Great performances, poor players

Medicine is a learned profession, but clinical practice is above all a matter of performance, in the best and deepest sense of the word. —Frank Davidoff, M.D.

Years ago I recall watching a television documentary on Arthur Fiedler, the conductor of the Boston Pops orchestra.

The camera caught Fiedler backstage, stooped and shuffling slowly about as he struggled with his tux in preparation for the evening performance at Symphony Hall. He looked like the old man he had become—tired, fatigued, worn out. But then, as he stepped out onto the stage, a miracle happened. Fiedler’s frame straightened, his head lifted squarely onto his shoulders, a big smile flashed across his face. Proudly, he assumed his position at the head of the orchestra, pumped up by the thunderous applause.

We are what we are; we become what circumstances require of us.

Fiedler’s transition occasionally flashes through my mind as I step across the threshold into an exam room to meet a patient. Almost always I offer a big smile and extend a hand in greeting. I attempt to hold my composure throughout the interview, adjusting my demeanor to reflect the emotional state of the patient. I become, as it were, a player on stage where the art of medicine is performed countless times in daily rounds.

I might move from an encounter with a new mother, freshly primed by a healthy, thriving infant to a silent teenager, subdued in the throes of a depression. In each case I’m cast as best supporting actor, called to muster my emotive repertoire at a moment’s notice.

Sometimes I don’t feel up to the task; I’m drained, exhausted, spent. Sometimes I want to turn tail and run as fast and as far as possible to distance myself from the suffering I witness daily. I want to cover my ears, shut out the woes, the aches and complaints, for I have more than enough of my own.

None of this is permissible, of course. The patient has come seeking expertise, care and compassion—what does it matter how I, the clinician, might feel?

Here Osler’s wise words of comfort seep into my mind:

Dealing as we do with poor suffering humanity, we see the man unmasked, exposed to all the frailties and weaknesses, and you have to keep your heart soft and tender lest you have too great a contempt for your fellow creatures…

Even I, a poor player who daily struts and frets his hours upon the stage of clinical medicine, am not one to wallow in self-pity. Ultimately, I can not run from the responsibility I have for those entrusted to my care.

I call to mind the image of Fiedler stepping out on stage. Once more I buck myself up, rap quickly on the exam room door and step into the limelight for my next performance.

It will be the best I have to offer.

A plea for poetry in medical practice

I was pleased as punch to peruse New York Times executive editor Bill Keller’s delightful essay on the relevance of poetry, I Yield My Time to the Gentleman From Stratford-Upon-Avon. Here Keller expounds on the relative weight that a seemingly small, insignificant seminar carried in his course of summer study at the Wharton School of Business.

In my book we would do well to advocate for the inclusion of poetry in the medical curriculum—for largely the same reasons.  more»

Literary medical weblogs

Dear J.B.,

Your comment on my blog posting The stories we tell came in just as I was re-reading the first chapter of James Joyce’s Ulysses on the front porch.  Previously, I hadn’t run across the Joyce line you quoted about all novelists having only one story, which they tell again and again; but it certainly rings true.  Hemingway said that in crafting a piece of writing he could “cut the scrollwork or ornament out and throw it away and start with the first true simple declarative sentence” he had written. In my book, anyone who takes writing seriously has to start with a desire for truth and the stamina to pursue it, no matter where it might lead.

You also mentioned Dr. Robert Coles.  I too was fortunate to hear Dr. Coles speak two decades ago at a conference on medicine and the humanities.  I recently read Handing One Another Along, a collection of lectures from an undergraduate course which Coles taught at Harvard on literature and social reflection. (The title of the book comes from a line in Walker Percy’s The Moviegoer, one of Coles’ favorites.) Dr. Coles, of course, is an excellent resource for many good works on medicine and literature as well.

Decades ago I got interested in the idea of using story as a vehicle to explore the doctor-patient relationship.  Throughout my medical training (I am a practicing physician assistant) I was appalled at the insensitivity which many clinicians demonstrated in dealing with patients in their time of suffering.  I struggled to understand the source of this coarseness in bedside manner.  Had these clinicians always acted this way, or through years of training had their medical education squelched whatever empathy they might have once had?  Was this perhaps a defense mechanism they had developed over time to shield themselves from the suffering that they witnessed daily in practice?  If so, what could be done about it?  (It certainly wasn’t helping the patient to heal.)  Could empathy be taught, or was it an innate trait possessed by only a minority of individuals who opted for a career in medicine?

As I began to craft narratives of patient encounters, I discovered that the act of writing itself enhanced the way I related to patients.  Somehow writing the story down served to hone an empathetic response.  It also served to help me deal with my own emotions, guilt and grief which I experienced in encounters with patients.  As my perspective developed, I was fortunate to find several like-minded souls in the social ether along the way.  Over the years I worked with other colleagues to create several online sites which continue to function as forums for clinicians and patients alike, Cell2Soul and Dermanities among them.  After reviewing my book Patients Are a Virtue, Dr. Howard Spiro asked me to consider submitting a monthly piece—“Notes from a Healer”— for the Yale Journal for Humanities in Medicine; and I was also invited to write a bimonthly Humane Medicine column for the Journal of the American Academy of Physician Assistants.  I established this weblog to serve as a repository for my writings.

My hope has always been that with ongoing exposure to these sorts of narratives, more and more medical colleagues might come round to recognizing just how intimate and profound the doctor-patient relationship truly is, and come to an understanding that there is much more to the art of healing than just closing a surgical incision, dressing a wound or writing a prescription.  Medical practice is after all the stuff of life; and because literature historically has been an attempt to capture the essence of what it means to be alive, it is small wonder that the two complement each other so beautifully.  As you so aptly put it, medicine and storytelling go hand in hand.

None of us can be all things to all men; but we can certainly make some fumbling attempts to alleviate suffering in the world and bear one another’s burdens as best we can.  As Rilke so aptly put it, perhaps if we learn to love the questions themselves, we can one day live on into the answers.

Blue Collar, Blue Scrubs

It’s a fine spring day, the last of April. I’ve been sitting outside in the back yard all afternoon, plowing through Michael Collins’ memoir Blue Collar, Blue Scrubs: The Making of a Surgeon.

The first-born in an Irish-Catholic family of eight boys, Collins pursued an undergraduate degree in liberal arts from Notre Dame University before taking a job with a construction company breaking concrete for a living. Although he enjoyed the hard work, the long hours, the camaraderie (as well as the beer consumed on the job and in the pubs afterward), Collins reached a point where he needed to make a decision about what he wanted to do with the rest of his life. The answer he hit upon was to become a doctor.

It was an uphill battle. Collins had to spend two years completing pre-requisite courses in chemistry, physics and biology and sit for the MCAT just to be able to apply to medical school. Although he aced his science courses, his MCAT scores were average. Rejected by 7 of the 8 medical schools to which he applied, when Collins pleaded with the Dean of Students at Loyola in Chicago to be given a chance, he got in.

Blue Collar, Blue Scrubs describes his journey through medical school up to the beginnings of his orthopedic surgical residency at the Mayo Clinic. Collins spins the tale with wit, humor and pathos.

Throughout his training, while immersed in the seemingly overwhelming tedious task of rote memorization, Collins lapses into philosophical thought. “What, then, makes us human? A beating heart? A cogitating brain? Or is there something more, something, for want of a better word, we call a soul?”

At the conclusion of the first autopsy he witnesses, a pathologist tells him: “You have now peered into the deepest recesses of the human body and discovered the secrets of life.” As he files out of the room with his fellow students, Collins muses that “we haven’t even come close.”

Throughout his rigorous training Collins somehow manages to hold on to his humanity. He never loses sight of why he wanted to become a doctor in the first place: to render assistance to his fellow human beings, to alleviate their suffering.

It is good for seasoned clinicians to be reminded of such altruistic motives. Whenever I lose a patient to a terminal illness, I gravitate to the family. I sit with significant others, share the information I have at hand and prepare myself to listen to what they have to tell me. To do otherwise would be a disservice both to them and to myself; for in these instances, I’ve discovered that I need such interactions to help myself heal.

Patients are not the only ones who suffer.

What’s in a name?

What’s Montague? it is nor hand, nor foot,
      Nor arm, nor face, nor any other part
      Belonging to a man. O, be some other name!
      What’s in a name? that which we call a rose
      By any other name would smell as sweet.

Specific to the nomenclature of the physician assistant profession, the issue has become that, in this day and age, PAs no longer “assist” primary care physicians; rather, they practice with them as associates. Physician assistants have been integrated into not only primary care but practically every medical subspecialty in existence.  more»

Minimal Medicine

Sometimes I wonder whether we as a society have not over-medicalized life. We spend so much of our time browsing health columns, monitoring vital signs, ruminating on our symptoms, consulting our doctors. Many of us have become so health conscious that we balk at deviating from the straight and narrow path. When it comes to our health, we have become risk averse.

Even those of us who spend their days in clinical practice recognize that medicine does not encompass all of life.

Perhaps we need to learn to practice minimal medicine.

These thoughts ran through my head as I read Mark Bittman’s final NYT Minimalist culinary column. Over a span of thirteen years Bittman authored nearly 700 weekly columns for the NYT Dining section. As it turns out, the culinary arts share a good deal with medical practice.

“I discovered that you never cook with someone else without learning something,” Bittman writes. “In every case, there’s a two-way transfer of knowledge. If they know less than you do, you grow from teaching. If more, of course, you grow from learning.”

Bittman’s words bring to mind Sir William Osler’s description of medical teacher and student: “the pupil and the teacher working together on the same lines, only one a little ahead of the other. This is the ideal toward which we should move.” After 25 years of practice, Osler observed, “I have learned … to be a better student, and to be ready to say to my fellow students, ‘I do not know’.”

Osler reckoned that “no man can teach successfully who is not at the same time a student.”

Here’s Bittman musing again: “Usually, I was either taught to make something or I modeled it myself, as best I could. I refused to buy into the notion that there was a ‘correct’ way to prepare a given dish; rather, I tried to understand its spirit and duplicate that, no matter where I was cooking.”

Osler advocated that “the practical shall take the place of didactic teaching.” To acquire the skills necessary to perform medical procedures, students are encouraged to “see one, do one, teach one.” In 1867 the physician Oliver Wendell Holmes argued that the “most essential part of a student’s instruction is obtained … not in the lecture-room, but at the bedside.”

Bittman maintains that, “as Jacques Pépin once said to me, you never cook a recipe the same way twice, even if you try.”

How true. And you never perform a physical examination or surgical procedure in exactly the same way. There are always confounding factors which necessitate workarounds and thinking outside the box.

Medical practice, like cooking, is always a compromise. Like their culinary counterparts, clinicians “almost never have the time, the ideal ingredients or equipment, or all of the skills we’d like.”

“Shop avidly, keep a full refrigerator and pantry,” Bittman advises; “pull things out and get to work.”

Where would the good clinician be without a well-stocked surgery?

“My growing conviction that the meat-heavy American diet and our increasing dependence on prepared and processed foods is detrimental not only to our personal health but to that of the planet has had an impact on my life.”

A nutshell of sound dietary advice, one every practicing clinician should take to heart.

Bittman concludes: “What I see as the continuing attack on good, sound eating and traditional farming in the United States is a political issue.”

What I see as the continuing attack on good sound traditional medical practice has lately become a political issue as well.

What’s Wrong, What’s Right?

In a New York Times op-ed piece on the healthcare legislation, The Fight Is Over, the Myths Remain, Brendan Nyhan states:

Studies have shown that people tend to seek out information that is consistent with their views; think of liberal fans of MSNBC and conservative devotees of Fox News. Liberals and conservatives also tend to process the information that they receive with a bias toward their pre-existing opinions, accepting claims that are consistent with their point of view and rejecting those that are not. As a result, information that contradicts their prior attitudes or beliefs is often disregarded, especially if those beliefs are strongly held.

Nyhan addresses the curious tendency we humans have to regard opinion as factual information—in his example, popular myths about the content of the recently passed healthcare bill, now signed into law.  In short, it all comes down to preconceived personal perspective.  Here the old axiom about drawing your curve and then plotting your points is apropos.  We tend to view the world through tinted lenses, all the while assuming that we are the only ones who see objectively.

I was intrigued to read about the former medical student Michael Burry who turned his economic insights into a popular financial blog.  Impressed with his knowledge, Wall Street gurus began to take regular notice of his predictions.  Indeed, many of the financial companies he endorsed turned out to be winners in the market.  Everyone, it seemed, was on the same financial page, until Burry noticed a disturbing trend.  Solid institutions that went on to fail shared one thing in common:  all had invested heavily in subprime mortgage securities.  Eventually, Burry convinced Wall Street to issue credit default swaps through which he bet against the popular tide—and subsequently won big.

This scenario demonstrates Nyhan’s premise:  when faced with the same set of factual data, observers generate wildly different interpretations.  As a consequence of acting on the basis of these observations, the risks are enormous:  you could win big (like Burry), or you could lose big as well.

Which brings me to the role of science in contemporary society.  Just how objective a discipline is science?  When confronted with the same set of facts, how is it that scientists formulate theories with markedly different import?

Global warming:  true or false?

Health care reform:  good or bad?

Wall Street reform:  desirable or undesirable?

In his new book Wrong, science journalist David H. Freedman wonders why scientific pronouncements often turn out to be misleading, exaggerated or entirely off the mark.  Part of the problem, he opines, is that many times scientists are forced to rely upon surrogate measurements, because they cannot get at the things they need to measure directly.  Thus, they have to make inferences from suboptimal data.

Economists, for example, rely on economic indicators extracted from bits of data to identify trends and forecast the economic outlook. Unfortunately, most research papers published in economic journals don’t conclusively prove anything one way or the other.  Freedman wonders:  “If tests of the exact same idea routinely generate differing, even opposite, results, then what are we supposed to believe?”

Freedman highlights the work of Dr. John Ioannidis, an M.D. with an undergraduate degree in mathematics, originally published in JAMA (John P.A. Ioannidis, “Contradicted and Initially Stronger Effects in Highly Cited Clinical Research,” Journal of the American Medical Association Vol. 294, No. 2 (2005): 218-28).

According to Ioannidis, “most medical treatment simply isn’t backed up by good, quantitative evidence.”

The whole point of carrying out a study is to rigorously examine a question using tools and techniques that would yield solid data, allowing a careful and conclusive analysis that would replace the conjecture, assumptions, and sloppy assessments that had preceded it. The data are supposed to be the path to truth. And yet these studies, and most types of studies Ioannidis looked at, were far more often than not driving to wrong answers.

Ioannidis felt he was confronting a mystery that spoke to the very foundation of medical wisdom. How can the research community claim to know what it’s doing, and to be making significant progress, if it can’t bring out studies in its top journals that correctly prove anything, or lead to better patient care?

The largest source of wrongness in scientific studies is publication bias.  Prestigious medical journals eagerly publish studies that demonstrate novel or unanticipated results.  Witness Andrew Wakefield’s bogus study published in the Lancet that purported to link the administration of the MMR vaccine to autism.  This problem is compounded further by the mainstream media, which is only too quick to disseminate such conclusions to the public at large.  Such misperceptions have a tendency to persist for years.

In his classic treatise on The Structure of Scientific Revolutions, Thomas Kuhn argued that “professionalization” leads to “an immense restriction of the scientist’s vision and to a considerable resistance to paradigm change.” He opines that scientists become captives to a paradigm “like the typical character of Orwell’s 1984, the victim of a history rewritten by the powers that be.”

Perhaps scientists themselves possess their own set of preconceived notions, which in turn dictate how they interpret the data they measure.  I suppose that it all depends on which side of the emotional aisle you happen to take your seat.

As Mr. Nyhan writes: “People seem to argue so vehemently against the corrective information that they end up strengthening the misperception in their own minds.”

Web and Flow

On the morning of the day prior to departing for Atlanta, where I was scheduled to give a formal presentation about a pig and a spider, I rolled out of bed early—it was my Saturday to cover the office.

While toweling off after my shower, I noticed a grey spider descending from the light above the bathroom sink. Her spinnerets formed a nearly invisible silken thread as she dropped down to hang motionless before the mirror. Shortly, she retreated up to the light and selected another point from which to begin a new descent. This time she dropped down to the shelf below the mirror and crawled behind my toothbrush. Gingerly, I nudged it to the side to reveal the spider resting by a tiny puddle of water.

She measured a centimeter in length, double that if you included her front legs. I could see the array of her black eyes and mouth-parts moving as she drank from the miniature pool.

I exited the bathroom to dress, and when I returned I found that the spider had struck out in a new direction, cantering across the wall to the shower stall, where she tucked herself in behind the aluminum molding.

Here is E.B. White’s description of Charlotte in Charlotte’s Web: “Stretched across the upper part of the doorway was a big spiderweb, and hanging from the top of the web, head down, was a large grey spider. She was about the size of a gumdrop.”

I’ve seen plenty of spiders around our place, but never a solid grey one like this one in the bathroom. Uncanny!

With the exception of a minor glitch in the sound system (thankfully, there was a savvy tech in the room to remedy the situation), the presentation at the Georgia World Conference Center in Atlanta, What Charlotte’s Web Can Teach Us about Caring for Critically Ill Children, came off well.

When I arrived at the lecture room 10 minutes before we were scheduled to start, I counted 8 tables with 10 chairs at each table, and no one to fill them. I needn’t have worried—within minutes the hall was packed to standing room only. One group actually huddled on foot at the back for small group discussion over the entire two hours. (I found out afterwards that we hosted 125 attendees.)

I told a story as part of the introduction, then proceeded to show the video clips from Charlotte’s Web, pausing intermittently for discussion and feedback.

Several folks gave us two thumbs up afterwards. One fellow who works in interventional cardiology asked me if I might be able to give the same presentation at the institution where he works—Children’s Hospital in Dallas.

I also met a fellow who, after he learned who I was, told me that he’s read every column I’ve written for the past two years. Now what are the odds of that happening?

When I returned home, after I unpacked my bag and stowed my paraphernalia in the proper places, I retired to the bathroom. As I stood outside the shower, reaching in to test the water temperature with one hand, once again I glimpsed the grey spider. She descended from the storage shelf by a single silken thread, hanging motionless for a moment in the air, before continuing down to light upon a purple plastic box lying on the floor.

I bent down to have a closer look and studied her carefully. I was certain she was the same spider that I had seen that day before departing for Atlanta. The color and body size were identical, right down to her tiny facial features. Then there was the fact that she inhabited the same small room as before.

But what clinched it for me was when she said, “So tell me: how did the presentation go?”

Humane Medicine — House calls, Homebodies

In my student days, I trained at an urban health clinic. Although we saw the gamut of general medical ailments, my most invaluable lessons came when the doctor and I ventured out into the local community to make house calls.

Interested readers can now access my latest Humane Medicine column, House calls, homebodies: Remembering that you came, recently published in the Journal of the American Academy of Physician Assistants.

Memes and the evolution of medical practice

A meme is “a postulated unit of cultural ideas, symbols or practices, which can be transmitted from one mind to another through writing, speech, gestures, rituals or other imitable phenomena.” The British evolutionary biologist Richard Dawkins postulated this concept in his 1976 book The Selfish Gene to explain the spread of ideas and cultural phenomena in evolutionary terms. Susan Blackmore, the British psycho-theorist, further developed Dawkins’ theory and believes that we are moving toward a new form of meme, the teme, which is spread by the technology we’ve created.

If we consider for the moment that memes do indeed exist (and their existence is far from certain), we could postulate that medical memes propagate through the medical community via medical journals, lectures and mentors. Published research eventually generates new approaches to the diagnosis and treatment of disease. Much contemporary medical research in the U.S.A. is underwritten by the pharmaceutical industry.

Nowadays, children routinely take medication for chronic conditions such as allergic disease, asthma, ADHD, depression, diabetes, gastroesophageal reflux and hypercholesterolemia. A spate of recent articles documents that 1 in 4 children covered by health insurance took some form of prescription medication in 2009. Annual spending for prescription drugs in children increased by 10.8 percent the same year, and the price of branded prescription drugs increased by 9.2 percent. Clearly, someone besides the patient is benefiting enormously from these trends in medical practice.

As a clinician who has worked on the front lines in ambulatory pediatrics for 30 years, I can vouch that these statistics seem to be supported by what I have observed over the past decade. The sheer number of children who take daily prescription medication for chronic conditions is astounding; and in my opinion these numbers will only escalate exponentially.

What drives these trends? Are clinicians becoming more astute at recognizing and diagnosing these conditions in children? Are the conditions themselves growing at an alarming rate secondary to cultural influences such as high fat diets, readily accessible food, over consumption of calories, unlimited access to TV and video games? Are parents themselves at fault, seemingly unable or unavailable to rear children with their best interests in mind?

Although any or all of these factors could potentially contribute to these disturbing trends, might medical memes—those ideas which seem to infiltrate medical practice and become acceptable norms—also play a role here? Are we clinicians too quick to reach for the prescription pad at the expense of taking time to offer wise counsel to our patients?

Some memes may replicate effectively even when they prove detrimental to the welfare of their hosts. According to Dawkins, “systems of self-replicating ideas can quickly accumulate their own agenda and behaviors,” which ultimately might prove to be good or ill for society, culture and the population at large.

Perhaps the medical profession needs to examine itself and take a closer look at what drives contemporary medical practice. In the meme, that might be a good thing.