could suppress breathing.

Filial duty and medical power. These actions were driven by a complex mix of love, a desire to prevent suffering, and a sense of obligation to use his medical skills to "pay back" his family. He saw his ability to "act" as a powerful, albeit controversial, expression of care.

9. Growing Disillusionment with Modern Medicine's Bureaucracy

"My daily activities in the hospital are already swinging drastically in favor of documenting rather than doing," my father wrote in 1992.

Loss of autonomy. The later years of Dr. Lerner's career were marked by profound unhappiness due to systemic changes in medicine. Managed care, increasing paperwork, and demands from insurance companies eroded physician autonomy and interfered with patient care.

Focus on metrics over patients. He railed against the shift towards "cookbook medicine," where protocols and documentation seemed to overshadow clinical judgment and knowing the patient as a person. He saw this as a threat to the art and integrity of medicine.

Decline of hands-on skills. The move away from doctors performing their own lab tests and the reduction in resident work hours were seen as further undermining the deep, immersive knowledge base he believed was essential for good doctoring.

10. Slowing Down: Parkinson's and the End of a Medical Career

"There are definite signs of parkinsonism," the doctor wrote.

The inevitable decline. Symptoms of Parkinson's disease began subtly, marked by changes in handwriting and balance, before progressing. This diagnosis marked the beginning of the end of his active medical career.

One last hurrah. Despite his worsening health, he managed to publish one final article in the New England Journal of Medicine, a historical piece celebrating a doctor who bent rules for a patient's benefit, serving as an epitaph for his own approach to medicine.

Becoming the patient. As his disease advanced, Dr. Lerner became the type of patient he had often cared for – elderly, chronically ill, and eventually requiring nursing home care. This mirrored the trajectory of his own "three angels."

11. Reconciling Two Worlds: What Was Gained and Lost

Much has been gained during my time as a doctor, but much has also been lost.

A generational divide. The book chronicles the vast transformation in medicine over one generation, from the paternalistic "golden age" to the era of patient autonomy, technology, and bureaucracy. Father and son embodied these different worlds.

Enduring humanism. Despite their differing approaches and the systemic changes, both father and son valued the humanistic aspects of medicine. The author, while embracing modern ethics, came to appreciate his father's deep patient devotion and clinical intuition.

Lessons for the future. The narrative prompts reflection on the ideal physician: Is it the all-knowing, dedicated paternalist, the evidence-based collaborator, or something in between? The author suggests that while patient rights are crucial, the physician's expertise, compassion, and willingness to truly know the patient remain central to good care.

Last updated: May 19, 2025