Here’s an article I wrote on a reproductive method that uses DNA from three different people to prevent mitochondrial diseases. The technique raises challenging ethical questions.
While I feel privileged to practice medicine, from time to time I find myself becoming burned out and discouraged. Spending the time needed to care for a person at their clinic appointment without falling behind in the day’s schedule, angry calls from patients about their insurance no longer covering the medications they’ve been on for years, the sheer volume of labs to respond to and paperwork to review–all of this can leave a physician feeling like Sisyphus pushing the boulder up the endless mountain. When I feel this way, the writing of Daniel Sulmasy helps me to regain perspective. Sulmasy is an internist, palliative care physician, bioethicist, philosopher, and former Franciscan friar who serves on the Presidential Commission for the Study of Bioethical Issues. I had the chance to meet and talk with Sulmasy for a while at a conference a few years ago and found him to be kind, gracious, and humble.
Here are a couple of passages from his book The Healer’s Calling. It should be noted that Sulmasy is a Christian and these passages reflect his spiritual tradition:
“For the health care professional, love for one’s patients alone will not ultimately satisfy. Patients can be very fickle. They can bring frivolous lawsuits against those who did their best in love to help them, and this can be deeply hurtful. Patients can be demanding at times. The relationship to the patient will not be a full healing relationship if one cannot see it in the context of one’s relationship with God–one’s spirituality. If a health care professional is not careful to cultivate a spiritual life, he or she will quickly end up becoming cynical about patients. No physician or nurse will last very long in health care looking to patients themselves for personal satisfaction. Patients can only be the point of departure. They are not the source of satisfaction, but signposts that point the way to satisfaction. Physicians and nurses are really doing their jobs when they see each patient as a precious being swept up into the mystery of God’s love. . . No matter how sophisticated the technology of healing gets, true healing will involve three very simple human elements: compassion, touch, and conversation.”
Sulmasy’s words are lofty and well beyond what I achieve except in my very best moments. Nonetheless, he offers a noble vision of medicine that calls health professionals to strive toward something higher amid the daily stress and frustrations of clinical practice.
Tonight I spoke with UT’s Plan II Pre-Medical Society, answering their questions about what it’s like to become and be a doctor. Here’s some of the advice this old man shared with the youngsters.
Embrace Your Gifts and Passions
Early in his career, the late physician and author Oliver Sacks badly wanted to be a neuroscientist. The only trouble was he just wasn’t very good at it. After a number of mishaps in his attempts to do research, his supervisors firmly told him his future was not in the lab. Instead, he was sent to work with patients with severe degenerative neurological diseases living in a long-term care facility. While his contemporaries saw this kind of work as a dead-end, Sacks found it very much to his liking. At the nursing home, he was able to spend long hours with patients learning their stories. Out of this experience, he discovered his gift for writing about what it’s like to live with a serious neurological condition. Sacks’ books and articles have evoked empathy and interest in people who would otherwise be overlooked. He has drawn medicine’s attention to the patient’s experience of illness, rather than simply studying and addressing disease. As Nobel Prize-winning scientist Eric Kandel wrote, Sacks “transformed the view of the mind for millions of people in a way that is both insightful and entertaining.” Imagine how much the world would have missed if Oliver Sacks had insisted on being a neuroscientist instead of embracing his gift for hearing and writing patients’ stories.
I recently saw a patient with symptoms I simply could not make sense of. As I asked her questions about what she was feeling, more and more interesting details about her life came forth. I followed my curiosity and soon we were discussing changes in her most important relationships and transitions that were taking place. And then the cause of her symptoms became clear. Just by following my curiosity, rather than directly trying to figure out what was wrong.
It is also important to be curious about systems, customs, and institutions. Medical students should embrace the naivete they bring to their work. Medicine’s pedagogical method of apprenticeship leads it to honor tradition and hierarchy. It is slow to embrace change and question itself. While students are learning the culture and methods of medicine, I encourage them to also respectfully question why things are the way they are. This is how breakthroughs and innovation happen. The disciplines of hospice and palliative care emerged when people looked at how patients were spending the end of their lives and asked if there could be a better way. Was it really necessary to die in an intensive care unit connected to tubes and wires, surrounded by strangers and beeping machines? Or might it be much better to die at home in your own bed with family at our your side?
There is more to life than medicine Keep up your relationships with your friends and family. Exercise. Take time to do what recharges your battery–music, books, writing, sports, travel, being outdoors. What good is it if you become a doctor, but in the process are transformed into a miserable, boring person?
Anyway. I hope the students gained something out of our time together. I enjoyed being with them and sharing what I’ve learned.
In a wonderful essay, physician and educator Faith Fitzgerald writes about the importance of curiosity in health care. As dean of students at UC, Davis’ School of Medicine she sometimes heard complaints from politicians about medical students being “insensitive, mechanistic, technocratic, inhumane brutes.” After a good deal of research, she asked herself, “What is kindness as perceived by patients?” Her answer was
“Perhaps it is curiosity: ‘How are you? Who are you? How can I help you? Tell me more. Isn’t that interesting?’ And patients say, ‘He asked me a lot of questions’; ‘She really seemed to care about what was going on with me.’ Is curiosity the same, in some cases, as caring?”
Fitzgerald writes that
An endowed lectureship at my medical school allows us to invite Nobel Prize-winning scientists to visit and lecture for several days. What impressed me most about my conversations with these luminaries was their extraordinary broad range of interests, their enthusiasm, and their thought patterns. One thinks science has a sequential and controlled pattern of logical ideas, firmly grounded in antecedent principles and constantly cleansed of intellectual debris by the abrasion of skepticism. Listening to Nobel laureates in medicine was revelatory. . . The scientists seemed oblivious to intellectual constraints and unconcerned about seeming naive or unknowledgeable. . .”
She then asks
What does curiosity have to do with the humanistic practice of medicine? Couldn’t it just convert patients into objects of analysis? I believe it is curiosity that converts strangers (the objects of analysis) into people we can empathize with. To participate in the feelings and ideas of one’s patients–to empathize–one must be curious enough to know the patients: their characters, cultures, spiritual and physical responses, hopes, past and social surrounds. Truly curious people go beyond science into art, history, literature, and language as part of the practice of medicine. Both the science and art of medicine are advanced by curiosity.”
Fitzgerald writes that efficiency and time often undermine curiosity. For instance,
One senior resident once presented a patient in morning report and, as part of the physical examination, mentioned a scar in the patient’s groin. When I asked how the scar had been acquired, she said, ‘He told me he was bitten by a snake there.’ ‘How did that happen?’ I asked. ‘I don’t know,’ she said.
How could that be? How could one not ask? The imagination runs riot with the possibilities of how this man got bitten by a snake in the groin. But the resident was too busy (or not curious enough) to ask!”
“What is the reward of curiosity? To the patient, it is the interest and physical propinquity of the physicians, which is therapeutic in and of itslef. To the physician, curiosity leads not only to diagnoses, but to great stories and memories, those irreplaceable ‘moments of medicine’ that we all live for.”
You can read the entire essay through the link below, and I recommend you do–especially because the story she ends it with is very good.
As I’ve written elsewhere “physician-assisted suicide (PAS) laws in Oregon, Washington, and Vermont permit doctors to prescribe a life-ending medication to adults who are found to have decision-making capacity and a terminal illness that will lead to death within six months. But now groups such as the Society for Old Age Rational Suicide (SOARS) are advocating that people without terminal conditions also be granted means for committing suicide.” A recent New Yorker article describes how this is already happening in Belgium. With the Britney Maynard case sparking a movement to give people more autonomy end to their lives, it’s worth examining how this is playing out in the European countries that are doing so. Here’s the link to the New Yorker article. http://www.newyorker.com/magazine/2015/06/22/the-death-treatment
I’m resolving to keep this blog alive with at least 1 post a week. An easy way to do this is a brief comment on a medical study that’s been in the news that week.
Today, I read about a study about a class of medications called proton-pump inhibitors (PPIs). Millions of people take a PPI such as Prilosec, Prevacid, or Nexium to treat heartburn and other complications of gastroesophogeal reflux disease (GERD). Now a group of researchers from Stanford are raising the possibility that PPIs might increase people’s risk of having a heart attack. The investigators reviewed more than 16 million clinical documents on 2.9 million individuals and found that people with GERD who took PPIs had a 16% higher risk of having a heart attack.
Although researchers acknowledge that PPI usage may be serving as a marker for a sicker population, they believe this is unlikely since people taking antacids such as Pepcid and Zantac didn’t have a higher heart disease risk. The studies authors theorize that PPIs might increase the risk of heart disease by inhibiting an enzyme called DDAH that is necessary for cardiovascular health.
Dr. Nicholas Leeper, lead author of the study states that “we’re not recommending that people stop the drug (PPIs) at this point.” But he did suggest that patients reconsider their need for the specific class of medications as well as their individual risk.
To clarify if PPIs truly increase the risk of heart disease, we will need a prospective, randomized study. In the meantime, I will reassess if people with GERD truly need to PPIs or if they could get sufficient symptom relief through lifestyle measures or another class of antacids such as Zantac or Pepcid. I will be especially careful about recommending PPIs to people with vascular disease or at a high risk of developing it.
Here’s a link to an article I wrote on the microbiome, the one hundred trillion bacteria that live on or in the human body. I focus on possible links between the microbiome and obesity, immune disorders, and mental illness.