On Becoming a Healer

For years, doctors and those learning to practice medicine were told pain is “the fifth vital sign” and to treat it aggressively – including with opioids, "if that’s what it takes.” A consequent rise in opioid prescribing contributed to the devastating opioid crisis. Then the pendulum swung in the opposite direction, hard, with physicians cutting off opioid prescribing to patients, often without their consent. That too led to suffering with many deaths by suicide. What do these two seemingly opposing trends share in common? Both reflect a failure to embrace current knowledge about chronic pain and to bring compassion and caring to people who are suffering. Co-hosts Saul Weiner and Stefan Kertesz discuss the implications from two perspectives: Medical learners are still taught to treat chronic pain like a simple bodily injury (“somatically”) with the caveat to avoid opioids, spurring apathy and frustration. Stefan, an addiction medicine specialist who has been conducting a national study of suicides related to forced opioid tapers, argues that we have “become addicted to talking about opioids” rather than about all the good we could do if we applied current knowledge and compassion to help people who are suffering.

From the 1940 to the 1970’s, medicine went from an almost exclusively male club to a profession in which women physicians were commonplace. Our physician guest is Dr. Anne Walling, who has written a book about the experiences of 37 women who attended a Midwestern medical school, Women in Medicine: Stories from the Girls in White This was a time when pornographic images appeared in lecture slides, and sexual harassment and discrimination in the job market were ubiquitous. Despite the misogyny, the women interviewed nearly all expressed gratitude that they were able to have such meaningful, rewarding, and stimulating careers. Our guest told us that her interviewees described reunions where male colleagues seemed burned out and cynical, while many of these women remained upbeat and excited about their medical work. What can we learn from the story of women’s entry into mainstream medicine? How has the profession been changed (or not) by their presence?

Medical educators generally acknowledge the importance of training doctors who care for the whole patient rather than just treat the disease. Most medical school curricula attempt to teach to that philosophy, but how successful are they, really? Our guest, Robert C. Smith, is a physician and author, who trained with Dr. George Engel, founder of the biopsychosocial model. In his new book, Dr. Smith argues that medical education mostly pays “lip service” when it comes to training physicians who are ready and comfortable serving patients who struggle with unaddressed psychosocial and psychological needs. He calls for a complete overhaul of medical education. What would that take? Is an overhaul feasible, or are the market forces that now drive medicine as big business too overpowering to allow for transformative change?

Soon after Lisa Iezzoni MD was diagnosed with multiple sclerosis during her first year at Harvard Medical School, from which she graduated in 1984, faculty and administrators discouraged her from practicing medicine. And in her final year they made it impossible for her when the Dean’s office refused to write a recommendation letter (now called a Medical Student Performance Evaluation). This week marks the 35 anniversary of the American Disabilities Act which was signed into law on July 26, 1990. Much has changed since but -- as Dr. Iezzoni, who went on to become an eminent scholar and national policy leader on disability, has documented -- not nearly enough. She and others have documented wide disparities in the quality of care patients with disabilities still receive, and in 2021 she published the findings of a national study of physician attitudes towards disability that document’s persistent stigma and misinformation. Disabled patients were described as a “disruption to clinic flow” and a majority of physicians believed that patients with significant disability inherently have a worse quality of life. Practices are also ill-equipped to care for them, Dr. Iezzoni, who chaired the U.S. Access Board’s advisory committee on accessibility standards for medical equipment observed that “healthcare has been among the most backward environments, in terms of making itself accessible. Movie theaters are accessible, sports stadiums are accessible, transit is accessible. But healthcare facilities—no.” In our conversation with her, we explore why. How is it that physicians have such difficulty appreciating that disability is simply a part of the human experience? We explore the link between the culture within medical education and training, and the kind of people physicians become. ------ References: Physicians' Perceptions of People with Disability and Their Health Care US Access Board

It is difficult to overstate the achievements of Richard Clarke Cabot (1868-1939) a relatively little-known, old-moneyed physician of the early 20 century who was far ahead of his time in how much he contributed, and how willing he was to question his own limitations. Cabot's achievements include: creation and self-funding of the first medical social work service and establishment of the fields of clinical pastoral care and medical ethics. His work offered seminal contributions to the fields of hematology, cardiology, infectious disease, and medical education – including the clinical pathologic conference, case-based learning and the differential diagnosis; the first large-scale randomized experiment in the history of criminology; the science of medical error; and introducing the concept of a group insurance plan. He authored countless books, articles and textbooks. Most remarkable, considering Cabot's extraordinary intellect, was his openness to reflecting on his own deficits as a physician, including getting diagnoses wrong, and describing his own failures in seeing the humanity of his patients. Joy, curiosity, and generosity were among his distinctive personal characteristics. So, why is he not more widely remembered? Perhaps because of one of his greatest attributes: he pointed out things about his profession that the medical establishment didn’t want to hear.

In an April 23rd executive order (EO), the president of the United States alleges that the Liaison Committee for Medical Education (LCME) and the Accreditation Council for Graduate Medical Education (ACGME) are requiring medical schools and residency programs to pursue unlawful discrimination through DEI policies. The EO calls for the US Department of Education to “assess whether to suspend or terminate” them, and to “streamline the process” for recognizing new accreditors to replace them. In addition, medical journals, including the New England Journal of Medicine, are getting letters from a US Attorney, calling them “partisans in various scientific debates,” and requesting information. As a follow up to our last episode on authoritarianism and its implications for the medical profession, we consider these new developments from two perspectives: On the one hand we look for evidence to support the government’s claims; and, on the other, we consider how they fit into the authoritarian’s playbook of capitalizing on polarization to breakdown civil society and consolidate power. There are things physicians and other health professionals can and should be doing now – and we propose a few -- to protect our profession from an authoritarian incursion that threatens our commitment so scientific integrity, and to a medical education system that, however imperfect, is informed by expert knowledge and professional values.

The record of physicians standing up for their values as healers under authoritarian regimes is not good, whether it’s Nazi Germany, the former Soviet Union, or Iraq, with behaviors ranging from assisting in torture, to psychiatric hospitalization for political reasons. And sadly, it’s often without any coercion. More subtly, physicians may go along with authoritarian regimes' demands, thinking they can just "stay above the fray." But is that possible? Already, other professional institutions, including academia and law, have struck deals in the hope they they can move on, rather than defend academic freedom or long-standing legal principles. What’s in store for medicine? Some might say “not much” -- physicians must simply continue to take good care of their patients. But some are already acceding to orders to abandon care to certain populations, including trans people and refugees; or to compromise privacy. And professional organizations are saying little about looming cuts that would curtail access to care for millions of Americans. One scholar of authoritarianism, Timothy Snyder has written, “When political leaders set a negative example, professional commitments to just practice become more important. Authoritarians need obedient servants.” In this episode, two physicians wrestle with what those commitments are, and how we hold on to them.

Prescription Drug Monitoring Programs (PDMPs) were originally designed for law enforcement to monitor patients and physicians for criminal behavior before it became available to health care professionals. Physicians and pharmacists often find PDMPs helpful because they can verify what a patient tells them and will often decide not to prescribe or dispense opioids if they discover their patient has been going to multiple providers and pharmacies. But is that health care or policing? Who benefits and who is harmed? Those are questions we consider with our guest, Elizabeth Chiarello, PhD, sociology professor and author of Policing Patients: Treatment and Surveillance on the Frontlines of the Opioid Crisis. The themes we discuss are not unique to PDMPs. This is at least our fifth episode exploring how the criminal justice mindset has crossed into medical practice with harmful effects. Prior ones include: · Opioids and the physician-patient relationship: What are we getting wrong? March 2022 · Urine Drug Screening: How it can traumatize patients and undermine the physician-patient relationship without helping anyone August 2022 · My patient’s in shackles: Can we take these off? April 2023 · Drug testing at time of birth: How physicians are co-opted into harming families while thinking they are doing the right thing. Nov 2023

There are a lot of videos on YouTube that feature typically young physicians explaining why they decided to leave the profession after years of dedication and hard work. For some it appears that they were so successful at building a social media presence and related businesses, that they quit medicine. Others seem to just want to share their experience in the hope it might help others. They describe how a sense of exhaustion, dreading work each day and discovering that it wasn’t what they imagined when they dreamed of becoming a doctor drove them away. What they have to say feels quite convincing, and thousands of comments affirm them. At the same time, there is something missing. They rarely talk about their relationships with patients or how medicine, no matter how corrupted it is by profit seeking, really is a special and unique profession that is worth fighting for. We reflect on what to make of this blind spot, trying very hard not to sound preachy.

In December 2024, the three organizations that oversee medical school (MD and DO) and residency education released a set of “Foundational Competencies for Undergraduate Medical Education,” that represent a consensus on the observable abilities medical students should exhibit as they begin practicing medicine under supervision. Not surprisingly they include taking a relevant patient history, performing a relevant physical exam, and creating and prioritizing a differential diagnosis. But a new one – and it’s the first one under Patient Care -- entails integrating patient context and preferences into patient care. Stefan interviews co-host Saul Weiner who has documented a strong correlation between contextualizing care and patient health care outcomes in thousands of encounters. Saul reflects on how contextualizing care is a deeply human but teachable process that AI can’t replicate and that makes care measurably more effective for patients, and more meaningful for doctors. The Institute for Health Care Improvement’s new online course on contextualizing care is accessed at Contextualizing Care 101. For bulk orders email OpenSchoolSubsribers@ihi.org

At a moment of increasing isolationism and xenophobia and -- for physicians – burnout, in a highly bureaucratic and profit driven health system, service in low resource high needs settings can be an antidote for what ails America and American medicine, at least for the individual clinician. John Lawrence has spent decades serving all over the globe as a pediatric surgeon, most recently in war torn Gaza and South Sudan. He explains how he headed to college with plans to become a mathematician and then got diverted from that career trajectory while teaching math to Native American youth in Montana and seeing the consequences of poor access to needed healthcare. As cliched as it may sound, physicians are supposed to serve humanity rather than just the well insured, and John exemplifies that point of view on a global scale.

In can be confusing and even demoralizing for a medical student or resident to understand what’s expected of them when caring for patients with social needs. They already feel overwhelmed. Are they supposed to now also screen for housing insecurity? Is it their job to intervene to address social needs? And if someone else is doing the screening, what’s their role? And are they also supposed to be advocating for changes to social policies? Finally, what’s special about social needs as opposed to all the other reasons that, for instance, a patient can’t control their diabetes? A patient may not be able to store their insulin because they are poor. Or they may not be able to administer it because they can’t read the bottle or their fingers are arthritic. Our guest, Emily Murphy MD, an academic hospitalist, provides her perspective on teaching medical students and residents about SDOH. Co-host Saul Weiner, expresses concern that messages to trainees about their roles are confusing, that the SDOH movement is just the latest buzzword in medicine, like “patient-centered care,”, and that while getting a huge amount of attention the movement could ultimately have little impact on patient wellbeing. He, Dr. Murphy, and co-host Stefan Kertesz discuss these questions and concerns and consider what needs to change.

To commemorate the start of our fifth season, we revisit a conversation we had almost two years ago about the wisdom of Simon Auster, MD. Simon was a family physician and psychiatrist who inspired the conversations we’ve been having with each other and with guests on every episode. “Simonisms” embody Simon’s insights: pithy observations about the practice of medicine that are never cliché, challenge commonly held assumptions and offer fresh perspectives. We share -- and reflect on -- these pearls because we believe they can help many doctors, those in training, and those who train them, find joy and meaning in their work. You can learn about Simon, who died in 2020, in an online (open access) essay about his life, published in The Pharos, the journal of the AOA medical honor society.

The two doctors charged for their roles in the events leading up to actor Matthew Perry’s death were both involved in a “side hustle”: selling ketamine at a big mark-up to make extra money, above what they earned through legitimate practice. One was an internist-pediatrician and the other an emergency medicine physician. Their cynicism was starkly evident in a text one sent the other about jacking up the price: “I wonder how much this moron will pay. Let’s find out.” It’s easy to write off these doctors as just bad apples; regrettable examples of how difficult it is to prevent a small number of unethical people from making it through medical school and residency. But what about the profit-making that occurs when thousands of physicians perform procedures, including surgeries, for which there is strong evidence of NO benefit from randomized controlled trials, but with all the risks of pain and complications during recovery and over the long term? From a patient’s perspective is there really a difference between being subjected to predictable harm when you know your doctor is a drug dealer versus these practices within the mainstream of medicine where patients assume their physicians are acting in their best interests? Which is the greater betrayal?

The term “Narrative Medicine” (NM) refers to a range of activities, including close reading and reflective writing about literature, designed to improve the clinician-patient relationship. What could go wrong? Our returning guest, English professor Laura Greene, lays out the case for narrative medicine, while co-host Saul Weiner highlights his concern that the challenges and rewards of interacting therapeutically with patients are categorically different from those of a physician interacting with a text. Unless proponents of narrative medicine articulate these differences explicitly, they risk creating unrealistic expectations about what NM can achieve, particularly in regard to actual healing interactions in the exam room.

There is an idealized version of physician-patient communication that is taught in medical schools, reinforced with acronyms like PEARLS, SPIKES, and LEARN, but what resemblance does it bear to how doctors actually sound in the exam room? Co-host Saul Weiner leads a research team that has audio recorded and analyzed thousands of medical encounters. In this episode, he and Stefan read a transcript from a typical visit, portraying patient and doctor, respectively, breaking out of role periodically to reflect on what’s just happened. Throughout, the physician interacts with the computer, peppering their patient with questions while conducting data entry. On the one hand, the visit is unremarkable. The physician seems reasonably conscientious. On the other, it is disturbing for their lack of engagement even when the patient shows signs of distress or confusion. What can we learn and teach by studying transcripts of real doctor-patient interactions, warts and all? Saul has posted over 400 of them, all de-identified, in a federal data repository.

The National Institute on Drug Abuse defines addiction as a “chronic disease” occurring in the brain – Many believe this definition can help to reduce stigma. But, is it helpful in the care of individual patients? In this episode we discuss what we gain and what we lose when we speak of people with addiction as having “diseased brains.” The view of addiction as a chronic disease has traction, supported first by mid 20-century alcoholism research, and then by a flood of brain imaging and neurophysiologic studies. Functional MRIs highlight changes in the brain, whether the addiction is to a substance like alcohol or opioids, or to a behavior such as gambling or disordered eating. Many authorities suggest that the “brain disease” designation is not only correct on scientific grounds, but that it also advances a social priority: to blunt stigmatizing concepts of addiction as a weakness or moral failing. However, many neuroscientists disagree with the brain disease model. Without disputing the brain science, they note that all learned behaviors change the brain, not just addiction. Also, people who reduce or stop use often report they chose to make that change because of new opportunities or intolerable consequences. The brain disease argument invites a second criticism: arguably, it lets unfettered capitalism off the hook – predatory industries spend billions to get people addicted. Calling it a disease of an organ conveniently focuses attention away from a predatory system. Why does this debate matter for clinicians and patients? Saul interviews co-host, Stefan Kertesz, who is a primary care doctor and a board-certified addiction medicine specialist. Together we consider how addiction is a part of the human condition, which includes how we learn, how we relate to the environment in which we live, and how we are shaped by experiences. Nearly everyone has habits that are problematic to varying degrees. How we think about addiction can shape our approach to patient care across a wide range of clinical interactions.

In his book, The Present Illness, American Health Care and Its Afflictions, physician and historian Martin Shapiro, MD, PhD, MPH presents a scathing critique of a profession suffused with status, money, and power. At the same time, he also describes many deeply caring and rewarding patient care experiences, his own and those of colleagues. But these relationships are only possible when the clinician has a clear understanding of the pernicious corrupting forces in medicine and consciously rejects them. This is a moral act that must be renewed continuously. They also require a capacity to confront one's own insecurities -- Dr. Shapiro describes years of psychotherapy that were essential to his own growth as a physician who can be fully present in the face of suffering. Martin indicts the profession for producing far too many doctors who want to get rich and who are unprepared, through a faulty process of selection and training, to be truly caring towards those they serve. Martin reminds us that the motives of the profession have long been suspect, quoting Plato's Republic in which Socrates asks, "Is the physician a healer or a maker of money?" Never before, however, and nowhere on the scale found in the United States has health care become such a massive industry, one that keeps growing. Martin argues that the profession can only heal itself if it confronts its demons honestly and openly, beginning at the earliest stages of medical training.

A recent NEJM article and accompanying podcast episode (“Tough Love”) authored and hosted by the Journal’s national correspondent sound the alarm that a culture of grievance among medical students and trainees about the discomforts of medical training is threatening to undermine both their medical education and patient care. She also describes widespread anxiety among medical educators who feel fearful of speaking because of concerns of retaliation on social media. Absent from the discussion, however, are the voices of students and trainees who, in the podcast, are referred to as “our children.” Medical Students and trainees we spoke with did not feel that their concerns are experiences were accurately characterized. We propose that medical educators are ill prepared for the shifting power dynamics, both in terms of knowing how to listen and how to lead.

“Sonny’s Blues” is a 1956 story by the author, James Baldwin, about a “sensible” and pragmatic algebra teacher and his younger musically gifted younger brother (“Sonny”), who struggles with heroin addiction. Both of them, raised in Harlem, are deeply affected by anti-Black racism. Although the older brother, who narrates the story, feels responsible for Sonny, he struggles to relate to him. With the help of an English professor, Laura Greene at Augustana College, we reflect on some of the lessons of this story for the physician-patient relationship, especially when caring for individuals with substance use disorder. We explore the cost both to patients and to ourselves, as healthcare professionals, of holding patients at arm’s length because we fear engaging, especially in the face of suffering. A PDF of “Sonny’s Blues,” can be accessed from the story’s Wiki page (scroll down to external links).