Book Review – White Coat, Black Hat

August 4, 2011

In his book White Coat, Black Hat: Adventures on the Dark Side of Medicine (2010), bioethicist Carl Elliott MD PhD tells the story of “Len Shoemaker MD PhD” who practiced psychiatry for fourteen months as a medical resident before someone discovered that he didn’t have a PhD, never attended Harvard Medical School and had probably never graduated college. 

According to Elliott:

He did clinical rotations not just in psychiatry but in internal medicine and neurology, and he fooled those attending physicians as well.

Elliot “marvels” by how completely Len deceived everyone at the university, in spite of his obvious flaws.  When he applied for his residency, Len was interviewed by four different faculty members, each of whom gave him a rating of “outstanding.”

To experienced policemen – even those from multiple agencies – the idea that a new face could show up in uniform with a badge and gun is not inconceivable.  It has happened.  But after a few minutes in the roll call room or patrol environment, any officer with more than few years on the job could have identified Officer Shoemaker as a poser on the first day – and any police agency that doesn’t know the difference between competent and incompetent cops should be immediately disbanded.

But cops have guns.  Aren’t they more dangerous?

Think again.

While bad cops go to prison every year for the unwarranted injuries and fatalities they inflict while dealing with uncooperative suspects, preventable medical errors and complications kill or injure more than a million cooperative Americans annually, Between cops and doctors, Americans are safer in the presence of Sgt. Joe Friday than Dr. Mark Sloane.

Some folks feel compelled to lie about other little things.  While a spouse or casual friends might accept a story, it takes no more than a few questions before the poser is tripped up by those who actually were Marines or SEALS.  More often than not, the poser’s behavior, mannerisms, characteristics and explanations are enough to fully expose what they insist is only a misunderstanding.

Of Shoemaker, Elliott’s friend Hal said:

What we thought was that he was a narcissistic sociopath… We never thought he wasn’t a doctor… Actually, being a narcissistic sociopath is kind of a prerequisite for medical school.  Maybe that’s why he was so convincing.

It is unclear where Elliott’s jest ends and the seriousness begins.  After all, fourteen months suggests hundreds of patients and dozens of clinicians who either were too incompetent to notice, or were simply acquiescent.  Either way, such an environment invites the corruption that permeates the healthcare industry, setting the baseline of what is called the “medical standard of care.”

Unlike most industries, the healthcare industry is the only one that has learned how to make errors and complications profitable.  Any honest doctor will tell you that errors and complications result in more days, more drugs, more tests, more treatment and most importantly MORE BILLABLE HOURS.  To patients, a good doctor is one that keeps you healthy.  But to a hospital CEO, a good doctor is one who generates revenue.  So if good doctors generate $500,000 in revenue and bad doctors generate $5 million in revenues, it’s easy to see which physician should chair their department.     

So when an anomaly enters this environment – a lucid nurse or physician who recognizes the insanity – the anomaly soon comes to the attention of the those who practice within the medical standard of care.  This is why narcissistic sociopaths like Len Shoemaker fit in, and conscientious physicians like Andrew Wakefield MD don’t.

Elliott doesn’t explain how many incompetent sociopaths it takes for an industry to become so permeated by corruption that you can’t tell the difference between good and bad doctors.  That he is no longer shocked says enough:

… It might have been when I met a biologist who writes fake scientific articles for the drug industry.  It could have been when a friend confided that he used to produce fake television news stories promoting new drugs, or when a physician-researcher in Alabama was sent to federal prison for faking data in a clinical trial of the antibiotic Ketek.  But the real turning point probably occurred when I came across a community of professional research subjects who fake their medical histories to get into high-paying clinical studies, then fake painful side effects when they want to get out.  Fake science, fake news fake researchers, fake subjects: Sometimes it seems to me that Len Shoemaker is emblematic of what American Medicine has become.

That said, it’s probably a good thing for Dr. Elliott is no longer involved in the practice of medicine.  Medical careers are short lived when you expose and threaten the livelihoods of the Len Shoemaker’s that control it.