DATELINE: Tierra Tranquila, a house on a mountain above the Pacific in Costa Rica

LAST NIGHT we sat out under the equatorial stars and listened to the sounds of howler monkeys, birds, and cicadas. At 2,000 feet, there are no mosquitoes. This morning at dawn we watched three toucans zoom in and slash at their breakfast – a bunch of bananas we cut down from our trees and hung beside the patio. Among the plantains, mangoes, papayas, avocados, and limes, birds abound: hummingbirds hovering under the leaves of the purple banana flowers, flocks of parrots, a pair of blue-crested mot mots with tails twice as long as their bodies, soaring hawks, and portending vultures. Each morning you can spot a new, rolled-up banana leaf and watch it on and off all day until it unfurls fully, a lime-green flag of fecundity. On the dirt road, our neighbor goes by with his oxen dragging the trunk of a pechote tree – a wood that, like the native teak, resists termites. It is valuable, and protected. Only fallen trunks can be gathered and sold.

The community of 20 farm families live along the road up the mountain. There is an elementary school, a social center, and a women’s cooperative micro-loan bank, which in 11 years has never had a default. The nearest village is down a dirt road with 13 hairpin turns, and has two paved streets. Costa Rica is a designated world “Green Zone’’ – getting top scores for environmental policy – and our province is a world “Blue Zone,’’ for the longevity of its inhabitants.

The summer of 2004 my wife and I were asked to lead a cultural dialogue here between American and Costa Rican (“Tico’’) teenagers, in which our daughter participated. Our trepidation about what might happen in an America ruled by a second Cheney/Bush, coupled with our sense of sanctuary in Costa Rica, led us to buy the house. We have returned to the dialogue/camp each summer.

On a trip with the campers to a local waterfall, one of the counselors fell on the rocks and gashed his head. In the village was a modern, fully-equipped clinic: doctor, nurse, and pharmacist. The young woman doctor saw the patient right away, did a thorough exam, and sutured him up. By the time she was done, the pharmacist had brought in the antibiotics and pain medication. Our cost: zero. She told us that every village of any size has a clinic staffed by a doctor – all of it free.

How do they do it?

The answer came from a question the Ticos asked the Americans in dialogue: “What does it feel like to live in a country that’s always at war?’’

For my whole lifetime, America has been fighting an endless progression of foreign wars – and, truth is, it feels insane. America’s effort in World War II fattened into a military-industrial economy that has devoured our national purpose, which now includes lies and torture. Our healthcare, a for-profit “industry,’’ leaves 50 million uninsured, a national disaster. Here, every Tico has free healthcare. Hospitals are good – some Americans come to San Jose for the joint repairs they cannot afford at home.

How is this possible in a small country without valuable resources such as oil, gas, or metals? Simple: In 1948, the government outlawed an army. It cannot go to war. It spends zero on its Department of Defense – there is none. Rather, there is a single department for both Environment and Energy – all the energy (except gasoline) is renewable, from water and wind to geothermal and solar. The country is not a utopia – the Tico teens admired the Americans’ sense of freedom and individual possibilities, material wealth, and world leadership – but it is an enticement.

If you don’t waste money on an empire, you might just have money for a true democracy. This country that cannot go to war, that has a president who won the Nobel Peace Prize, generates a certain peace among its citizens. They know that if they get sick, they get care; if they want an education, they get one; if they want work, they can have it (not just bananas or coffee, but Intel chips); and whether or not they want natural beauty and the blessings of animals, plants, friends and family, and long life, they have them.

Throughout the country there is a common greeting: When we meet on the mountain and ask, “Como esta?’’ – “How are you?’’ – they answer, “Pura vida’’ – “Pure life,’’ or “Life is good.’’

Stephen Bergman is a guest columnist. Under the pen name Samuel Shlem, he is the author of “The House of God’’ and “The Spirit of the Place.’’

A COUPLE sits on a beach on a brilliant July day. They’ve just had a picnic lunch, and are in that hazy sweet space of watching the waves and the gulls, the passing sailboat, or, far out, the tanker. They feel close.

The woman, wanting to feel even more close, asks: “What are you feeling, hon?’’

Startled, the man blinks, glances at her, and not knowing what to say, says nothing.

The woman asks, “Can you tell me?’’

The man, wanting to respond and trying to gather his thoughts and feelings to do so, still comes up blank. A sense of panic blossoms in his gut and rises to his chest, cold and damp as if clenching his heart. Trying to stay calm he says, “I don’t know.’’

“Sure you do. Can you tell me?’’

The cold rises into his brain, all ice. Through gritted teeth he says, “Don’t spoil it!’’

The woman, startled by his tone and the glazed look in his eyes, says, “I’m spoiling it?’’

Things go downhill. They wind up miles apart, staring at nothing.

What is going on? In our work leading gender dialogues between thousands of men and women, boys and girls, Dr. Janet Surrey and I have come to understand this as a “relational impasse’’ – the “dread/yearning impasse.’’ If the woman, yearning to feel closer, approaches, often the man starts to feel “male relational dread,’’ and retreats. In his head is a little voice: “Nothing good can come of my going into this, it’s just a matter of how bad it will be before it’s over. And it will never be over!’’

As one man put it: “I woke up this morning and she turned to me and I was in dreadlock!’’ The paralytic feeling of dread is familiar to many men. It contains a sense of failure, humiliation, shame, and paranoia. It is part of normal male development – and it is hell on relationships. Anything, even the cap let off a tube of toothpaste, can trigger it. Relational dread is a basic human experience, although the male and female versions may take different forms. This is the male version.

How does male dread develop? A patient’s story gave me a clue. When he was 6, he had been beaten up at school. He wasn’t hurt physically, but felt terrible. He walked home up the railroad tracks through the woods so no one would see him crying, and couldn’t wait to tell his mother. He went in through the back door into the kitchen, anxious to tell her. She was at the sink. She turned around, saw the tears, and with concern asked, “What’s wrong, dear?’’ Despite wanting to tell her, he said, “Nothing,’’ turned away and walked back out.

What had arisen was not just in him – after all, he walked into the kitchen intending to tell her. But when she moved toward him emotionally – in the interaction between them – he felt exposed, and dread suddenly arose and did its damage. It was a relational impasse.

Although we all – boys and girls – come into the world with a primary desire for connection, there is an early fork in the path. Many boys are pushed by the culture to disconnect from their relationship with mother in order to grow, and become less valued for their relationships and more valued for themselves; while many girls continue to grow in relationships, and are valued as the carriers of connection in the culture.

But scratch our surface and you find that we men desire connection every bit as much as women, and get sick and even do sick things – think of all the destruction wrought by male “loners’’ – if we don’t experience it. Given the chance, we’re just as good at it as women – witness the revolution in fathering in the past few generations, fathers as caregivers. Male relational dread may arise from time to time, but male relational love, living “in the we’’ with a partner or a child or a dog or a student or a shortstop-or-dancer-in-training, is right there in us, waiting to prevail. We men yearn more than anything to live not in the “I’’ or the “you,’’ but in the “we.’’

Stephen Bergman, MD, is a guest columnist. Under the pen name Samuel Shem, he is the author of “The House of God’’ and “The Spirit of the Place.’’

MEDICAL STUDENTS in their course on diagnosis are taught: “When you hear hoof beats outside the window don’t assume it’s a zebra.’’ This means that you should think of common diseases first, not exotic ones.

Decades ago when I was a medical student in Boston at one of man’s greatest hospitals, I was assigned a woman with “difficulty breathing.’’ She was 56 years old, a mother of three whose husband had died two years before. In good health all her life, she worked in a flower shop. She had never before had trouble breathing. Her husband’s death had been a shock, but with the support of friends and family she had gotten through it pretty well. The resident – my boss – came in and took her history, in a rat-a-tat technique of asking a probing question that had to be answered yes or no, and as soon as there was a response, cutting her off and moving on to the next. I knew he was filling in his grid, a decision tree that would provide the diagnosis. No new information came up. A physical exam showed nothing but her panting. Lab work revealed increased eosinophilia, the blood cell that increases when the body is allergic to something. The resident went back and grilled her on allergies. Nothing.

Her workup proceeded in classic academic fashion, with increasingly refined blood tests and X-rays. The latter showed a diffuse pattern of lung irritation, but no lesions or tumors. Experts were called in, and each diagnosed something in their area of expertise, from the psychiatrist diagnosing “melancholia’’ at her husband’s death, to the surgeons wanting to cut. She kept getting worse, the oxygen levels in her blood falling lower and lower, bluing her lips, paling her face. A look of doom seemed to cloud her eyes. The surgeons did a lung biopsy, which showed only that her lung was reacting to some antigen, as the blood test had shown.

She continued to decline. Palliative treatment was begun. The resident and staff doctors seemed reluctant to enter her room. I felt scared for her and sorry, and spent more and more time sitting with her, just talking – a medical student has time for this arcane procedure. One day I asked where she lived. She said that after her husband died she’d taken in boarders to survive. I asked about them. “One of them’s. . . a real trip,’’ she gasped. “A magician.’’ I smiled and asked more about him. Part of his act involved trained pigeons, which he kept in cages in the basement. “The cages are right above my washer drier.’’ My ears perked up. It turned out that whenever she ran the drier, the pigeon droppings were aerosolized and she breathed them in – for the past two years. I rushed to the medical library – in those days we still used books – and found “Pigeon Breeder’s Lung Disease.’’ Treatment: get rid of the pigeons; and a course of steroids. Prognosis: excellent. The magician suffered. She got well.

Looking back now, what did I learn?

That the science of medicine is astonishing and useful, but it can keep us from practicing the human art of listening and responding, face to face, heart to heart, without a decision tree in mind or a computer on our laps so we stare into the screen instead of look into the eyes, all to “save time.’’ That the for-profit insurance industry dictates that we doctors don’t have time to listen to our patients if we want to get paid. That if we rely on technology and tests and neglect “being with’’ the patient, we may well miss the vital human facts that will solve the mystery and bring the cure. And that the patient is never only the patient; the patient is the spouse (alive or dead), the family, the house and who lives in it, the friends, the community, the toxins, the climate, where the water comes from and where the garbage goes. The patient is the world.

And finally that the “hoof beats’’ outside the window can be zebras – or, if you listen carefully, just the light steps of a common bird.

Stephen Bergman, MD, is a guest columnist. Under the pen name Samuel Shem, he is the author of “The House of God’’ and “The Spirit of the Place.’’

LIKE THE arcane process of film developing in a darkroom tray, several Laws of the Novelist have appeared, and are offered as a guide to those so inclined.

Law Number One: Don’t Believe Teachers. The son of a dentist, I always wanted to be a writer. At college I worked like hell on the first essay of the freshman writing course, and got it back with one comment, in red letters: “See me.’’ Her feedback: “This is too terrible to mark, it’s below F.’’ Devastated, I tried again, and again, and always: “See me. Still below F.’’ Later that year, I was on the golf team with a blond Adonis named Ray. He said he was getting a straight A. Ray was a great golfer, but could barely talk, much less write. “What, you an A?’’ “Yeah. I’ve been sleeping with her all year.’’

Could this be the meaning of “See me’’?

I didn’t believe her, and kept on.

Law Two: Editors Are Ephemeral and Don’t Edit. The editor of my first novel moved to another publishing house for my second. In the middle of my third, at another publishing house, she was fired, and my new editor, after sending me terrific edits, was fired the next day. The editor on my fourth novel, at still another publishing house, said, “I love this novel. I won’t change a word.’’ But when I got the manuscript back she had marked it up with so much red pencil that each page was pink. We struggled. I took few of her suggestions. In our final conversation she said, “You’ve ruined this book. It will get bad reviews,’’ and then she was fired.

As one editor told me: “We no longer edit, we acquire and market.’’

Law Three: Publishers Don’t Publish. When my first novel was about to come out, I asked my publisher if it would sell. “No, your novel won’t sell.’’ This startled me. “It’s about medicine, and that’s good, and it’s funny and sexy, and that’s good.’’ Why won’t it sell? “Because it’s a good book. Good books don’t sell.’’ Bookstores can return any book for a full refund, a business model that spells doom for publishing. Only about 5 percent of books pay back their advance. Those hardcover remainders piled up in stores mean that the publishers overpaid, overprinted, and undersold.

Law Four: There Is No Humiliation Beneath Which a Writer Cannot Go. My second novel had come out in paperback, and my wife and I were on a hiking trip in New Hampshire. We stopped in a mom-and-pop store for lunch. There, in a spindle bookrack, were two copies of my novel. I immediately suspected my wife had placed them there, to make me feel good. Nope. I took both books off the rack and went up to the little old lady at the counter, and announced, “I wrote this book.’’

“Oh, you wrote that book?’’ she asked.

I averred yes. I asked if she would like me to sign the copies.

“Oh no, our folks would never buy a book that was writ in.’’

Another standard humiliation: At an author-signing in a bookstore, sitting at a desk near the window, facing a wall of Grishams, watching people hurrying past as if you are a child molester. Not fun, especially if your publisher has overlooked advertising the event.

Law Five: There Is Only One Reason To Write. During a post-second-novel depression, I spent six months, more or less, in the bathtub, trying to give up being a writer. Finally I realized that while I disliked publishing, I still loved writing. But if you want to respect what you write (rather than write for cash), you need a day job. Luckily, decades previously I faced a choice: between Vietnam or Harvard Med. I became a psychiatrist because I might learn about character and story, and could leave mornings free to write. Not as good a day job as my first, working the graveyard shift as a toll collector on the Rip Van Winkle Bridge – you can learn pretty much everything from what goes on at night in cars – but still.

Only write if you can’t not.

Correction: In last week’s column, in reference to the Clark Rockefeller trial, I erroneously reversed the words “prosecution’’ and “defense.’’ The prosecution psychiatrist concluded that the accused was not insane; the defense psychiatrist and psychologist concluded that he was insane.

Stephen Bergman, MD, is a guest columnist. Under the pen name Samuel Shem, he is the author of “The House of God’’ and “The Spirit of the Place.’’

THE RECENT verdict of guilty in the “Clark Rockefeller’’ trial was an affirmation by a jury of his peers that he was not insane at the time of the crime. But the duel of prosecution and defense psychiatrists was at best a farce, at worst a travesty of the profession and the law. As a former psychiatrist I am appalled.

For the prosecution: one psychiatrist, famous from Fox TV and psychiatric thrillers, was paid $10,000 for his expertise as part of an “insanity defense,’’ testimony that was challenged by his offering opinions about Rockefeller on TV in advance of the trial; a prosecution psychologist agreed with his diagnosis, basically of a narcissistic character who was “delusional’’ – that is, insane. For the defense: a psychiatrist who had seen the accused once for 2 1/2 hours and had never before testified in court came up with the diagnosis of narcissism and sociopathy – that is, not insane.

Diagnosis of mental conditions is not the same as that of kidney disease. From the birth of psychiatry, diagnoses have been determined not by hard numbers but by cultural/historical norms. After Freud “discovered’’ During Freud’s time, after he “discovered’’ hysteria to be “a wandering womb,’’ the diagnosis became all the rage, as if suddenly hysteria had become epidemic, wombs wandering all over Europe; in recent decades the diagnosis of attention deficit hyperactivity disorder has boomed. Hysteria is a rare diagnosis now; perhaps ADHD will decline in popularity as well.

These days, psychiatric diagnoses are based on the “Diagnostic and Statistical Manual of Mental Disorders,’’ published by the American Psychiatric Association. This hefty volume is a main money-maker for the association, upward of a million dollars in annual sales. It is written by panels of psychiatrists who are each specialists in their own diagnosis and it is flawed, one example being its listing “homosexuality’’ as a psychiatric disease long after society had not.

It is also tarnished by many of the specialists being paid to be involved in studies of drugs to treat the illnesses they list as their expertise. The temptation for them to find a drug that will treat a diagnosis they can specify and in which they are the expert is significant.

The current conflict-of-interest investigations – including by Congress – into psychiatrists getting paid to do research that might prove the efficacy of the drugs they use to treat their patients are well documented. If a drug company can link a particular drug to a particular diagnosis, bingo – a blockbuster drug can earn over a billion dollars a year. The lucrative link between a diagnosis and a drug to treat it, when diagnosis itself is culture-bound and often subjective, pollutes the impartiality of the “Diagnostic and Statistical Manual,’’ and opens the courtroom door to the psycho-battles that demean and confuse.

If psychiatric diagnoses and treatments have an element of fuzziness, how could doctors paid by one side or the other not come up with a diagnosis wanted by their employer, prosecution or defense? Luckily, juries are savvy and sensible, and seldom buy an insanity defense. Dueling psychiatrists confuse, more than persuade them.

The solution is simple, and clear. First, do away with psychiatrists being paid by either defense or prosecution. Rather, have a paid panel of psychiatrists and psychologists independent of government or law, charged with determining legal insanity; both sides would have to agree to abide by the panels’ conclusion – as in binding arbitration.

Second, instead of either “guilty’’ or “not guilty by reason of insanity,’’ establish a verdict of “guilty and insane.’’ Convicted, the insane guilty would be held in psychiatric prison, eligible for treatment and perhaps available for statistical and clinical studies of the link between insanity and crime. Useful information – like the data suggesting that 80 percent of violent crimes are committed under the influence of alcohol or drugs – could be obtained, and could be useful in early intervention.

The circus atmosphere of shrinks in the courtroom, which devalues the profession and the law, would cease. As for the what’s-in-fashion friability of the “Diagnostic and Statistical Manual’’ and the money-making links of diagnoses to drugs, that’s another, more scary and intractable matter.

Stephen Bergman, MD, is a guest columnist. Under the pen name Samuel Shem he is author of “The House of God’’ and “The Spirit of the Place.’’

Boston Globe
July 6, 2009

John and I met in 1979 at a writer’s party, shortly after my first novel came out. My impression was clouded by nervous awe, but luckily it was summer and our conversation turned to golf, John’s passion, and my sport at our shared alma mater, Harvard. A week later I was out on a public golf course playing behind two carts full of beer-swilling guys whose swings seemed converted from hockey. There had been a mistake and we were a five-some. A six-some, actually. Another young writer, married, had brought along his petite blond girlfriend and spent a lot of time in the woods with her while we played on. Reappearing, flustered, they would walk along with her arm around his waist, her hand tucked neatly into the hip pocket of his jeans – a true Updikean touch.

You can tell everything about a person by the way they play a sport. In 30 years John and I spent at least 5,000 hours playing golf. We had a regular foursome, but often it was just John and I, walking along side-by-side, bags on our shoulders, talking. In golf, John was meticulous – our scorekeeper, cherishing those little yellow golf pencils; frugal, picking up pencils and tees; steady as a fair Christian but for an uncontrolled deviance into the raw sensuality of woods, briars, swamps, lakes, and sand traps; reliable on the greens; capable of astonishing flights of golf poetry and sudden crashes into golf trash – and really funny.

Once when he and I were teamed up against the other two and I complained of a bad back, he said: “I want you to know if helping the team means hurting your back, I want you to hurt your back.’’ Always on the fourth hole he would ask for medical advice; always the eighth fairway saw our “literature and career’’ chat, what we were reading and writing, the folly of both popular and literary taste. Often he would repeat something I said, and I knew I would soon see it in a book. He had an astonishing eye. One fall day he walked off the course to identify the last tree to turn color – I believe ash, or hickory.

Holes 10 through 18, with the wet, hot sun beating down, frayed our youthful start and saw a slippage of conversation. Despite the sudden heaviness of the bags and soreness of the joints, I never saw fatigue in John, never saw him yawn – he was just too damn interested in golf, and life. The 19th hole, in the cool, woodsy men’s bar, was jovial, John tallying up who owed what. We celebrated The Most Humiliating Moment of the Round, each of us offering an example – from someone else’s round. This John often won.

The last few years were not on the golf course, but at lunch. He timed our lunches to his delivery of boxes of his papers to Harvard’s Houghton Library. He always seemed shy announcing himself there – John was modest, but with a rock-solid confidence. Once, after a novel had gotten panned, I asked how he handled it. “They’re talking about my novel, not about me,’’ was his reply.

Last summer we had a belated joint-birthday lunch at John’s exclusive old-Yankee golf course, at which he never seemed quite comfortable. I noted his old man’s wrinkled, scarred face – but then in his eyes I saw the boyish joy at being alive and at play for another great day. He and I, two small-town boys sitting there in a grown-ups’ exclusive club eating our BLTs off bone China on a starched white tablecloth. The sun shone hot on the 18th green, lighting it up as if it were made of crushed emeralds.

Over lunch we laughed, hard, happy to see each other again and delighted with our good fortune in life, talking about everything as best friends do, and then parting, he with his gentle handshake and slight stammer. As I drove off I turned and saw him walking away slightly stooped, snowy hair shining in the sunlight, but with a bounce in his step as he swung his putter along, heading toward the green to practice.

That was the last time I ever saw him.

Stephen Bergman, MD, is a guest columnist. Under the pen name Samuel Shem, he is the author of “The House of God’’ and “The Spirit of the Place.’’

THE REASONS for the shortage of primary-care doctors have been clearly described: low pay, long hours, the crossword puzzle of insurance forms required to get paid – which leads to three administrative assistants for every doctor. But the issue is being framed using a classic tactic of the private insurance industry: in order to make ends meet, cut payments to higher-paid specialists and redistribute to primary-care doctors. This pitting of doctor against doctor is a classic tactic of the disastrous healthcare system in which we find ourselves.

When managed care came into Massachusetts decades ago, there was a massive advertising campaign to all doctors: “Unless you sign up with our company, you will wind up having no patients.” One would think that doctors would have gotten together and made it clear that they do the work. Without doctors, there is no healthcare. In a theater when someone collapses, has anyone ever heard the call go out: “Is there an insurance executive in the house?” If doctors had stuck together they could have prevented the abuses they’re now are battling.

The issue isn’t that primary-care doctors get paid less than cardiac surgeons, but that the system of healthcare rests on insurance companies and their CEOs making huge profits. No amount of cost-cutting can save enough money to support a for-profit system. The only solution is a universal, government-run healthcare system. Surveys suggest that a majority of Americans and doctors desire this. Any plan that puts private insurance in anything other than an optional, “concierge” system for the rich is just whistling past the graveyard of American healthcare.

The administrative cost for a private, for-profit health insurance system is approximately 33 percent ($300 billion annually); the administrative cost for the two government-run health systems, the Veterans Administration and Medicare, is about 3 percent. The level of satisfaction with these two nonprofit systems is high; that of for-profit is low.

Why in the world should healthcare be for profit?

Under a nonprofit system it would be easier for medical school graduates to go into primary care. Paperwork would go down drastically. No longer after a long day would a doctor have to spend an evening filling out dozens of different insurance forms, and then resubmit them a month later when they are denied or reduced. Doctors know that long hours come with the territory – most go into primary care because they like being with patients over the long haul of their lives. In a nonprofit system, they would no longer have the insurance industry rewarding them for limiting patient visit times to eight minutes average or stop themselves from ordering important referrals or tests.

Imagine yourself as a doctor: getting paid to practice bad medicine.

In order for a nonprofit system to work, two other needs must be met: tort reform, which will keep doctors from ordering needless tests to cover their butts for fear of litigation; and paying for medical education in return for national service, so that students don’t graduate with $200,000 in loans, and can’t afford to go into a lower-paying specialty.

How to pay for this? It is simply a matter of priorities. A whole year’s budget for the National Institutes of Health is a few days’ budget for the Department of Defense. In a humane society, providing good healthcare for all has to be a higher priority than spending half of our tax dollars for what, in my lifetime, seems like an endless progression of foreign wars.

How to get this done? The insurance industry is a powerful and ruthless lobby. Congress has an exquisite susceptibility to fear – in this case – “socialized medicine,” which we already have in the VA and Medicare. If all else fails, we may have to do what workers usually do to get bosses to give: organize doctors and other healthcare workers and plan a nationwide strike.

Stephen J. Bergman, under the pen name “Samuel Shem,” is a doctor and author of the novels “The House of God” and “The Spirit of the Place.”

RECENTLY A Boston hospital was cited for “hours violations” by the Accreditation Committee for Graduate Medical Education (one of 227 violators this year), and was told it would jeopardize its accreditation as a surgery training program if it did not correct the problems – which it acknowledged “is not easy.” After the Libby Zion case in New York City, when a young woman died as a result of resident fatigue in 1984, an 80-hour-week limit was placed on doctors in training.

Why isn’t it easy to enforce?

Thirty years ago, I was a medical intern at a Boston hospital. In my novel “The House of God,” I describe how doctor fatigue often harms the patient. The Zion reforms are in the best interests of both.

There have been reports of frequent violations of time restrictions, residents working more than 80 hours a week, or being off duty for less than the specified 10 hours at a time. While this may seem masochistic, doctors justify it by the necessity of “continuity of care” of patients and being on call long enough to “see a large variety of cases.” Unstated is the need to join the long mythic tradition of doctors who, with a little superhuman effort, rescue the sick and dying.

Surgeons have a special place in the pantheon of medicine. With astonishing skills, determination, and judgment – and, yes, valor, for they will sometimes endanger their own lives to save others, as in a blood-spattering gunshot surgery on an AIDS patient – they actually reach into the body and heal. The valor sometimes gets out of hand.

Surgical programs are still heavily male and the macho image still rules, colored by aphorism: “The only problem with being on call every other night is that you only get to handle half the patients,” or “The only way to heal is with cold steel,” or “A chance to cut is a chance to cure,” or even, when things go wrong, “You can’t become a good doctor without killing a few patients.”

In terms of valor and hours worked, these brave residents have a point, wanting to do more surgery and post-op follow-up rather than stop at a specific time. It gets hard to stay away from the hospital for 10 hours at a stretch. But anyone who has done it knows the debilitating effect on both doctors and their loved ones of working in a hospital for 36 hours, getting six hours sleep, and going back in for another 36 – every other night on call.

In addition to valor, the issue is fear – a word surgeons might deny. The source of fear is not personal, but fear instilled by the system. An unspoken reason that residents secretly work over the legal limit is that in the pecking order of the wards they fear the implicit power of the hospital hierarchy, the attitude of “we had to go through hell, and so do you.”

Oversight of limits is difficult, and in that vacuum the fear of not being tough enough, skillful enough, or resourceful enough to stay up (sometimes aided by drugs) can affect behavior.

When a senior doctor at the top of the surgical pyramid gives the impression that the limits on hours are not all that useful at the moment a horrific new case comes in, the fear of standing up against that pressure is almost palpable. In a power-over system, there’s always someone with more power than you.

But all the valor in the world can’t make up for a fuzzy mind, and fingers that feel strangely distant. In terms of the best care of the patient, the real valor is to turn it over to the fresh surgeon just coming in after a good night’s rest.

In these last gasps of the pathetic Bush era, the fear culture pervades all of our lives, and it takes regulation (by a group like the accreditation committee) and advocacy by a union (the Committee of Interns and Residents) to get all members of the hospital community to embrace and prioritize the humane training of residents, and the human-to-human goal of good medical care.

Stephen Bergman is also Samuel Shem, whose fourth novel, “The Spirit of the Place,” has just been released.

SOON AFTER HMO/managed care came to Massachusetts in the late ’80s, I got a call from a patient I had admitted to the 28-day alcohol unit at the hospital. He said that he was being discharged after three days because that was all that the HMO would now pay for alcoholism. He said the HMO representative told him to go out and get drunk again and they would readmit him.

How did this happen? Managed care let it be known through massive advertising that either doctors join up, or be left out — we would lose patients to HMO doctors. This seemed strange: Doctors did the work; without us, there was no “care” to manage. If we stuck together, we could get what we wanted from the insurance industry. Instead, doctors elbowed each other out of the way to make sure they would “get in.” We lost our clout in setting standards for good care for patients, and a work environment that would allow it.

Now, healthcare in America is a national disgrace. Forty-five million are uninsured, most are underinsured — one illness away from bankruptcy, poverty, or homelessness. Our private healthcare system is worse for patients and doctors and better for the insurance industry. Even the insured are suffering. Their doctors are rushed, mistakes are made, good care is hard to find. Private health insurance spends about 30 percent on administrative costs; government-run Medicare spends 3 percent. The single-payer national model seems inevitable.

Yet it has not happened. The health insurance industry is profitable, and a well-funded lobby. Only one of the presidential candidates (Dennis Kucinich) is sponsoring a single-payer system — the others are just whistling past the grave of medical care. However, elements of change are arising — scholars, politicians, media, pundits, and the public, and now Michael Moore, in his new documentary “Sicko,” pointing out the relative inadequacies of our system. But one piece, a vital piece, has been missing.

Change will not originate from the top. In any hierarchical system, the only threat to the dominant group is the quality of connection among the subordinate group. This is true of race, gender, class, ethnicity, and sexual preference. In three great movements of my lifetime — women’s rights, civil rights, and the ending of the Vietnam War — change came from my generation seeing an injustice and believing that by organizing together at the grass-roots level we could right an obvious wrong. And now?

I propose a doctors strike (or a healthcare workers strike, but I can only speak as a doctor). First, doctors would recruit enough colleagues to pledge that if, in two years (say, by July 4, 2009), there is not a federal law for a single-payer, universal coverage health system, we will go on strike.

At first we will be dismissed as idealistic or ungrateful nuts advocating that horror of horrors, “socialized medicine.” We may not have many members, and the insurance industry will mobilize in a way that makes the ads against the Clinton health bill look like musical comedy.

Six months pass; we remind the public that in 18 months we will go on strike. Our ranks increase — patients, realizing that it is in their interest to directly support the strike, join us — and more attention gets paid. Twelve months until the strike, we are growing in membership — other healthcare workers join, maybe even a company like General Motors that is sick and tired of paying more for health insurance than for the steel for their cars — and we spell out exactly what we won’t provide and the resulting chaos in our hospitals, emergency rooms, outpatient clinics, etc. Perhaps those in the government start to notice.

At six months, with tens of thousands pledging to strike, we may be taken quite seriously — the public understands that the consequences of a strike would be disastrous. What irony: To protect patients, doctors have to go on strike!

I predict that it will never come to that. We will put real health insurance on the books.

We are the ones who do the work. If we care for our patients, and for our Hippocratic ideals, we have no choice but to try. Our efforts, in sync with the rising tide of public and political movements, might just lift us all, leading America into the fold of those rich nations who put first things first: the health security of their citizens.

Stephen J. Bergman, under the pen-name “Samuel Shem,” is author of the novels “The House of God” and “Mount Misery” and co-author of the play “Bill W. and Dr. Bob.”