Sliding Scales and Competency Porn

On The Bear, Michael Lewis, and the Future of Medicine

© Photo by Bertie

A lot has been written about the hit Hulu series, The Bear, enough that Rachel and I decided to give it a second chance (we had previously dropped out after the first episode). 

Sure enough, it turns out to be a phenomenal show - loud, profane, brutal, and kinetic - the story of a young, troubled but accomplished haute cuisine chef who comes home to Chicago to inherit and run the greasy-spoon family restaurant his older brother left to him after committing suicide.  

I mentioned the show while on a bike ride in the Catskills with my brother, who is a film producer. “Yeah, it’s great,” he said. “Have you ever heard of competence porn?”

Competence porn? Turns out that’s a thing. It describes the pleasure you get from watching someone do something really, really well. 

Competence porn does indeed describe a major appeal of The Bear - not the only appeal, mind you - the earthy characters, the camerawork, the Chicago setting, and the gritty kitchen vibe and banter are others - but definitely one.

Watching the main character, Carmy, and his sous-chef, Sydney, do their thing - chopping, dicing, zesting, basting, and frying while the camera lovingly pans and lingers over ingredients as they move from stoves and pots and trays to metamorphosize into mouth-watering plated dishes - it all makes you feel a certain longing, like competence is the path to truth, or at least an antidote to existential discontent…

According to tvtropes.org, competence porn usually sits on the idealistic end of the Sliding Scale of Idealism Versus Cynicism, a conceptual framework whereby stories are situated based on how idealistic or cynical they are toward a given idea. 

For example, take the idea that competence is a fundamental good. An idealistic story would have Carmy achieve salvation in the end, despite the human toll of his achievements; whereas a cynical story would have Carmy fail in the end, despite his achievements, precisely because of their human toll. 

We’re only halfway through the second season, so I don’t know if The Bear as competence porn will prove to be simply idealistic, or if it will dive deeper and show how the relentless pursuit of perfection can turn into a kind of idolatry - corrupting and corrosive when taken too far. I kind of hope it does, as that would correspond with my personal worldview, but we’ll see….

At the other end of the Sliding Scale of Idealism Versus Cynicism - i.e. the cynicism side - is Playing to Win, an audiobook written by Michael Lewis and recommended by my sister-in-law, that Rachel and I listened to on our drive back home (well I listened to it, anyway - podcasts in our minivan have the interesting side effect of immediately putting Rachel to sleep). 

Lewis tells the story of his experience as a sports dad, a role which is near and dear to my own heart. 

His first daughter was a gentle type, who thrived in their local Berkeley softball league, modeled after the Norwegian approach to competition where everyone gets equal playing time and the score doesn’t matter - New York parents, think Westside Soccer. 

Then came along his second daughter, who turned out to be a gifted athlete and a fierce competitor. She actually cared about the score and wanted only to win, and soon enough Lewis found himself in the world of elite travel softball - New York parents, think Manhattan Soccer Club, aka MSC.

From there, Lewis takes us on a journey into the heart of what he calls the Youth Sports Industrial Complex, a 70 billion-dollar high-stakes juggernaut of intense coaches, year-round training, and far-flung tournaments. 

Interposing personal experience with economic analysis, Lewis sketches out how this industry, driven by forces like college football, Title 9, and college athletic scholarships, has exploded over the past twenty years, growing to dwarf even professional sports, while sucking parents dry of both funds and spirit.

It’s an amazing tale, distinctly American, and definitely on the far side of the Idealism Versus Cynicism scale, at least when it comes to the idea of sports as a wholesome, innocent, healthy, character-building, childhood activity. 

For those of you without kids in travel sports, I imagine the book would be hard to believe - surely Lewis must be kidding, or at least exaggerating for dramatic effect. But for those of us with kids in elite travel sports, it’s like looking in the mirror the morning after a really long night on call - yup, no doubt about it, that bedraggled guy definitely looks familiar….

All of which makes me wonder where Medicine falls on the Sliding Scale of Idealism Versus Cynicism, at least as I’ve tried to honestly portray it - both the life and the business - over the past two years in Full Stack Family Medicine. 

On the idealism side, life in medicine has an element of competence porn. It feels good to master a craft, to spend years learning and honing a skill that you then get to apply to complicated and important problems. 

I am reminded of an ENT resident I knew as a medical student. We were sitting together in the cafeteria late one night after a difficult facial surgery, when he said to me, “You know that feeling of sitting with a beer on a deck that you’ve just built with your own two hands?”

“Yeah,” I said. (Actually, not a clue - I do know what it’s like to deal with a contractor, but yeah, OK, go on…)

“That’s exactly the feeling I’m looking for in surgery.”

On the cynicism side, as I alluded to above, there is a way in which technical mastery can blind you to the human factor. 

Patients are subjects, not objects like food. Clinical detachment may be a necessary part of what we do, but so is the ability to situate an illness within the full context of a patient’s life experience. As technical mastery - the science of medicine - advances, human empathy - the art of medicine - is all too often left behind.

On the idealism side, the business of medicine gives a practice like Westside Family Medicine the ability to do its own thing. 

There’s still room for us in the market, buyers for what we are selling: a personalized, holistic, high touch, low intervention, Family Medicine approach to primary care. It’s still possible to find the right neighborhood, open a small office, integrate with the community, and survive as independent, small-town doctors in the big city. 

On the cynicism side, the forces of conglomeration are massing against us. And those forces - in Lewis’ terminology, the Medical Industrial Complex, or what I prefer to call Big Medicine - are growing ever stronger.

Independent doctors are falling like flies. 

Just last week, I heard that a friend of mine from residency, who had built a great little sports medicine private practice in Chelsea, sold himself to Optum in the wake of Covid. His practice is now part of the large medical chain, Caremount, which is owned by the giant mail-order pharmacy, Optum, which is owned by the humongous insurance company, United Healthcare. 

Similarly, doctors at the primary care startup, One Medical, now work for Amazon, which also owns the national mail-order pharmacy, Pillpack. In the immortal words of Kurt Vonnegut, so it goes.

All doctors are trained in medical school to see the patient as their primary responsibility. That’s all fine and good when the doctor calls the shots and is able to structure things such that the interests of the practice align with those of the patient - call it swimming with the current.

But what about when the doctor becomes a cog in the machine, a tool at the bottom of a pyramid of bosses - who may have gone to business school, not medical school - and who are in turn beholden to shareholders, whose primary goal in investing, I think it’s fair to say, is not necessarily great patient care… what happens then?

I’d love to see Michael Lewis tackle that one.

I see a lot of parallels with Playing to Win. On the one hand, it’s still a pure and awesome experience to watch your kid play their heart out on the field. On the other hand, the Youth Sports Industrial Complex looms over kids, parents, and communities, with the potential to do a lot of harm. 

Likewise, on the one hand, it’s still a pure and awesome experience to sit in the room with a patient, take their history, examine them, and create a treatment plan. On the other hand, Big Medicine looms over patients, doctors, and communities, with the potential to do a lot of harm. 

Net net, I hope that Full Stack Family Medicine falls somewhere on the idealistic side of the sliding scale. If not, then I’m failing to communicate the way I truly feel.

Thus far, at least one of our kids seems to be squarely on the path to medicine. Georgia has a history of congenital heart disease and required open heart surgery as an infant. She joined ski patrol last winter and is currently at a summer school program in Oxford, England. Yesterday, she sent us a picture of herself smiling while holding up a pig’s heart that she was about to dissect. 

Full circle?

Almost. In any case, I was thrilled. I still see medicine as a great job, and view the opportunity to treat patients as the ultimate privilege. Count me and Rachel in the rapidly shrinking pool of doctors who would be happy for their kid to go into medicine.

So I remain an optimist but stay tuned. We’ll see how it all wraps up. After all, it’s only halfway through the second season….