The Physician in Modern Society

The Physician in Modern Society



Stanford University thank you very much Phil for that wonderful introduction can you hear me pretty well at the back there I must say I'm I'm actually slightly intimidated by being the first in this series of lectures because I've looked at the list and it's really quite remarkable what you were going to be hearing but I must say I think I prefer to be the first I've had the misfortune of always having very hard acts to follow and I remember the last time this happened was at the University of Iowa I was at a conference not on medicine but on the narrative voice and the speaker before me happened to be the University of Iowa's professor of religion and he was a rabbi he stood about six foot six he had a wonderful baritone voice he had won every teaching award the University of Iowa had ever offered and when he got to the podium he had such presence that I thought the microphone would turn into a snake or the podium would catch fire and he actually began with the amazing proposition that the narrative voice originated at the moment that God spoke to Moses on the mountain and he held forth on that topic in the most erudite fashion for one hour sat down to thunderous applause a standing ovation then I was introduced and I remember getting up there and saying that I I knew nothing about what God had said to Moses on the mountain but I'd heard this apocryphal story which I'm about to repeat to you about what Moses said to the Restless masses below Moses said I have good news and I have bad news the good news is that it's down to 10 the bad news is that adultery is still in there I think that there is great irony in this title that I've picked the physician and modern society because ladies and gentlemen I have never lived through an error more exciting than the last couple of years both in terms of the tremendous technological advances that we're seeing but also in terms of an important philosophical question about the role of the physician in modern society and I'm going to try my best to give you my my take on it and it's very much a personal take and I'm going to use this painting by Sir Luke fields a very famous painting that most of you have seen in some fashion or other and a hundred years ago or so Mitchell banks a professor of anatomy said something prophetic because he said a library of books written in our honor would not do what this picture has done and will do for the medical profession remember always to hold before you the ideal figure of Luke fields picture and be at once this was an era when it was largely men be at once gentlemen and gentle doctors and I want to tell you a little bit about Luke fields because I think it's it's germane to our discussion Luke fields was born around 1846 he grew up in Liverpool his grandmother was an important social activist and I think his grandmother gave him his wonderful social conscience he went to London and was educated at the Royal Academy and became an artist and sought employment as such one of his first Commission's was for a magazine called a graphic and they gave him free rein and asked him to just illustrate whatever caught his fancy and he had been very struck one night when he was walking down the street in London he saw people lined up waiting for tickets to get into the casualty ward or the police station to spend the night outside away from the cold and it was a scene that he could not erase and so that became his first composition he actually paid people to pose for him and when this came out it actually caught everyone's fancy it was really quite a striking drawing for that time it caught the fancy of someone by the name of Charles Dickens who was looking for an illustrator for his new book the mystery of Evinrude which he never completed by the way and so he hired Luke fields and Luke fields also got the Commission to change this drawing into an oil painting which he did and when this painting was displayed at the at the Royal gallery they had to have barricades to prevent people from mobbing it it had enormous appeal because for its time it was a very different kind of painting and I just want to lead you through it he now retitled it applicants for admission to a casual ward and by the way that word casual really means indigent if you wondered about the origin of the casualty service or the casualty Ward as emergency rooms are called in Britain for example that refers to indigent care and and and I think what's most striking about this painting is the way we as viewers are sort of forced into the painting because of that wall at the back that kind of for shortens their aesthetic distance so that we cannot escape from this picture of misery and there is no relief in the wall except where the policeman stands where he's handing our tickets and there are no more tickets and the only figure that you see clearly is this woman who is somewhat well-to-do compared to the people out there and the child is begging for money from her this was a very very important painting in fields career and it led to a commission from Henry Tate a man who made his fortune in the sugar business in the Caribbean how many of you have been in the Tate Gallery wonderful gallery where by the way this painting hangs and Tate Commission feels to do a painting that he called an English painting of importance and by the way the word English in that context at that time meant something that was socially important and field's decided that he would set out as his ambition to put on record the status of the doctor in our time and he was moved to do so because of a very significant event in Luke feels Sir Luke feels life his son Philip aged 9 years of age died on Christmas Day in 1887 and it was obviously a huge blow to the family and to him and yet he wanted to record not not so much the death of his son but the Grace and the care which his son received from a doctor Marie and so when he finally set out to do the painting as you can see in the bottom left he constructed this replica of a fisherman's cottage and he posed actors and he set about doing this remarkable painting and I wanted to sort of take you through this if I may as you can see in the centre is this child who really occupies our attention right away and we don't know if this is a boy or a girl but something in the posture of those hands suggests that she is mortally ill she's quite ill and you also have a sense that this is a makeshift bed and the child normally sleeps on a pallet of straw on the back of the cottage somewhere and the pictorial space is nicely divided between the doctor on one side you know the professional world on this side on that on the other side the mother and father waiting anxiously and the doctors attentiveness to his patient is really quite striking what is also striking is the absence of any of the instruments of medicine so to speak all you see there is the doctor and his attention and when Sir Luke Fields was asked about this because the moment is pregnant what is going to happen next interestingly he did not say well what's going to happen next is that the child is going to die he said this painting is all about light coming through the window the break of dawn and how hope springs eternal for all of us he never mentioned his dying child this painting became not surprisingly the most famous medical painting in the world for many many reasons I think it had great emotional appeal but it also was at a time when people were very very conscious of the latest painting there's a couple of unusual things about the doctor that I'll point out to you first of all the doctor in that picture and by the way there were many physicians who once they heard that sure Luke fields had this commission for this painting who jockey to have him model them because they thought that and they knew that that would really help their practice enormously dr. Murray the one who took care of Philip I declined to be a model for this a humble man and ultimately feels used sort of a composite of many different people but the doctor in this painting is in the role of a general practitioner he's in a fisherman's cottage but he's in the dress of a consultant so for those of you who are finicky this is really something that's a little strange about the painting what's also strange is that this is a time of huge medical advances ether and as ether anesthesia surgery and yet fields choose to depict something much less dramatic than say Ekans famous painting of the grouse clinic that you see you see on the bottom right there and as I mentioned feels son dies and yet the painting radiates hope and the doctor doesn't carry a stethoscope he doesn't carry a thermometer and when Fields was asked this he his feeling was that he wanted to depict the doctor in our time and that had as far as he was concerned very little to do with instruments and the other accoutrements of the profession the image became so popular that it was actually issued as postage stamps in 1949 the United States made it into a postage stamp to commemorate the hundredth anniversary of the American Medical Association and the AMA used this figure and this painting in their campaign against socialized medicine President President Truman tried to bring about socialized medicine at that time and the AMA in the persona of Morris Fishbein a very interesting character mounted this huge campaign that effectively undid President Truman's efforts and many of you of a certain age will remember this poster in your doctor's offices will remember this being on calendars and the caption was keep politics out of this picture or that the government is going to take the doctor out of this picture a real misinformation campaign alas whereas by contrast in Britain this painting was used to celebrate the and the anniversary of the National Health Service where where a national health service was adopted very very early on to end the club Wars and I should explain what that was a in that painting in the cottage the kind of doctor who would have taken care of that patient would have been a club doctor meaning about 70 families in one area would get together and hire a physician and work that poor person to death he was the club doctor and he had to come anytime he was called and if he didn't do that then they would not renew his contract it was a very unfair difficult practice and the National Health Service actually came about in large part to to overcome the club club Wars as they called it they've been there's been so much commentary on this painting so many observers have had lots to say about it and I like this that was said by my colleague colleague Howard Brody runs the humanity center at Galveston he felt that this painting was all about the fact that character and virtue are as important as knowledge and skills in describing the ideal family physician and Howard Brody is a family physician he felt that this painting conveyed the fact that medical practice is more than maintenance of a network of human relationships than it is the application of scientific knowledge and I will tell you that my own take on that is quite different when I present this to physicians I often say it's not about you this painting is not about you it's about you and I identity identity ourselves with that child with that patient and when we're in that role of patient this is the sort of physician we would want taking care of us someone who gives us their undivided attention so to me this this painting really recalls a line in the New Testament I was ill and you cared for me this is the sort of care we want to see this is how it expresses itself and my great worry I know that Phil and I share this worry with the tremendous advances that come with medicine my great worry is that it feels had to do this painting in this day and age it might look something like this and sometimes I think that if a anthropologist from Mars descended on our institutions and came to our hospital they would make some very bizarre conclusions they would conclude that the main business of my specialty internal medicine took place in a conference room somewhat removed from the patient they would conclude that the virtual patient the eye patient was infinitely more important than be real patient and they would also perhaps conclude that there was something toxic in the patient environment so that physicians minimize their exposure as much as they could and they would also conclude that the patient's personhood was relegated to the margins of our attention and we were far more interested in their two-dimensional images on x-rays and whatnot than we were in who they actually were which would probably be a fair take for an observer from Mars I want to switch gears and tell you a little bit about my own humbling if you will as Phil mentioned I trained in infectious disease in Boston and finally went to Johnson City Tennessee population 50,000 at a time when HIV was just appearing in Boston I remember taking care of the first couple of young men coming to Boston City Hospital with bizarre infections on Pneumocystis pneumonia and Mycobacterium avium infection all of which we've seen before but always in the context of immune suppression or transplant but these young men had no such explanation and I remember how the numbers kept growing and I also remember the fear and excitement of that era because clearly this was something new but it was also something that seemed ripe for science to have a major breakthrough and indeed while I was still in Boston I heard I picked up the Boston Globe one morning and read that gallo and Montaigne had discovered the cause for this illness and I felt as did many of you I suspect that it was just around the corner that we'd have a cure and in fact when the iliza tests the that test was developed a few weeks later it became apparent that for every one young man we were taking care of in the hospital we were perhaps dealing with a hundred to two hundred others out there carrying this virus and and the full implications became clear but I was leaving Boston I was going to Johnson City Tennessee population 50,000 a small medical school and all the pundits said that I could expect to see maybe one or two infected patients every year or every other year and when I first got there in 1985 that seemed possible but very soon I saw my first patient and then in a few months my second and in about three years I was following a hundred people with HIV in a town of 50,000 a hundredfold more than anyone would have predicted for that small town and it was the most important lesson of my life it was a very humbling moment I I remember thinking that I had gone into infectious disease because to me infectious disease was the one specialty in medicine that was all about cure I mean I looked at the cardiologists you know putzing around with their roto-rooter's and you know no I you know the idea of infectious disease that you could see someone with a fever from the Congo we just flown in and had this hemorrhagic rash and you made an astute diagnosis and they rose like Lazarus what irony that a fatal illness should land in the laps of people like me caught up in what I call the conceit of cure and there was a wonderful lesson that that I think we all learned in the process I began to feel that I could not offer much to my patients in the hospital they we had no drugs we had none of the new cocktails that we now use and out of frustration I began to leave the threshold of the big medical industrial complexes we work in and I began to go to patients houses and I did that out of as I said frustration and when I landed there in their homes I realized that my visit had a profound effect on me on them it was just tremendous the family welcomed me and it seemed to make them feel really happy that I'd come the patient I felt that I had not abandoned them after all there I was and it gave me a sense of purpose and over the years I've tried to define what that is all about and III explained it to myself this way I discovered in that moment the difference between healing and curing and lest I become hokey I want to explain this to you I want to explain this to you in the way that I explain it to my students I try and give them an analogy for them to understand the difference between healing and keurig and I say imagine you go home from this lecture and you go back to your homes and you find that the doors been kicked open the lock is splintered and all your belongings are strewn around your money is gone your jewelry is gone television to the students I say God forbid your iPod has been taken you will be devastated and then if you imagine the police come by a couple of hours later and say you know we found the person who did this here is all your stuff back at that moment you will be cured but you will not be healed your sense of violation will be so strong that you might even move from that dwelling and the point I make with them is that all illness has a physical component and sometimes if we're lucky in medicine we can fix that but all illness always has a sense of violation a sense of why me and with diseases like cancer and HIV that sense of violation or was huge and so this was a tremendous learning moment for me as a physician an understanding of what was truly important and what it was the horse-and-buggy doctor of 100 years ago or so was able to offer in the absence of all the therapy that we now have Eric Castle has something to say about this he says as far as I can see you can heal somebody you can be complete about it but I'm not convinced that you make a bit of difference in the bodily disease I think he was referring to that and Roy in the house of God says I didn't give a damn about their diseases Cure's what they wanted was what anyone wanted the hand in the hand the sense that their doctor could care and my mission with our students is to make sure that they appreciate this before they going to practice and have it arrived to them the hard way instead that they be aware of this dichotomy I think and maybe you can correct me during our discussion I think that patients often see us as inattentive disease and tests procedure oriented the caption there says the tests have ruled out anything expensive so I'm referring you to a doctor who specializes in cheap diseases and I've been doing a lot of reading around this business of Technology and where do we fit it in and a interesting book that I've been looking at is this one by postman it says technology baguettes more technology and tech driven policies and economic economics and finally people who can either function or think beyond the limits of the machine I've become a big fan of this particular individual and if you are interested in extra reading this is a great book that I submit to you as worthy of your consideration David Orr has been a very interesting thinker and this book is called the nature of design he makes a distinction between what he calls slow knowledge and fast knowledge and I've been trying to bring this back to my medical students he says slow knowledge is all about resilience it's about harmony the preservation of long-standing patterns that gives our lives aesthetic spiritual and social meaning snow slow knowledge rest on these beliefs that wisdom not cleverness is the goal of learning that the velocity of knowledge is inversely proportional to the acquisition of wisdom the careless application of knowledge can destroy the conditions that permit knowledge to flourish and that rising volume of knowledge cannot compensate for increasing errors caused by malfeasance and stupidity generated in part by inappropriate knowledge and then and when I read this I thought you know I've never heard character referred to in any of our medical discussions the good character of knowledge creators is relevant to the truth they intend to advance this is not something we normally think about in medicine but perhaps we should I think TS Eliot had something very similar to say TS Eliot said where is the knowledge we have where is the wisdom we have lost in knowledge where is the knowledge we have lost in information so there are dangers to our great acquisition of knowledge if we don't apply it correctly and forget the human connection so how do we how do I try to convey to my students that the care and attentiveness that was conveyed in that wonderful painting by fields Peabody many many years ago Sir Francis Peabody said not Sir Francis but Francis Peabody said the secret of the care of the patient is in caring for the patient and I think that's very true our attentive presence means everything the careful examination by the history and physical reflection on the problem by having one physician play quarterback by the maxim that no tests before a patient is interviewed and examined by beginning to think how we could manage if tests procedures and care were rationed and they assume will be by celebrating wisdom over knowledge and Slow knowledge over fast measure less reflect more perfect the life as well as the work I want to wind down with one anecdote that has been terribly important to me I in Texas before I moved here I developed the reputation of being interested in people with chronic fatigue you don't want to wish this on your worst enemy this is not a depiction that in normal circumstances will be good for you because these patients can be very very difficult and I don't quite know how it happened but one patient led to another and pretty soon I was seeing a steady stream of patients with chronic fatigue and I realized very early on that I could not address their needs in one visit a new patient visit I could not do a history and a physical and needed much more time than that so I hit on this method with my patients which is I would give them the first visit just to tell me their story and I would try not to interrupt them the average physician we are told interrupts their patient in 19 seconds and if I ever go to heaven it'll be because I held my peace for one full hour while they told me their story which is very important for them to do I would then schedule the visit the physical exam for another occasion a week or two from the first visit and since I had a lot of time now to do the physical I would do a very thorough physical I like to think I do a very thorough physical anyway but I did a very thorough physical on these patients invoking every maneuver that I could think of to invoke and a very interesting thing happened with one of the first patients a very voluble patient who wanted to continue telling me the story in the second visit became silenced in a sense by our ritual and as I kept doing what I did I had a feeling that I had slipped back into an ancient ritual one in which she had a role and I had a role and that the ritual was powerful I could actually sense it it was a very important moment for me and when I was done with her this is one of my first patients with chronic fatigue she said to me in all in all she said I have never been examined like this before and when I then had her get dressed and come to my office and I told her the same things that she had heard at the Mayo Clinic and the Scotland White or wherever else she had been that this is not in your head this is real the good news is it's not cancer it's not Histoplasma it's not coxy to mycosis the bad news is we don't know exactly what causes this but here's what we should do and I always felt that if they gave up the quest for the magic bullet the magic doctor or the magic test it was because I had earned the right to tell them that by virtue of the ritual of the careful exam and that is really ladies and gentlemen what I try to teach my students I want to close with this quote from Yeats which I think is sort of operative in our lives it says that the intellect of man is forced to choose perfection of the life or perfection of the work and if it takes the second must refuse a heavenly mansion raging in the dark sometimes I think that is the choice being faced by us in medicine our work is so seductive our work in this day and age is so technologically mind-boggling and brilliant that we sometimes forget the life and I think one has to keep both of those our together I'm going to close by reading you one paragraph from something that is in your your reading in your reading list this has to do I wrote this fairly recently and submitted it for your reading I remember all those years of taking care of people with HIV Phil recalls those days when we had really very little to offer and I would go to the room and visit with the patient and examine them every time that was my ritual and I remember leaving the room feeling are so inadequate so unable to help them and the next day I would come and we do it all over again and I wanted to read this last paragraph to you and I'll stop with that and then we'll take your questions and here it is I recall one patient who was at that point no more than a skeleton encased in a shrinking skin unable to speak his mouth crusted with Candida that was resistant to the usual medications when he saw me on what turned out to be his last hours on earth his hands moved as in slow motion and as I wondered what he was up to his stick fingers made their way to his pajama shirt fumbling with his buttons I realized that he was wanting to expose his wicker basket chest to me it was an offering an invitation I did not decline I per cust I palpated I oskol dated I think he surely must have known by then that it was vital for me just as it seemed necessary for him neither of us could skip this ritual which had nothing to do with detecting as in his lungs or finding the gallop rhythm of heart failure now this ritual was about the one message that physicians have needed to convey to their patients although God knows of late in our hubris we seem to have forgotten we seem to have drifted away as if with the explosion of knowledge the whole human genome mapped at our feet we are allowed into forgetting that this ritual is cathartic to the physician and necessary for the patient forgetting that this ritual has meaning and a singular message to convey to the patient and the message which I didn't fully understand then even as I delivered it and which I understand better now is this I will always always be there with you I will see you through this I will never abandon you I will be with you through the end thank you so much question is about concierge practices and what the motivation is for them I believe that most of us when we are in training are our dream of what a practice will be like is really a concierge practice and then the reality I think of what happens is the way reimbursements work is that you literally have to have a panel if you're in private practice of to 3,000 patients and you can't spend very much time with them in order to make the overhead and there comes a point I think when many physicians are frustrated with that and changed your concierge practice which gives them all kind of all kinds of time with the patient so I don't think the motive is monetary I really think that they do it with great thought and with some regret because they are closing the door in a sense on many people but what it does do is allows them to have the kind of time that they want to spend with patients it's you know this is really a manifestation of reimbursement the sad fact is that a psychiatrist gets less for a 45-minute therapeutic visit with a patient then he gets for he or she gets four 15-minute medication encounter and so these perverse incentives out there make us often wind up practicing medicine that's not what we intended to to practice in the first place and if you wanted to add to that I went to take in I agree with but I want to also say that I hope we as a society don't move toward a concert practices is currently in established I hope that that principle becomes part of medicine writ large if that is the kind of medicine that we wish practice this is one of the sad Testaments of our lives it truly the fact that medicine has moved from a perfection of care into a business model and it's not in any ways isn't sustainable business model follow us if you've experienced this yourself you go to see your physician you're lucky if you get 10 or 15 and it's on good day and you know the bonding and the kind of description that you articulated is very hard to establish them because physicians in most practices hold volume is what counts driving the cost is the human connection it saddens me that in midst of all were debating in this country about health care reform but that kind of part communications are happen well the question is about our approach to mental illness and the mental illness that accompanies serious physical illness and I think that is sort of what I was getting at in the sense that almost any illness has this accompaniment of mental anguish and sometimes with trauma especially it's it's huge people can be incapacitated by by a post-traumatic stress disorder so we're all for it the question is how do you pay for it and I think that very often people get acute care very effectively you know we speak of the forty five million uninsured if they had an emergency they are really attended to but what they don't get is the very thing that you're talking about which is preventive care maintenance care you know the sorts of things that I think an advanced society should be able to offer all its citizens so the question is the the coping mechanisms that the physician has when caring for very ill patients and actually fill probably has the world's experience with that dealing with very very sick shouldn't leukemia and I'll ask him to address that but let me just tell you that I I think this is a very important issue our medical students when they come to the wards for the first time the kind of carnage that they see is really not something that they are prepared for and it shocks them and until just a little while ago in the macho culture most Hospital training programs you were not free to say how much it bothered you to see this site in fact the match of culture encouraged you to sort of not focus on the emotional content of what you were seeing and you know that becomes sort of a coping mechanism and I've become very interested in the phenomenon of physician suicide and addiction and in researching that for my second book the tennis partner by the way if you didn't know this the highest suicide rates in the country are amongst doctors lawyers and dentists they're 20 fold higher than any other profession the lawyer part we don't worry about none but but I tell my medical students that every year it takes to complete classes of medical students about twice the people in this auditorium to replace the number of physicians who committed suicide that here and the great majority of those are from interim intemperate use of drugs or overdose and I've wrestled a long and hard with what's the mechanism and I think my thesis is this is completely unsubstantiated is that when students arrive on the wards and see this the things that they do see if we don't have a healthy way for them to talk about it and as I said in the old days when we trained there really wasn't a culture that allowed you to talk freely about this people quickly learn to sort of shut out the emotional content of what they're seeing and frankly if someone's bleeding on the street that's appropriate you should focus on airway breathing circulation and not be worrying about you know the family and the social situation but the thing that doctors do I think eventually is as they learn to shut out the emotional content they do to themselves and pay and physicians are notorious for denying their own patient hood and when they get ill themselves they present with a symptom a symptom that with any other physician any other patient you might say well you know before we get to the symptom – tell me about your marriage and how much alcohol are you drinking and how much weed are you smoking and you know what else is going on in sleeping well with a fellow physician we don't address that and when I went to this one center called the Talbot center which at any one time has 80 physicians inpatient treatment for addiction I remember a very distinguished orthopedic surgeon telling me that he went to a colleague for a trivial somatic symptom which was in retrospect an expression of his angst and he was prescribed tylenol with codeine not prescribed given from the sample cupboard and he said when I took that first tablet I felt this weight that had been on my chest for 23 years slide away and it was a very important revelation to me that that day that physicians don't take drugs to produce euphoria they take drugs to relieve the dysphoria of their existence and my mission is the teachers to make sure that on my watch if possible that we don't have students become so disconnected from their emotional state that they hurt themselves it's a difficult thing to do because the culture doesn't always encourage them to speak freely but your question about very six children I could not take care of very sick kids with HIV thankfully I had a pediatric colleague and I always wondered how they did that it was hard we just a couple of very good cons first I think that to the points that you were making on I felt very fortunate when I was in ministry this speaks to the process of education you can learn and be taught sensitivity as part of it so I was in medical school where there was a lot of interaction between Factory and intro medicine this was at the University of Rochester New York and the person who is the legal it was a billionaire remember I made with George Engle who they founded the field of called psychosocial on the biological parts of Medicine and we were taught literally as tipping students to learn how to this faculty the the important point was that when you're beginning your introduction nation it's imperative that you don't ask a lot of questions that you ask just one what brings you here today or how are you and then you can pause and allow the patient is your ticket your neighbor to tell their story because you have at only one time to do that after you've gotten quiz you've contaminated the relationship to maybe suppress on the information so that message is held me very well I think over the years is actually not only useful in the practice of medicine but it's pretty useful and I would further say that to your comment about and Ryan's question about the healing of sick children or sick about spacing illness first of all I think I would add that with Syria so that no one is left untouched you know many patients in my experience get stronger as a consequence but some break down but no one is left untouched as constants and physicians are left untouched in fact what we did in our problem when I was in Thursday he said he worked with psychiatrist who met with our trainees every week and they would I would when I was adream and subsequently our trainees would in a group session share their experiences in you know an experienced actress to help us put them in context and that was very powerful because it gives permission to say how hard it was tough difficult it's how you slam the door because this was such a huge in but I think it creates any chose a very different way of approaching practice of medicine in my own case so I feel that it's very important to share the pain and the discomfort I try very hard when I'm in the room with someone who's suffering to feel that it suffering not to sort of block it out and it does take a toll on you I agree but I think if you don't allow that to happen you can't Forge that important connection then you need to think about it circle ways of being able to process that when you're outside of that connection and that takes Foles on all of us so just if you were to ourselves as individuals honor families in terms of how we communicate because seeds that will need a public interaction at private sure appreciate that comment very thoughtful so the question is does that picture truly represent what we're dealing with now and is that desert really is that really germane to the practice I would argue yes I would say that the population of this country is aging rapidly the great burden that we're dealing with day in and day out is chronic disease and I find that the thing that young doctors are most uncomfortable with our diseases that have no epiphany no dramatic resolution with the administration of antibiotics and so on and what the patient needs I think when they come in day in and day out or weekend we got with the same set of chronic conditions they need that affirmation that you are that they are still worthy of that kind of attentiveness and they need the the sense that you will be that constant and your your your attention will not vary because they've become less and interesting at this point so I find on the hospital wards this is not a critique of the House staff this is universal that our House staff are very ready to label people with acronyms such as when you come in with chest pain you become a Romi which is a rule-out myocardial infraction and a couple of days later you become a mirror which is myocardial infraction ruled out and you know and and we are very adept at labels and acute care all the things that they could not do in that era but I'm always interested when there's I sense a resistance to go into a room because quotes there's nothing we're going to do now and I always think well that is the beginning of the very thing that we're going to do and I actually see that picture to me as emblematic of that thing which is to go in there and give them your undivided attention just because you can't cure it does not begin to mean that you have no no role in there in fact I would argue that is when your role is most maximal and I have one patient who comes to mind who I follow for a number of years and from Texas she still comes to see me has come at least once now and I've often wondered what is it that I offer her since nothing about her illness is getting better everything is progressing but what I give her is my full attention my validation that her illnesses is important just because it doesn't have a magic fix it is two very important and I've come to think of myself as almost a coach encouraging her to hang in there just as we all hang in there and I think that's what that picture is about is a dawn breaking hope coming William Osler said it is not for us to take hope away from the patient hope that comes to us all and I think that's true even when you have a chronic condition that cannot be cured I hope that addresses your question but your points well-taken thank you so the questions if I can summarize it is about primary care and the crisis of not having enough physicians to do the kind of thing that I'm describing I think that's a very real concern and I think it's one of the reasons that Phil wrote a very lovely editorial some weeks back in the LA Times and I hope it becomes part of your package because you know those of us who are in health care feel very strongly that reimbursement provides perverse incentives that take our students in different directions our students sometimes speak tongue-in-cheek but not entirely about the road to happiness and the road is radiology orthopedics anesthesia and dermatology and it used to be that when Phil and I trained the best and the brightest would often go into internal medicine and primary care and Pediatrics the very things that you know are not rewarding and I don't blame them they come out with so much debt that you know it's not illogical for them to think of how to pay that so I think a crisis in health care quite apart from the uninsured and so on is how do we train more primary care physicians and that alone I think should be a great incentive for restructuring a restructuring payment right now in America I think we paved people to do things to patients as opposed to do things for patients procedures make money and so we have a profusion of procedure related you know places and things you know short-stay certain centers and the center in that Center how many of you ever seen a free-standing jury at rec center we've all seen short-stay surgery you know there's a reason for that there's no money and then I think that reimbursement has to change in order to change these strange incentives that make it hard to generate primary care physicians yeah I just would add one other comment to that I think that part of it is is just as you've heard that we're also dealing with a different generation who has a different set of values I mean we grew up at a time with you know a dedication to work we recognize that we're dealing with different kinds of values and individuals but I think you may not know this an average medical student graduating today has an indebtedness of a hundred and seventy five thousand dollars right so that's how they start their life and that's a pretty big pill to swallow and it does influence what people decide to do and then it's made worse by the subtle messages that are given you know you talked about the language that we inadvertently used sometimes to describe patients in a dehumanizing way well in our medical care system primary care is often looked at as the quote lost leader lost leader I mean that's the message that gets conveyed what what does that mean it means that the primary care physician doesn't make herself or himself enough to really compensate themselves someone else to do that the procedure based individuals so if you're a student and you begin to hear that it doesn't really inspire you to think that this is a pathway that makes a lot of sense the other thing that I would say to your your comment is I think we need as a nation to look more broadly at the healthcare providers it's not just about doctors providing health care there are wonderful nurse practitioners and nurse clinicians who can complement this work enormous Lee and spread it into more directions there's been a move over the last couple of years sponsored by the Society that deals with medical schools and education actually increased by 30 percent the number of physicians I'm not sure that that's the right thing to do and the reason is unless we can guide where they go they're going to continue to make exactly the same choices that they have up until now which moves into areas where we already have a surplus so we need to think more constructively about how to both train educate and distribute physicians and other providers in a more rational way and that isn't easy to happen without a rational healthcare system I think one of the most wonderful movement so that that has happened in the last decade or so is the emergence of the hospice movement and palliative caring and the emergence of palliative care is a specialty our best and brightest are often heading in that direction and so I'm very encouraged I think that our students like never before get wonderful lessons on how to break bad news how do how to deal with situations like that they have both classes and hands-on sort of training so I think we're doing a much better job then and you know in my arrow training I think most of us learned on the job which in retrospect is a terrible way to have to learn it so at least on this campus but I think also uniformly in America medical students are getting that kind of training in a way that they never got before I think that the question is about the last six months of life and how oftentimes a person will spend all their savings in that last six weeks sometimes of life and you know I think you're very you're very correct and the way you phrase that Allen Garber one of our professors here at the Medical School I think you're hearing from him this quarter Allen Garber has a wonderful article a couple of months ago in the annals of Medicine where he described our healthcare system as a menu without prices you know it's like you're going to restaurant and you order filet mignon every time because you you're not conscious of how much anything costs I think that's true both on the doctors end and on the patients and to some degree so other issue how much is this going to cost if we prolong this ICU care doesn't really enter into the discussion very much it's much more of a question of how we ready to give up or not and I think that you know as a society we expect I think we have every right to do that we're very uncomfortable with any notion of ceasing care I was at a meeting earlier today where someone mentioned that the American public has never met a test that they did not like or a procedure they did not like and so you know I think there's a great sense that well I don't want to miss something that might be helpful as a result I can tell you our young trainees are our residents and interns when you ask them what is the single most important thing that frustrates you about your training they will often say it's all the activity that we have to do around care that's clearly futile but we haven't gotten everyone to come around to that and in the days that it takes to get everyone to come around to that thousands and thousands of dollars are being spent at that moment please so I want to just also offer comment on this because I think it really is a critical issue and it's part of our culture as we think about healthcare reform one topic that's not made it to the agenda is our expectations in this country as individuals and this is really really a big part of it unfortunately it's gotten reframed in a different way with you know the concept of death panels and the like which is a very unfortunate way of addressing a critically important issue which is what are the appropriate limits of care and it's it's interesting to me as someone who's as Abraham has said you know cared for children with chronic diseases over the years to think about that is different from as it applies to adults facing the the terminal aspects of life because in Pediatrics I've watched children suffer enormous Lee and watch their parents try and grapple and understand what the boundaries might be and I fear that we have so conditioned ourselves to quote expect that we will do everything that we've lost the sense of reality my approach to medicine has always been to be as aggressive as one can be there is an opportunity for survival in life and to be equally aggressive if you will when there is none because I think that's a way of addressing an issue that unfortunately we have not as a nation been willing to to accept or even think about you know I will say it here because it may engender some discussion which is appropriate on this topic that other nations have dealt with this perhaps the most poignantly is the Netherlands where there has been a whole policy of quote euthanasia and you know that engenders a lot of fear doesn't it when you hear the words and yet because of the policies and the approaches and the sensitivity and compassion that's been exercised at least in that nation where the discourse has happened it's not adversely impacted on the perception or the culture of individuals about the endpoints of life here it evokes fear it evokes anxiety and it lends itself to hyperbole in ways that don't allow us as a nation to really think seriously about a very important topic the question is about alternative forms of medicine if I can summarize that you know I think that it's very telling that patients are going in droves I think to acupuncturist massage therapist is on and the one thing that all these individuals have in common is for the most part they listen and they touch and I suspect that if we in medical in medicine were attentive and have the time to be attentive and you know believed in the ritual of examining them well some of these things would be would be addressed I am a person of science and so it's it's difficult for me to you know not ask for the scientific method when trying to evaluate different therapies and an alternative medicine is something that I've really wrestled with I I never try and dissuade someone from taking something if they truly believe but I always worry about harm you know and that the huge lobby sort of took all those drugs out from the purview of the FDA and so as long as you have a drug that doesn't make any claim to cure only to improve your prostate health and enhance your male vigor and promote the growth of your hair and you know etc you can put anything in a pill and give it to the American public and the huge Lobby out there which is making a lot of money on this you know fights any attempt to regulate that so I'm completely for all forms of therapy that are holistic and helpful I think couched in they're hidden in there is a huge drug lobby that lobbies for drugs that are you know at best not very effective because if they were as we study them you know we find very few that are really holding up but at worst as has been shown recently some of them are actually contaminated with things that you would not know about because there's no regulation so this is not to disagree with you on anything that you said I'm all for alternative forms of therapy and especially with chronic illness I think that we in Western medicine don't do a good job of making the patient feel better and move ahead and all those modalities I think do a much better job of that well you know osteopath train with us they're very much part of the Western medical establishment even though they have this grounding in a different science actually many of them that I know don't really do that much of that anymore they're much more very difficult to differentiate from us in what they what they do but they do have a grounding that I you know admire and wish I knew more about but I'm really not qualified to speak of it as long as they you know my biggest fear as a physician my nightmare which I'll share with you is that you come to see me with something that is diagnosable and treatable and slips through my grasp because I wasn't thinking of the of the diagnostic imperative and I missed it so I'm all for you know all the other modalities that make you feel better I would want to be sure that we don't miss something that could affect you and so I think a lot of medicine is practiced that way with a view to let's make sure you don't have this you don't have that you don't have this which is you know in a sense it's appropriate but what happens as a result is you often feel that you were marched through all these hoops at the end of which I mean there was a the New York Times there was a story of this guy who had a headache went to see someone they thought they Scottie did something that's carotid so he got an angiogram and he finally came out of it with a bill of about a hundred and twenty thousand dollars and it turned out that nothing was wrong and that that might be an instance where a careful history and you know 40 minutes of spending time might have saved a whole lot of money I don't think that answers your question but I you know I respect that there are many ways of doing this so the comment is about the novel the house of God how many of you know know the double house of God I mean it's an interesting knowledge really as a it's written by a friend of mine Samuel Shem and what I find very interesting is that if you go on Amazon for example and look at the comments about the novel you'll find medical students who've stumbled onto it and see it as an instruction manual you know it was clearly meant to be you know an allegory it was meant to be you know ironic but I think it's it's important to point out that yes many of the things that happen during training still can't happen in some ways things are much better we are now working with an ADR work rule limits so we cannot have people work the kind of hours that you saw in the house of God our residents have to be sent out at a certain hour now the clock is always ticking I think it's made them healthier and more wholesome it's raised a new problem which is handoffs so we have so many people coming and going that I have great fears about you know people being patients being handed off and I sometimes worry that they don't get to see the whole course of the illness there used to be a joke when I was in training which i think is reflective of the machismo of that era and the joke was what is the disadvantage of every other night call which is what what we did is every other night call can you imagine that my residents can't when I say that by the way and the question was what's the disadvantage of every other night call and the answer was you miss half the interesting patients and we are very far away from that so I think we're a much more humane training program we have lost something we have new problems that have crept in because of that but but I don't think that the dehumanization that once saw in that book again largely amplified and you know ironically delivered I don't think we see those extremes now we're much more conscious about that yes so the question is the impetus for writing the books that I've written on a novel I've written the first book came out of the great desire to to capture the story of what happened in that small town I mentioned that you know there were a hundred fold more people with HIV in that small population than anyone would have expected and I actually wrote a scientific paper one day that explained that and I one day I actually understood the paradigm of why I had so many patients with HIV they turned out that this was a phenomenon of migration young man grows up in a small town leaves for all the reasons that you and I leave small towns are jobs education but in their case they were leaving because they were gay and they left as part of the general Exodus and went to the big cities and you know lived there for many years and at some point they were infected with HIV and then they started coming back to their rural homes either because they were sick or because they were well but hoped to escape this plague that had killed everybody else in their in their neighborhood and there I was at the tail end of that migration and I wrote a scientific paper much cited describing this because I thought it was important to point out this is going to happen was happening in all rural communities but even as I wrote the paper I had the strong sense that the precise language of science didn't begin to capture the grief of these families didn't begin to capture the tragic nature of the voyage didn't begin to capture my own heartache at seeing this happen again again and that was the moment that my great desire to write came about and I thought I would tell the story in fiction I'd always thought that this would be fiction would be the way I did it and I actually had a short story in The New Yorker a very dark AIDS story fictional story and that when the editors found out about my background they invited me to write a long non-fiction piece which wound up being my first book about it but I've always had a good conviction that fiction is terribly important Dorothy Allison D the novelist says that fiction is the great lie that tells the truth how the world lives and we use fiction with our medical students if I want to have my medical student truly understand what it's like to be at the end of life dying I can point them to a hospice textbook or we can read together the death of the vanillish by Tolstoy wonderful story a brilliant story or if they want to understand child abuse really understand it I point them to bastard out of Carolina by Dorothy Allison so I think literature is a wonderful complementary way to illustrate the great truths in our lives and that was Ray my my impetus to write fiction was to it was to tell a kind of truth if you will I think it's you know as you the question is about the Internet patient as you as you as you put it the Internet has given access to all kinds of medical information and actually for the most part I think it's been good I think people are informed about their diseases and about their medications it depends on certain patients they can actually some patients I think are not served well by reading all the side effects of the drugs you prescribe you know and I have some stoic patients who don't want to know and I think that's that's healthy in its own way so you know you can't you can't fight it there it is and but there's a lot of misinformation out there unfortunately there's a lot of sites that my own father I'm always engaging in these debates with him and he's gotten his information from the internet and quotes it to me and I try to tell him what it's not a peer-reviewed control study and you know you know it just doesn't work I think Phil could speak to the the talking to each other part I do think that the crisis in nursing is something that we are witnessing too there's a lot of people on the words who look like nurses they dress like nurses but the actual RN who's in charge is you know stretched very very thin we're using a lot more nursing assistants and you know people often will say at least in Texas this was a truism that the best nursing care was in the ICU because you had really skilled nurses there who were very attuned to critical disease but on the floors because of Nursing shortages I think nurses are spread very very thin I think that the nurses and physicians can do a lot more together given that we train in the same environment and I've always been one the fact that we don't do as many things together as we should I don't know feel it coming on I think it's a very very important question and I think nurses also in many ways suffer from the same problems the amount of paperwork the amount of computer time if you ask many of them that separates them from the very thing that they care deeply about there are different choices that we make them in terms of going into nursing or into becoming a physician and I think one of the great values is that patient contact and in most of our institutions that is altered I would say that the team-based concept which is what you're alluding to I think is very much part of our future solution that is the only way we're going to really be able to have a broad enough sophisticated enough workforce to really address on these issues and that does mean getting out of our silos you know the physicians try to control their space the nurses are trying to control there's there's a lot of don't cross this line even in among physicians there's constant tension about who controls a technology or a technique you know things at once belong to the surgeon now belong to the radiologist and a lot of this unfortunately speaking bluntly but honestly is driven by financial motivations to some subtle undercurrent degree and I think until we can reconcile that we'll lose really the focus on what's really important how do we provide the best acute and then chronic care to individuals and that will be by a team-based process I think that's a fair statement the question is 90% of illness is caused by stress that might be a little more than I would be willing to accept 90% but I do think that stress certainly complicates illness it certainly brings on illness and we don't do a very good job of addressing that primarily because we don't really have good continuing relationships with a huge segment of our population forty-five million Americans get their care only in emergency situations and so I could not fault you for saying that we don't address stress well I think that's true as a population we don't do that very well now the questions about medical ethics and what role they play actually at Stanford we have a very vibrant ethics program and they're very involved in the ICU they round once a week there and they do get involved in just those situations where the wife says the husband didn't want anything more done the daughter says no he wants everything done and you know there's a lot of conflict and that they get an ethics consult and their decision is binding and so we are using them all the time the ethics of the health care debate is you know is actually a very interesting question because the ethics of distribution of resources the ethics of you know of containing your expenditures that you can benefit the the greater good if you will I think that that's very much at the heart of this debate and the whole notion of greater good versus the best treatment for the individual is really what we're talking about so ethics is really front and center I think it's just couched in terms like death squads and so on but it really is an ethical discussion that we're talking about the although it is a movie of a lot of anecdotes Michael Moore's movie if you saw it called sicko ended with a phrase to me that resonates very closely with what Abraham spoke and he said one of the things we need to reconcile is whether we're a nation of wheeze or mieze and I think that cuts right to the heart of that so the question is uh how do the medical students respond to the AI patient and the computerized medical record I can tell you that when I take them on bedside rounds and and we go around and examine patients and I'm able to show them fairly simple straightforward things that the body is willing to reveal to us should we be looking are they absolutely love it and I'll often hear them say this is why I came to medical school and I imagined that it would always be like this and they are disappointed to find that so much of the activity takes place around the computer so I think they are my strongest allies in in getting them out of the bunker if you will and getting them out to the wards they truly enjoy that and they just needed some faith to see that it can work and that it you know is rewarding it's a you know places it's very accurate some places some diseases are diagnosed entirely by the physical exam you know Parkinson's disease Bell's palsy there are no tests for this you have to examine the patient come up with these kinds of conclusions so the question is about medical errors and duty are so you know medical errors are something that I think we become very conscious of and the electronic medical record with all its disadvantages has huge advantages in terms of preventing certain kinds of errors and that's been a great boon I don't think anybody works you know 40 hours continuously anymore at all so you know after the Libby's on case in New York has been a huge you know change in the way we train residents and some talk recently of shortening the hours even more and I actually think that the du/dr problem is something that was just in hosed on us that has never been you know examined systemically to see if it really translated into more patient safety my own bias is that all these handoffs are potentially more dangerous and we just simply have not studied them adequately so it's a double-edged sword you cut down duty are as you increase handoffs but you do have a more fresh and sane resident there's a 60-hour work rule I believe it's not ADR right now it's an ADR work rule there's a limit on the amount of time of life I think you're asking about just to be clear you're asking about whether or not we help patients to be compliant with the therapies that are being administered is that what you're asking yeah yeah it's a tremendous this is also a big historical issue there's been problems with compliance for the generations if you will I mean the classic studies that go back to strep throat and penicillin shows that you know if you prescribe 10 days most patients take three or four and they're feeling better and they stop and I do think it's a matter of both education discussion follow-up and compliance believe it or not has effects in and of itself because it carries with it a placebo effect that has an impact as well so it's an interesting interesting concept well let me let me thank again dr. Vargas for wonderful I hope from your applause that you did enjoy this session tonight next week as promised we're going to move from these important social and ethereal values right down to the molecule we have only we have one book if you haven't gotten it already you may want to look it's actually pretty good it's called the body and how it grows how it works and how it keeps healthy on the website or the advanced readings for the next lecture I will provide additional readings and for you as well as we go along but hopefully you'll find the presentations to be quite compelling in their own right so thanks for being here tonight look forward to seeing you next week for more please visit us at stanford.edu

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17 thoughts on “The Physician in Modern Society

  1. I trained at Boston City Hospital from 1958 thru 1961. Abraham must have trained after, since he talks about HIV patients. Beauty and for that matter painting is in the eye of the beholder. To talk for 16-17 minutes about a painting and his perception of the painting is a waste of time. Didn't impress me!. Even in being a specialty, I did house calls for $5.00 in Maine!

  2. check out a short witty video defining personalized medicine made by PhD students called "The greatest drug in the world " on the genomics education youtube channel

  3. I have a question regarding emergency medicine as an undergraduate desiring to go into emergency pediatrics: How can an emergency physician care for many patients quickly in an emergency setting and still provide each patient with personal care as opposed to ritualistic and detached care?

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