No social encounter delights me more than meeting a doctor at a cocktail party. In clinical settings, doctors tend to be guarded and aloof. Catch one with a whiskey in hand, though, and you might find yourself in possession of all sorts of inside information. Among the nuggets I’ve gathered in this fashion are: that salt and butter aren’t really bad for you; that nicotine is a marvelous antidepressant; that vegans are no healthier than the rest of us; and that early cancer screening may be pointless, since many small tumors vanish on their own and some grow so slowly that their human hosts will die before they do major harm. Some of this may be inaccurate, perhaps, but most of it is worth repeating at other parties.
Last May, at a party in Las Vegas, I found myself chatting with a surgeon, the type of doctor I most idolize. Along with fighter pilots, surgeons represent to me the pinnacle of courage, self-mastery, and independence. They are the elite of the elite. This one, however, whom I’ll call Dr. Dave, felt deeply disgruntled and unappreciated. He assured me that these feelings were common in his field — he had been a head and neck surgeon who specialized in facial reconstructions — and were part of the reason he’d retired early. Dressed in the kind of loud Hawaiian shirt often favored by men who’ve flipped off the system, he blamed his foreshortened career on what he termed, with patent distaste, “consumer-driven medicine.”
The situation, he said, was this. About a decade ago, hospitals began distributing patient-satisfaction questionnaires designed by the Department of Health and Human Services. In 2010, the Affordable Care Act linked Medicare reimbursements to a set of quality-of-care measurements that included patient-satisfaction scores. A few years before, Dr. Dave had left private practice in part because insurers were paying solo doctors less than big hospitals. At the hospital, he felt pressure from administrators to keep his scores up. This meant catering to his patients’ whims, and sometimes to their neuroses and addictions. As “a slave to opinion,” he found himself ordering unnecessary tests to head off complaints from anxious, demanding types. He continued to treat people after they were well. He also grew reluctant to give advice that, though medically sound, might cause offense. Once, when he urged a patient to lose weight, Dr. Dave was accused of calling him fat. Then there were the patients whose aches and pains he diagnosed as symptoms of depression. They sometimes took umbrage, driving down his grades.
Dr. Dave went as far as blaming our prescription-opioid epidemic on the questionnaires, which sounded like the kind of cocktail-party medical chatter whose reliability seems questionable in the sober light of day, until later research showed that many experts agreed with him, including one doctor who linked the scourge, in an article for the Boston Globe, to the “era of patient-satisfaction surveys.” To Dr. Dave, though, there was a larger issue: the creeping usurpation of his authority by people who hadn’t a clue about his craft, let alone the workings of their own insides. Here he was, a highly skilled practitioner who’d once replaced a child’s missing ear by growing tissue on the child’s own head and then delicately harvesting and shaping it, being critiqued by laymen, by amateurs, whose only qualification to judge his work was having ears. It was crazy. It was upside down. In the name of empowering the patient, the physician had been diminished, deposed, degraded.
“When you go to a Starbucks, you’re pretty sure whether you got a good cup of coffee,” said Dr. Dave. “But if you have your appendix taken out, you only know what kind of job they did by whether the scar is pretty.” He took a sip of his drink and shook his head as if to wish his old profession good riddance. His Hawaiian shirt blazed with annoyance. I felt for him. Thirty-five years of training and experience thwarted by our belief that the customer is always right, even if the customer is stupid or addicted to prescription narcotics.
My sympathy for Dr. Dave turned into something more immediate the other day, when a notification appeared on my desktop, from where I’m not quite sure. My wife, I think. As an active Twitter user, she’s often the first in our household to hear the bells toll. Sometimes, as in this case, they toll for me. “Introducing Book Marks,” the announcement read, “Lit Hub’s ‘Rotten Tomatoes’ for Books”:
Book Marks will showcase critics from the most important and active outlets of literary journalism in America, aggregating reviews from over seventy sources — newspapers, magazines, and websites — and averaging them into a letter grade.
As a novelist and book critic myself, I found this exuberant proclamation jarring, partly because of its stilted rhythms, which didn’t instill much faith in the ability of Lit Hub’s staff to showcase, aggregate, and average the critical prose of anyone — if such tasks even required thought rather than brute digital force. I also detested the publication’s name, which reminded me of GrubHub, the site that delivers meals to your front door. “Lit” rankled, too. So breezy and diminishing, like calling San Francisco “Frisco.” And letter grades? Those are for book reports, not books. How would they be generated, anyway? Through what process of distillation and dehydration could reviews of varying lengths and styles, some of them rich in wit, presumably, and shimmering with connotative subtlety, be turned into little easy-to-swallow pills?
In a tone of cheerful full disclosure apparently intended to disarm skeptics, Lit Hub offered a so-called grading rubric. It fascinated me, with its odd, futuristic sensibility of silicon humanism.
(10/9.5/9) totally positive
Compelling content · Does something new/profound with form · Reviewer enthuses
(8.5/8/7.5) mostly positive
Compelling content and competent form, or visa versa · Flawed in a way that brings the book down but doesn’t destroy it
You get the picture.
The rubric, I sensed, was the work of committee; it had that aggregated, averaged ring. It was also, to my mind, utter nonsense. Years ago, when I wrote a regular book column for New York magazine, I often found it hard to characterize my own reviews. My raves had tricky undertows, my pans had silver linings, and the mixed reviews, which outnumbered the others, skittered all over the place, pure monkey mind. Book reviewing, as I conceived of it and strove to practice it, was chiefly descriptive, not evaluative, and what it described was not the book itself but my encounter with the book. It tried to make manifest the act of reading in something like the way that travel writing dramatizes journeys. It wasn’t scorekeeping. It wasn’t grading. It didn’t break down into 8’s and 8.5’s.
When my mother, God rest her soul, was nearing forty, a spell of religious fervor overtook her. It came without warning, like a tick-borne illness. She hunkered down in our den with a strange volume that purported to unlock the secrets of ancient prophecy by assigning numerical values to Hebrew letters. Her mania scared me and didn’t last long, luckily, but her eyes shone wildly while it did. The notion that language can be converted into math and math into meaning is pure hermetic madness, the alchemical essence of delusion. But at Lit Hub, it’s policy. It’s principle. The site has many worthy features, from author interviews to essays, but the grading business undermines it all. Works of literature are among the most intricate and elusive of human artifacts, the crudest of which requires more creativity than twenty trillion acts of aggregation. A site created to celebrate them now aimed to reduce them to an alphabetic omega point.
Ezra Pound defined literature as “news that stays news.” I’d offer a less elegant definition. It’s complexity that stays complex. In engineering terms, it’s holistic and synergistic. In human terms, it’s heroic, like surgery. It’s a feat of stupendous risk and difficulty that, because it so often comes to nothing after taking one’s all, can only be made worthwhile by the prospect of glory and prestige. But this is not the era of prestige. This is the day of the letter-grading locust.
If this all sounds a bit elitist, it might be worth asking who actually benefits from digital populism. Does it really help readers to take the complexity of the reading experience and reduce it to a number, complete with decimal point? Probably not, but it will certainly help Amazon, and anyone else who seeks to make a profit, by treating books as essentially fungible and squeezing the writers, editors, and publishers who make them. After all, if my publisher refuses to make my latest novel available on Kindle at a steep discount, there’s no need to buy it at price from your local independent; just find another 8.5 — God willing — to download for a dollar.
Similarly, the primary beneficiaries of Dr. Dave’s patient-satisfaction surveys are not patients but insurers — both government insurers and the private insurance companies that follow Medicare’s lead in setting rates. Low ratings allow them to save money by cutting their payments to providers, creating the pressure that had pushed him into retirement.
In our age of incessant disruption from below, with elites being toppled on every side — in journalism, in commerce, in politics, and now in medicine, it seems — the battle cry is “Power to the people,” but the spoils have a way of flowing to the middlemen. Thus, the great political populist of our time, the man who promises to save us from all the corrupt politicians who have sold our country to corporate interests, is just another billionaire businessman, a man whose chief qualification seems to be that he lacks the technocrat’s competence and expertise.
Not long after my chat with Dr. Dave, which, along with the rise of Donald Trump, had put me in an antipopulist mood, I took a stab at rereading Ayn Rand’s The Fountainhead, a lousy novel whose theme is excellence. The first time I read it, in 1980, I was about to turn eighteen. The Space Age had wound down quite a bit by then, the roaring Apollo launches of my boyhood devolving into the Apollo–Soyuz joint production with the Soviets. There wasn’t a war on, nor did one seem likely. History was in a lull. But I was maniacally excited. I’d been admitted to Princeton a few months earlier and very soon I’d fly there from Minnesota. I knew not to brag about this in my small town, but inside my head I was soaring. Here I come, world! To open The Fountainhead in such a state was like touching a blowtorch to a haystack. Later, I couldn’t recall a single line, only the conflagration in my ego.
When I reread the novel, my brain was cooler. I’d been thinking about elitism. I missed it. I missed a world that had a top and a bottom, that wasn’t just a networked, horizontal, spreading expanse of averaged cultural mulch. Even the titans of industry seemed dull, especially Zuckerberg and Bezos, whose faces had a weird, undeveloped aspect that seemed to belong to a new, transitional species, no longer Homo sapiens, not yet E.T. They were geniuses, supposedly, but somehow they failed to stir the soul. There was nothing defiant about them — maybe that was it. To me, elitism meant battling the odds with nothing but a scalpel or a pen, not brainstorming with your team to fashion systems for pleasing everybody all the time.
Howard Roark, The Fountainhead’s rebel architect, believes in pleasing no one but himself. He is practically unemployable. A terror. He’s also a rapist, but a winning one, with an indomitable sense of destiny that bores through female flesh and solid rock. He’s basically a chiseled spermatozoon with tense biceps and a high I.Q. He represents the opposite of something that Rand despises but never succinctly defines, despite about seven thousand tries — plasticity, mediocrity, collectivism. He resembles no one now alive except perhaps, at moments, Kanye West, but minus the raging thirst for adulation. Anonymity suits him as much as fame, and he withdraws to a quarry for a spell of sweaty, contented labor. As a role model for a revived elitism, he’s perfectly useless and without appeal, a stoic lunatic porn-star intellectual, more fantastic than Tarzan but less relatable. Forget my rant about novels and letter grades. The Fountainhead gets an F.
Still, the elites, or whatever remains of them — those rare and lonesome worthies of skill and courage — deserve some protection from us, the aggregate. Prestige, irreducible and absolute, has its uses, and the very highest is inducing people to do hard things, things that take a lot of time to learn and exceptional nerve to execute, like building a child a new ear and reattaching it in such a way that blood flows through it and it doesn’t die. Should a person who’s managed to do this even once have to duck Rotten Tomatoes from the cheap seats? The meek will inherit the earth (the wealthy, Mars), but until then we’ll still need heroes. Let’s honor them, not average them.