27 August 202124 September 2021 Television / Long read / Health / Friday Features The doctor’s disease Sam Lieblich “I will not use the knife; I will leave this to those who are trained in this craft.” Hippocrates of Kos “Truth is the result of our tone of voice and the conviction with which we speak… Your grandfather has never stepped in poop his whole life, and never will.” Toni Servillo’s Silvio Berlusconi in Paolo Sorrentino’s Loro (2019) Joshua Jackson has always played the slick guy. To play the surgeon who is the subject of Dr. Death (2021, streaming on Stan in Australia) there’s a reason they chose Pacey over Dawson. Since he was a kid Jackson has had that silky-smooth salesman’s tone of voice, and he’s always conveyed the sense that the smoothness was obscuring something shameful. His new role in Dr. Death is as Dr Christopher Duntsch, a charming and arrogant spinal surgeon who maimed or killed thirty-three patients in Texas through a mixture of what might be hubris, what might be incompetence, or what might be something even more sinister than hubristically operating while incompetent. The show flashes back and forward from his days in college and med school where he showed an unwillingness to learn from his mistakes — favouring bluster and charm as a technique to obscure them — to his time in surgical training where allowances were made for his poor engagement in training (because he started a business and offered to cut in his supervisor), to the time — more recent — spent by two surgeons, Randall Kirby and Bob Henderson, pursuing him for his surgical crimes. I hadn’t intended to watch the show because, as a doctor working in a hospital, I don’t much like watching things about work. It gets tiresome watching people playing doctors on television doing things in TV hospitals that would never, ever be done in a hospital. All medicos will agree, there was never any medical team like Dr House’s, and there aren’t any newly graduated doctors who perform the duties that Meredith Grey is seen to perform in her first day on the job. But when I chanced to watch a scene or two of Dr. Death, I found the accuracy and attention to detail in the portrayal of doctory things so refreshing that I kept going. In the series surgeons behave like surgeons, medical boards behave like medical boards, and hospital administrators behave like real life hospital administrators. One supposes this might be because the scenes portrayed in the series are ‘based on actual events’ though that’s never been any sort of guarantee. When television’s Dr Death scrubs for theatre he scrubs properly, like a surgeon, he wets his hands and forearms, he applies an amount of an appropriate antimicrobial solution from the dispenser taking care to use his elbow to dispense it into his hands, he works the cleaning solution into the hands palm to palm, creating a lather, he rubs his right palm over the back of his left palm and his left palm over the back of his right palm with his fingers interlaced, he rubs his hands palm to palm, with his fingers interlaced, he performs rotational rubbing backwards and forwards with the fingers of his right hand clasped into his left palm and the fingers of his left hand clasped into his right palm, with a level gaze directed through the scrub room window he performs rotational rubbing of his right thumb clasped in his left hand and his left thumb clasped in his right hand, he rubs the fingertips of his left hand on the palm of his right hand and his right hand on the palm of his left hand, he continues with a rotating action down each arm, working to just below the elbows, he then rinses and repeats these steps again always keeping his hands raised above his elbows so that dirty water doesn’t drip back onto his fingertips, finally he enters the operating theatre and dries his hands with a sterile towel passed to him by a nurse; he does something like this or some part of this procedure in most episodes of the show, and although we don’t see the full duration of what should be a 5 minute procedure on our televisions, the comprehensiveness of the procedure and the accuracy of the little details means that even a medical viewer can feel as if the writing team did its research. When Duntsch washes his hands in a bar in front of another surgeon, there, too, he does it properly: he clasps his hands together, attends to his web spaces, and the backs of his hands, he performs rotational rubbing of the thumbs, and he asks the other surgeon to pass him a towel to dry his hands with; the character includes those details in his washroom routine just like a surgeon would either out of habit or because he is advertising himself as a surgeon, as a surgeon would do, in front of another surgeon. Amongst all the hand washing in the first episode there is also a lot of time spent in the operating theatre. In one scene—shot from the perspective of one of the nurses who is watching Duntsch operate—we catch sight of a tear in Duntsch’s scrubs. The camera zooms in slowly on that little detail, alternating with shots of the scrub nurse’s blank stare. This captures very well the sort of atmosphere that prevails in the operating theatre. Everyone is on high-alert, waiting to see what the surgeon does, waiting to see what the surgeon needs. The patient is cut open on the table, all else is submitted to the emergency of that fact and the only escape from the intensity of the experience is to dissociate within it about its little details. What’s interesting is that by faithfully depicting these ‘actual events’, and all the quotidian moments that necessarily make up the day as a doctor, what Dr. Death highlights is precisely what is wrong with a Gregory House or a Meredith Grey. The first episode of Grey’s Anatomy (‘A Hard Days Night’, aired 27 March 2005), depicts Meredith Grey’s first day at Seattle Grace Hospital as a surgical intern. She wakes up in disarray after a hook-up with a handsome stranger, stumbles into work, finds out the handsome stranger is her boss, a surgeon. He asks her to work out why a young girl is having seizures that have been difficult to diagnose. She outsmarts a male colleague. She betrays a female colleague. She receives instruction on how to resuscitate a dying patient when she has already taken the lead on the resuscitation (how did she get there?). In one scene a patient crashes, the nurses want to know what to do but Meredith chokes and tries to page the boss (who she fucked) but he’s unavailable. She nuts-up and weighs-in despite insufficient knowledge or practice and triumphantly saves the patient’s life by doing something the nurses think is unwise. Take, that idiots. the doctor wins on pluck alone. In one scene, Dr Grey is inexplicably in the room with a family and is asked whether their daughter Katy will need surgery, to which she hesitantly replies: ‘I’m not the doctor, well I’m a doctor, but I’m not Katy’s doctor.’ From Katy’s perspective it’s Meredith’s hesitant tone that proves she is just ‘a doctor’ and not her doctor’ – she would otherwise not be able to know. As a sick patient she neither has the knowledge nor the time nor the social permission to question Meredith’s expertise or position with respect to her own care. Questioning the doctor takes quite some effort, it requires specific knowledge, and the self-confidence to swim against a strong tide of social and professional norms and financial interests (as we’ll see). Dr. Death demonstrates this well in every scene, but especially when characters explain how hard it would be to prove his deadliness in court. ‘No way! In a few short days we’d have to teach 12 jurors how to perform surgery themselves!’ says the District Attorney when he’s asked to prosecute. In the final scene of ‘A Hard Day’s Night’, Meredith Grey scrubs in to assist her boss (the one she fucked) in brain surgery. We do not see Meredith, or her superior, wash their hands. The episode also follows another intern George. We see George watching and learning when a family asks his surgical supervisor if they should worry, to which the surgeon replies: “I’m very good at what I do”. The same surgeon forces George to do an appendicectomy unaided, to see if he’ll crack. George starts off doing ok but near the end of the procedure he almost kills the patient. After this he attracts the nickname “007” (license to kill), in response he complains that he should have gone into geriatrics where it’s ok to kill people. Yet we side with George, ‘he was under too much pressure!’ In a lighter moment, George tells a patient he won’t be able to eat bacon after his heart bypass, to which the patient replies: ‘kill me now’. ‘I wish I could but I’m a healer,’ quips George, before casually promising the patient’s wife that her bacon-loving husband will survive the surgery. The patient dies on the table. The surgeon emerges from the theatre claiming ‘there’s nothing we could do’. George is forced to inform the wife. All of this to a soundtrack in a bright 90s sitcom style to suit the adorkable stylings of Meredith, George and the gang. All these activities are presented to us as a regular day at Seattle Grace Hospital for a neurosurgical intern, and while their depiction is ludicrous, some of these activities are actually pretty standard for a surgical trainee. It’s just that none of them should be. If a surgical unit is running well, junior trainees are not relied upon to do surgery independently. They are neither able nor expected to do the diagnostic heavy-lifting that is asked of Meredith Grey. They are not permitted to do any delicate surgery inside the cranium. And they should not be fucking their superiors. All this stuff does happen, it’s just that it shouldn’t, and that’s why it’s so maddening watching it portrayed in such an affirmative way on Grey’s Anatomy. But it is the inaccuracy of the details on this show that permits the playful attitude towards the dark side of doctors being doctors. Scenes proceed from one emotional climax to another like a fever dream — Sex! Resus! Surgery! The patient is crashing! Sorry ma’am we killed your husband! Death! Sex! Resus again! You bitch! She’s having a seizure! Get out of my OR! — with none of the interstitial moments, none of the drudgery that truly makes up the day as a doctor. And nobody washes their fucking hands. Where Dr. Death gets its menace from is by instead being accurate in these details — by admitting the banal day-to-day stuff — whilst still portraying the pathological side of doctors being doctors. The show illustrates in fact the relation between the small gestures of doctorliness and their pathology, inasmuch as it can be enough for a patient — like the elderly and ordinarily wary Mrs Beyer — to meet an apparently rich man in a white coat; to watch him remove his latex gloves in a way that implies he’s done it a million times before; to watch him pluck the bottom cuff of his left glove with the gloved fingers of his right hand without ever touching the inside of the glove or his hand; to remove the left glove that way then to tuck the naked fingers of his left hand under the cuff of his right glove rolling the cuff up from there without ever touching the outside of his right glove, and then to have the two gloves rolled up in such a way that the weight of the whole assemblage is in tension between his two thumbs, and to use that tension to accurately slingshot the whole lot into a nearby bin marked ‘hazardous waste’, for her to think ‘that’s my guy’ and to then let him cut her open and fuck around with her spine. For contrast, when Christopher Duntsch – accompanied by an ominous and dissonant soundtrack by Atticus Ross of Nine Inch Nails – is seen assisting his surgical mentor, Dr Geoffrey Skadden (played by Kelsey Grammer), in a scene more realistic than any in Grey’s Anatomy, the effect is very different. Skadden orates in a professorial tone to the assembled students observing the procedure, while he explains what he and his assistant, will do next. However each time Duntsch goes to place his instruments on something Skadden has to correct him. He makes all these corrections quietly, never breaking the suspension of disbelief for the observing students. There is a moment when Duntsch is about to clamp down on something in the patient’s spine with a long pair of forceps, and Skadden abruptly reaches for the forceps to halt him, then he gently moves them to an entirely different part of the surgical field. We can’t see in the wound, but we know Duntsch was about to make a grave mistake. After this, whilst still operating, the pair go on to talk about getting seed capital for their joint-venture start-up company. It is the high resolution of the portrayal that distinguishes this scene from the scenes in Grey’s Anatomy where George screws up an appendicectomy, or where Meredith assists with intracranial neurosurgery. These are completely devoid of detail, and it’s the details that make the depiction so menacing, because even the viewer at home can see what delicate work it is to cut somebody open and work on their spine, and it’s all so obvious he’s fudging his homework. The frequent flashes back and forward in time do similar work for the viewer, who’s already privy to the crimes themselves – shown in graphic detail – before watching him not paying attention at med school. We therefore have the possibility of knowing what ignorance and what hubris is at play when Duntsch wades in too hastily, puffs out his chest too far, deludedly reassures a family, or undermines a nurse. The inclusion of the details – alongside the half-assed surgical training, alongside the crimes themselves – is what really makes all the bluster as scary as it should be. It’s also what (accurately) suggests that all doctors have a little in them of what makes Dr Duntsch into Dr Death. We see him tell a patient in 2012 ‘we’ll get you doing cartwheels in no time’. Then we go back to 2011 and watch him utterly failing to learn how to operate. Then we flash forward again and see him crippling that same patient. Then we see him fucking a nurse. Then we see him driving his BMW. He is an extreme case, but of a type of guy who is too common for comfort. He reminds me of a few guys I went to med school with or encountered in hospital during training, including a few who were chucked out before the independent practice stage of their careers, a few who chucked themselves out, a few who escaped censure for bad behaviour through long careers but were finally outed in the #metoo moment, and a few who are still going. One of the most arrogant guys I knew in med school caused a bunch of trouble because he wouldn’t admit he didn’t know how to read a heart rhythm – though he was arrogant enough to offer to teach med students how they should do it. We used to gather round in the emergency department to read his excessively long notes, which were notable for never committing to any particular diagnosis. Another guy, when working as a geriatrics intern at a major metropolitan hospital, noticed a bump on an old man’s head and started cutting into it with a scalpel ‘to explore the lesion’ before realising he’d fucked up and calling for help – on the phone he acted as if the surgical registrar should have been thankful that he’d already loosened the lid of the jar. Another was an older surgeon, famous outside the hospital as a healer, and famous inside the hospital as a bastard, who treated everybody like shit and eventually got retired in a secret deal because he sexually assaulted a junior doctor. In the course of Dr. Death we are invited to wonder whether Duntsch’s misdeeds constitute the incompetent bungling of a poorly trained surgeon who knows better, the hubristic mistakes of a surgeon who should know better; the wilful mistakes of an arrogant surgeon who does know he should be better but can’t do any better and whose hubris won’t let him stop; the acts of a frustrated underachiever with an overachiever’s ambition who maimed all those bodies because they wouldn’t rise to meet his instruments to fix themselves; or the crimes of a violent man who used his access to the operating theatre as a license to wantonly harm people for his own enjoyment. The distinction between Grey of Grey’s Anatomy (longest running, most beloved of TV doctor shows) and Duntsch of Dr. Death gives us a fruitful approach to these questions. Grey’s Anatomy started when I was in the third year of med school, and when Christopher Duntsch was at the beginning of his surgical training. While I knew better even by then that my life as a doctor would not really resemble Meredith Grey’s, my future patients did not. The predominant cultural figuration of the doctor as reassuringly self-assured, cutthroat, and either infallible or useless, is faithfully reflected in Meredith Grey and her mates. The doctor’s charm is supposed to involve arrogance, and when it turns to modesty, that modesty is false. Who would want to be treated by a doctor who earned their modesty? That what Grey does laudably in her day’s work as a healer becomes the evidence of malpractice in Duntsch’s case proves it: the patient asks the doctor to be like Dr. Grey, but if any doctor were to accept that invitation literally, we would end up calling them Dr Death. It is the pass from pure fantasy to ‘actual events’ that Duntsch fails to achieve and what is so monstrous about him. It’s for that reason the spectre of a Dr Death shimmers like an aura around every Dr Life. * There have been so many Drs Death—both real and imagined—that a comprehensive account of them could become a branch of medical history all its own. There’s physician Philip Nitschke aka Dr Death, whom Newsweek called ‘the Elon Musk of assisted suicide’; there’s medical pathologist Jack Kevorkian aka Dr Death, portrayed by Al Pacino in 2010 movie You Don’t Know Jack, who championed euthanasia, said ‘dying is not a crime’, and is in jail for second degree murder; there’s surgeon Jayant Patel aka Dr Death who was kicked out of a hospital in Buffalo for incompetence then had his New York medical license revoked, then was named ‘Distinguished Physician of the Year’ at Kaiser Permanente Hospital in Oregon, then was struck of the medical register in Oregon for maiming and killing patients, who then moved to Bundaberg Base Hospital in Queensland where he maimed or killed 87 people, was convicted of three counts of manslaughter and one case of grievous bodily harm, and sentenced to seven years’ imprisonment, then let off on a suspended sentence and flown business class back to the USA on Australian tax-payer’s money; there’s general practitioner Harold Frederick Shipman aka Dr Death, who killed 350 of his patients and was convicted of the murder of 15 elderly women to whom he administered lethal doses of morphine after doctoring their wills to include him as a beneficiary; there’s forensic psychiatrist James Grigson aka Dr Death who testified as an expert medical witness in 124 murder trials, and who—because of his own beliefs about the nature of psychopathy—recommended the death penalty to the jury in every one of them, and got his way in 115 of them, and who was profiled in a Vanity Fair article in 1990 in which he called himself proud to have been responsible for so many deaths; there’s cardiologist Wouter Basson aka Dr. Death who in apartheid era South Africa supplied and produced ‘kidnapping drugs’, ‘suicide pills’, and developed chemical weapons, and who—as head of the apartheid government’s secret biological and chemical weapons program—tried to develop viruses that would kill only black people, who was acquitted of 67 charges relating to war crimes (including 200 murders) in 2002, who continues to work as a cardiologist in Cape Town and who, when asked what he thought of people calling him ‘Dr Death’ said ‘I knew of no earthly reason why they would do that’; there’s family doctor and local politician Santosh Pol aka Dr Death who confessed to killing 15 people (but probably dozens who went missing in similar circumstances) by lethal overdose in Maharashtra, who then used his standing in the community to rob his victim’s estates; there’s sexual health clinician Melusi Dhlamini aka Dr Death who boasted on twitter about bullying someone to death and was later fired from his position as head of the Sandton Marie Stopes clinic; there’s emergency physician Maxim Petrov aka Dr Death who anaesthetised and robbed tens of patients in St. Petersburg, and was convicted of killing 17 of them; there’s surgeon Aribert Heim aka Dr Death who volunteered for the SS in 1940 and performed grotesque surgical procedures like the removal of organs without anaesthetic on possibly thousands of prisoners at the Mauthausen concentration camp, whom one prisoner, a certain Karl Lotter, testifies to have seen anaesthetise a patient who came in with a sore foot, and who then proceeded to cut open that patient’s abdomen, castrate him, remove one of his kidneys, revive him briefly before his death, then decapitate him, boil his head, strip the flesh and keep his skull on his clinic desk as a paperweight, who was captured by the US in 1945, who was released in 1946, who practised as a gynaecologist in Baden-Baden for a time before he escaped arrest by the West Germans in 1962 and who fled to Cairo where he continued to practice medicine as an apparently devout Muslim by the name of Dr. Tarek Farid Hussein until 1992; there’s anatomist Gunther von Hagens aka Dr Death who pioneered advanced techniques for the preservation of corpses, became famous for exhibiting them on television, and who, when he learned he had a terminal illness, asked his wife, also a doctor, to prepare his corpse for display in his own exhibition saying ‘Angelina, you are entitled to freeze me down to -25C for one year, but after that time you really need to put your hands on me because otherwise I will get freeze burn’; there’s medical policymaker Dr John Kitzhaber aka Dr Death architect of The Oregon Plan a framework for healthcare resource allocation who denied coverage of bone marrow transplantation to a 7-year-old Coby Howard resulting in Coby’s death; there’s general practitioner Maurice Généreux aka Dr Death who helped patients suffering from AIDS commit suicide with barbiturates; there’s GP turned finance executive Edward Vandyk aka Dr Death who was responsible for tanking the stocks of a number of previously successful businesses, but who remained confident in his skills as an executive even once City of London bankers started calling him Dr. Death; there’s medical scientist Sidney Gottlieb aka Dr Death who led the CIA effort in ‘brain warfare’, killed and maimed an unknown number of people used in secret experiments and died a free man in 1999; there’s Dr EJ Death, pronounced Deth not Dee-ath, of the The Two Ronnies 1976 sketch in which Ronnie Barker’s Dr Death’s slips of the tongue include references to ‘a slip of the scalpel’, asking the patient if he is ‘single or buried’ and calling the patient ‘Mr Corpse’, who confuses food poisoning with tennis-elbow, whose history taking effort involves the (all too true-to-life) question ‘when were you born and what do you enjoy and how often’, and who – while protesting his popularity as a doctor – finds only a dead rat and a lady’s high-heeled shoe in his ledger of patients; there’s the mysterious Mornington Peninsula based chiropractor known only as Dr Death who apparently helped Juddy out when he first came to Carlton, and who can get you back on the footy field in all but the worst circumstances but who will first cause you pain worse than you’ve ever felt; there’s party drug para-methoxyamphetamine aka Dr Death, which is similar to ecstasy but has been known since the ’70s to be responsible for many more hyperthermic deaths than other psychostimulants; there’s professional wrestler Steve Williams aka Dr Death who in 1988 alongside Mike Rotunda defeated The Road Warriors to win the NWA World Tag Team Championship; there’s 2019 movie Doctor Death directed by Rob Pallatina in which a surgeon becomes a murderous stalker; there’s 2020 movie The Legacy of Dr. Death directed by Yoshihiro Fukagawa in which a detective investigates a series of suspicious medical deaths; there’s the 1930s comic book series Doctor Death which depicts Dr Rance Mandarin’s twisted scheme to topple modern civilisation and send humanity’s survivors back to the purity of a Stone Age lifestyle; there’s The Chronicles of Dr. Death a book by Wright, Schutz, and Kaviraj; there’s the song Dr. Death by U.D.O. that begins Doctor Death Is On The Ward/Searching For His Prize/Body Bags Are Cold As Ice/Screams Cut Through The Night; there’s the pantomime DR. DEATH & THE MEDI-EVIL MEDICINE SHOW about a time travelling doctor whose ‘cures’ are suspect, which played at the Brighton Science Festival in 2017; there’s the 1974 movie Doctor Death: Seeker Of Souls directed by Eddie Saeta in which Doctor Death translocates the souls of injured ‘patients’ into the more beautiful bodies of sacrificial hosts and has sex with them; there’s the book Dr. Death by Claire Carmichael; there’s the book Doctor Death by Jonathan Kellerman; there’s the book Doctor Death by Edgar J Hyde, and Chloe Tyler; there’s the book The Island of Doctor Death and Other Stories and Other Stories by Gene Wolff; there’s the Dr. Death escape room in Montgomery, Illinois; there’s the book Doctor Death by Lene Kaaberbøl; there’s the DC comic books supervillain Dr. Death who was Batman’s first recurring foe; and believe me, there are many more. * What we’ve not yet discussed is the commodification of medical treatment: how The Doctor, and The Doctor’s Way, are co-opted for profit and how these work upon the hopes of the patient for a quick fix. As the fictional owner of ‘University General Hospital’ Dr Sasani says in episode 4 of Dr. Death when he justifies not having looked closely enough at Duntsch’s past record, ‘the average neurosurgeon is worth 2.4 million in revenue’, so it doesn’t pay to look too closely. For a few years I worked alongside pain specialists, physiotherapists, orthopaedic surgeons and neurosurgeons in some very wealthy suburbs of one of Australia’s largest cities. I’ve seen first-hand how the chronic back pain pipeline operates. By the time patients get to a surgeon they have suffered pain for a very long time. Some of them have structured their lives around it. Some of them have tried very hard to get better. Some of them have tried not to get better. They may blame quite a bit on their pain. Rightly or wrongly they may blame pain for their lost career. They may think it’s the reason they can no longer enjoy themselves. They may hold pain accountable for lost love or poor relationships with family. So, when they approach a surgeon, ostensibly looking to be fixed, they tend to be in states of exasperation and desperation. If they are fixed they may be able to regain what they believe they have lost, or not, but it’s clear that a lot more than the presence or absence of pain hangs in the balance. The surgeon tells them, ‘I’ll fix your pain’ (we’ll get you doing cartwheels again) and recommends admission to one of the hospitals they’ve partnered with. The hospital collects fees upon entry, a daily fee for the bed, a connection fee for the television, and numerous fees for other services. The admitting doctor refers to other doctors who also charge the patient or their insurance company a fee for their services: they’ll usually refer to a pain specialist, and then they will usually refer to a psychiatrist. If other complex medical interventions are required, they’ll then refer to a physician or a geriatrician who might want to refer to a cardiologist or a respiratory physician prior to surgery. The surgery requires an operating theatre – that’s money for the hospital, and for the assistant surgeon, and the anaesthetist. If the surgery goes well there’ll be rehab from physiotherapists, occupational therapists, nurses, exercise physiologists, maybe a psychologist and maybe a psychiatrist. Insurance gets billed for all these services. All the while, the daily bed fee racks up. That’s why profit-making hospitals don’t like to have empty beds. If the surgery goes badly there’ll be all that same stuff, plus revision surgeries (sometimes many), plus more consults to other doctors to help solve whatever problem the surgery has now caused, and many more days in the bed. Bad back surgeons, provided they are never outed as bad, are brilliant for a hospital’s business. This is one reason why it’s so hard to call-out or prosecute a dangerous doctor. A difficulty well presented in Dr. Death as we watch Drs Henderson and Kirby struggle for years to have anyone listen to their concerns about Duntsch’s practice. In the process, they have to push against cultural and professional norms, strong financial imperatives, and legislation in Texas that limits any ‘non-economic’ damages won in a malpractice suit to the low figure of $250,000 because lobbyists working for hospital owners have worked to push through legislation that insulates them from financial risk. The over-treatment of back pain, like all cons, operates on the need or the greed of the mark. Either the patients are driven to desperation by their chronic pain, or their pain gives them something they reason they can’t get elsewhere. Back pain is almost always a mixture of anatomical dysfunction, hard to define changes to the function of the nervous system (usually figured as ‘neurological’) and hard to define changes to the psychical mechanism that detects and responds to pain (usually figured as ‘psychological’). These three elements come bundled in different proportions in each patient who presents with ‘back pain’, and they require various medical approaches that might encompass all or some of surgery, medication, physiotherapy, implanted electrical devices, psychology, psychiatry, psychoanalysis etc. In my work — as a psychiatrist — with patients with chronic back pain, I have seen people subjected to horrendous accidents whose pain subsided quite quickly. This is the case for instance of a man buried alive under rubble on a construction site whilst working in a deep pit, who had a strong family and a relatively flexible sense of his role in the world – and came good pretty quickly. I’ve also seen people who had no demonstrable anatomical problem in their back, had no clear injury, but have spent decades in pain and dedicated their lives to treating that pain. Backs are highly complex, as are minds, and there is simply no way of making any proper diagnostic claim about the origins of pain in any instance. But in all cases, we know there is a positive outcome from what are called ‘non-specific effects’ and the ‘therapeutic alliance’, all of which can essentially be summarised as ‘all that the doctor and their process is that has a placebo effect’. For this reason, whatever else the doctor does, this sort of healing bedside manner is encouraged by the system and by the patient (because it truly does contribute to healing, as long as everything else is kosher). What Duntsch does is just offer the healing manner, without any of the capacity to otherwise heal. Jeff Glidewell, one of Duntsch’s victims, said in a 2018 interview that he found Duntsch’s name on a website called ‘Best Docs Network’ associated with ‘a slickly produced video showing Duntsch in his white coat, talking to a happy patient and wearing a surgical mask in an operating room’. These are the non-specific effects specific to a surgeon. What we could call the ‘specific healing effect’ of doctoring – like prescribing the right antibiotic or choosing the right surgery and performing it correctly – requires the sort of humility expected of a scientist confronted with the adversity of nature. But this humility is in tension with the ‘non-specific healing effects’ which are in fact useful for something, but which (in most cases) require that the doctor’s sheer ignorance in the face of the nature of disease be obscured from the patient. It is in fact these ‘non-specific qualities’ – which describe their manner, their impression as a person, the idiosyncrasies of their decision-making – that essentially constitute the cultural figure of ‘the doctor’ and their ‘bedside manner’. The bedside manner can be good or bad, but its consideration is of chief importance to the question of the doctor. At this point I want to highlight two idioms I was taught as a med student: ‘Young surgeons kill people. Old surgeons leave them to die.’ ‘When a GP refers to a specialist, they consider the the As: Availability, Affability, and Ability. In that order.’ What distinguishes a doctor from a scientist or a textbook is their figuration in culture, their supposed ability to incorporate something more artful than scientific into the treatment, and their manner at the bedside. It’s for that reason we can say that the doctor presented in this series as ‘Dr Death’ is indeed monstrous – but monstrous in the most doctorly way. Monstrous inasmuch as what is doctor in him has grown malignant. Throughout the series, the dialogue between Randall Kirby (played by Christian Slater) and Bob Henderson (played by Alec Baldwin) – the two surgeons who make it their mission to stop Duntsch from operating – addresses the debate between hubris, incompetence, and wilful violence: KIRBY: A guy from a top medical program followed by a top residency followed by a top fellowship. He keeps getting these surgical outcomes because (A) he’s either doing it on purpose or (2) he just sucks. HENDERSON: I can’t make sense of it. KIRBY: Personally I’m leaning towards (B). HENDERSON: The question isn’t why he did it. It’s how he got away with it. That is, there are systemic forces trying to obfuscate the clear equivalence between stupidity and mendacity in a field supposed to be defined by compassionate care, technical expertise, and scientific rigour. KIRBY: The system is broken. HENDERSON: And we are a part of that system. There are doctors doing harm through incuriosity. However, since their incuriosity serves the status quo of profit-driven or KPI-driven medicine, it is rewarded. Duntsch is today’s monstrous doctor who must be punished but one reason his story was compelling enough to be the subject of a television series is that he embodies the monstrousness of the system itself: it is the inhuman system that treats good patient outcomes as an unfortunately costly part of profit-making. Patients are uneasy about the way the system works, but because the personage they encounter as the manifestation of that system is the charismatic or kindly figure of the doctor, this unease seems to them to come from themselves, and they play along. They inflate the position of doctor because they hope that (so-inflated) the doctor will truly be able to cure all that ails them. If he cures my back pain, the problems in my marriage would also be solved; if he cures my back pain I’ll be able to return to the career in professional skateboarding I dreamed of but could never achieve. Surgery itself becomes emblematic of several losses or deferred desires, so that the surgeon becomes invested with an excessive power. To paraphrase (and soften) Jacques Lacan’s words to the would-be revolutionaries of 1968: If what you aspire to as patients is a new master. You will get one. This aspiration is presented best in the series when Duntsch’s patients – somehow unconsciously aware that he is no good – hope that if they believe he is good and they say he is good, it will be enough to get them the surgery their heart desires. For instance, consider this exchange as Duntsch’s friend Jerry Summers lies on the table, ready to have his neck surgery: SUMMERS: Hey Chris? DUNTSCH: [leans in] SUMMERS: I’m the luckiest bastard alive! [looks anxious] DUNTSCH: [nods in false modesty] I’m gonna fix you. In the next scene, Jerry wakes up a quadriplegic. Or when Mrs Keller tells her husband to shut up because he has asked Duntsch about the patients he’s killed. When the husband finally quiets down, she turns back to Duntsch and says, in a commanding tone: ‘You’re not gonna do that to me though are you?’ Overland’s Friday Features project is supported by the Copyright Agency’s Cultural Fund. Sam Lieblich Sam Lieblich is a writer and psychiatrist working in Melbourne, Australia and conducting neuroscience research at the University of Melbourne. More by Sam Lieblich Overland is a not-for-profit magazine with a proud history of supporting writers, and publishing ideas and voices often excluded from other places. If you like this piece, or support Overland’s work in general, please subscribe or donate. 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