Monday, August 10, 2009

“The Hurt Locker,” and What It Tells Us About Serious Medicine

What does an Iraq War movie tell us about Serious Medicine? A lot, if the movie is “The Hurt Locker.”

“Hurt” is one of the great movies of the year. But don’t take my word for it: The film has a 98 percent “fresh” rating from all the movie critics surveyed by And yet the raves for “Hurt” are not the result of liberal critics trying to agitprop the film into bigger box office; “Hurt” takes absolutely no political position on the merits or demerits of the Iraq war. Instead, it is simply a great action movie that provides even greater insight into its characters.

And if we come to see those characters as heroes, and we do, then one could even say that “Hurt” is pro-war. So for those of us who advocate a “hawkish” position against disease--an all-out war, using all available technology--then the movie offers many parallels, and many lessons.

So what, exactly, does “Hurt” have to do with Serious Medicine? Well, for openers, the men of Explosive Ordnance Disposal are, literally, lifesavers.

As an aside, a key point to make in our consideration of a Serious Medicine Strategy for America is the distinction between Serious Medicine and Routine Medicine. Routine Medicine is just what it sounds like: It’s predictable, it’s routine. Routine Medicine is important; it is the stuff of life, but it is not the stuff of life-and-death.

Serious Medicine, on the other hand, is what’s needed when the routine turns into something worse--when the headache proves to be an aneurysm, when the tummy ache is revealed to be a burst appendix. Serious Medicine is the stuff of life-and-death drama, and it’s real. Serious Medicine is the battle of life against death that plays out in ER’s and ICU’s and laboratories and proton-beam cancer centers across the country.

So here are seven points about Serious Medicine, derived from “Hurt”:

, technology is your friend. If the other guys are trying to kill you, you need the best shields, and the best tools, to deflect and disarm their weapons. The best stuff is vital. And if you have nerves of steel and a keen eye for the best solution, like Staff Sergeant William James in the film, that’s all the better. And so it is, too, with Serious Medicine. You need the best medical equipment, the best everything. And yet you then need, as well, a great team of medical professionals, who go above and beyond the call of duty, driven by idealism, compassion, pride--or, in the case of James, by an adrenalin rush. In Serious Medicine, we worry less about motives and more about being healed.

Second, statistics, and statistical analysis, are not your friend. If you are in the EOD, it doesn’t do you any good if you disarm most of the bombs you set out to disarm. Bomb disposal might be government work, but “close enough for government work” is not acceptable level of performance in the ordnance world. Abstract discussions about cost/benefit do you no good if lives are on the line--including your own. What the EOD needs is the best equipment and the best training, period. Because as with doctors, if EODs don’t do their job right, or can’t do their job right, people will die--a battle will be lost. Therefore, those who seek to judge medicine according to “metrics” conceived in some academic ivory tower, or bean-counting bureaucracy, miss the point--we don’t seek to save lives according to some financial or ethical formula, we seek to save lives, period.

, a relentless focus on the bottom line is critical. In the film, a colonel asks James, who has made a name for himself within the Army by disposing of 873 improvised explosive devices, about the best way to get rid of an IED. “The way that you don’t die,” comes James’ answer--an answer that is one part smart-ass, one part simply true. Moral of that story: Discussions of process and procedure pale into insignificance next to the question of whether or not people get killed.

Fourth, a healthy respect for the job, bordering on fetishistic fascination with one’s duties, is an inevitable, maybe even desirable, corollary to the mission itself. In the film, James builds up a collection of disarmed explosive devices, keeping them under his bed. It’s a remarkable thing, he says, “to hold something in your hand that could have killed you.” If that sounds a little weird, well, as the film makes clear, James is weirdly obsessive. But he is also good at what he does. And isn’t that what we want in our doctors? Don’t we want them to be obsessive enough to save our lives?

, everything is dangerous. All through the film, the Americans are acutely aware that they are surrounded by Iraqi civilians who might also be bomb-planting insurgents. There’s no real way for the GI’s to deal with this danger, other than to act with profound caution. The same holds true with Serious Medicine: We can assume that just about everything in the world is dangerous, if taken at the wrong dose, if we receive it the wrong way. And so we want our doctors--the medical equivalent of EODs--to be equipped, trained, and motivated to deal with all possible threats. And we want them to succeed in neutralizing those threats, no matter what the cost.

Sixth, the core group becomes a kind of knighthood, set aside from regular people. That’s clear in the movie; James doesn’t pretend to be normal. For one thing, he likes his job as an EOD; indeed, there’s nothing else he’d rather do. And the rest of us “civilians” will never really know what goes on in their heads, the best we can do is gawk at the occasional movie dramatization. And the same is true with health care professionals. Most of them do what they do for a reason other than money. By virtue of what they do, they are a breed apart, And if such differentiation and apartness strikes some as elitist? “Hurt” provides the answer: They are what we need. Whatever their motives--high, low, crazy, whatever--they are the ones who can save our lives.

Seventh, “Hurt” is, in fact, steering us toward the conclusion that the lessons of the EOD, and the lessons of war, can be usefully applied to other fields. The name of the hero in the film, William James, can hardly be an accident. William James (1842-1910) of course, is one of the giants of American philosophy, whose most famous phrase is “the moral equivalent of war.” Which is to say, we don’t want to be fighting wars, but we should approach other serous problems as if they were a war. (James, interestingly enough, was trained as a doctor, so he knew, up close, what it was like to see humans defeated by then-rampant diseases as such as tuberculosis--surely he appreciated the need to fight a winning war against such contagions.)

And so it was that back in 1977, President Jimmy Carter tried to rally Americans to fight energy dependence by invoking James. On national television, he said that the energy effort should be “the moral equivalent of war.” Not everyone likes Carter, of course, but just about everyone thinks that energy independence is a good idea. And if we are ever to get to where we need to be, it will require more technology, not less. And it will take a dedicated vanguard, of some kind, to get us there.

In any case, Carter or no Carter, the Jamesian point about martial mobilization is profound and enduringly true: The best way to get something important done is to treat it as an all-out struggle. A war, or its moral equivalent. So, William James, meet... William James.

Serious Medicine is war. It is a war against disease, injury, and incapacitation. And if we can’t win that war permanently, in the sense of staving off mortality, we can, at least, stave death off for a while. Such mortality-staving is the work of the EOD, and it’s also the work of the MD. And we should be grateful to both of them. And if, on top of that, we are curious as to how an elite team of life-saving heroes does its work, “The Hurt Locker” provides a harrowing, exhilarating vision of the greatest grace under the greatest pressure.


  1. As a former nurse and medical office manager, it has been my privilege to encounter more than a few "William James'" in the medical field. Men and women who take death as a personal affront to their abilities and fight it with everything they have. Of course, we will all die, but I'd much rather leave that in God's hands and engage a physician that's bound and determined to keep me alive. It has always seemed to me that those physicians that leave the daily treatment of patients for the "ivory towers" of academia or government consulting needs must be required to return to the trenches every so often. It is far too easy to distance oneself from the ugly business of defeating disease and death and start to look at human lives as mere numbers.
    There are definitely problems that must be solved with our system of health care delivery. There are even a few problems with our "health care" itself. We focus too much on the "organ" and not enough on the "organism". A return to the days of the family doctor who treated the whole patient would go a long way to both improving our quality of care and decreasing the cost of that care. Nothing that I have seen or heard about the current proposal addresses that. And forgive me if I don't embrace the thought of some bean counter in a cubicle determining whether I live or die and whether my last days are spent in pain or ease. I'm just sort of selfish that way.

  2. As a person who knows an EOD Sergeant who spent time in Iraq and returned to his wife and child and is now in Reserves, we owe our winning the war by these men. They are the brave. They are the real heroes. I could never stand over a bomb with all the equipment on, sweating so that I could not see, because I wear glasses, and decide how to disarm an IED. But they did day after day so that we could have all our soldiers out of the cities now, elections coming again and hopefully the medicine our people used in Iraq will find it's way into our hospitals as well. As it says, "Serious Medicine" for serious people.

  3. I really don't know how to express what I wish to say. While I too wish that my Dr, or any Dr that anyone in my family sees is in the, "
    william James"; I have met too may Dr's who have lost touch with their own patients. AN Orthopod who won't talk to a patient unless they either have insurance or pay up front - even if he and they are in the same room at the same time; a general surgeon who decided I had to be stupid because I wasn't hysterical enough when my daughter had a life threatening injury, a geriatric physician who,"listened" when I kept asking her why my m-i-l was sleeping 20-22 hours out of 24; but then never scheduled a vital drug level test until 3 months later when my Mother-in-law was so over-dosed that no one could wake her up.

    The opposite is my Dad's Cardiologist, who not only handles Dad's heart problems and solutions, but has taken him on as his regualr Dr. a wonderful man who really cares for his patients.