Physician Suicides

~ iduncun ~ Leave a comment

Last week I read about a medical student and a resident at my former medical school killing themselves within a week of each other. It brought back memories of how depressed I’d gotten in medical school and ways I’d coped. I cut off all my hair. I stopped going to classes. I didn’t show up to nonessential rotations; instead I spent my time wondering around the Lower East Side pretending to study in coffee shops. Medical school was grueling. The first two years I shoved enormous amounts of information into my brain, with no time to process or understand it, in order to regurgitate it during endless multiple choice exams. And then, even worse, in the second two years of clinical rotations I was constantly overwhelmed and frightened by the responsibility of taking care of patients in a teaching culture where students were belittled and pit against each other for approval. My most successful defense mechanism was to stop caring what those evaluating my performance thought. I almost worked at under-performing. The only things that stopped me from failing outright was an unshakable sense of self-pride and a true concern for my patient’s welfare. And, luckily, having an inspiring third year resident who taught by nurturing, not destroying.

I tried to follow in his footsteps in my residency but I’m pretty sure I fell short. The work was more emotionally and physically taxing than I could have anticipated. The people I trained under in my residency were even more abusive than in medical school. The one thing I can look back on with some pride is I always tried to protect the students and residents who trained under me. In fact, I probably took it too far. My main focus became getting my team’s work done and getting them out of the hospital as soon as possible.

Instead of learning to connect with patients and practicing empathy I spent my training developing skills to emotionally survive. And that meant limiting my time with patients as much as possible. Patients who spoke more than a few sentences at a time to their doctors were labelled talkers, as in watch out for that patient, he’s a talker. Schemes were hatched to ensure no one got stuck, as we called it, in a talker’s room. For instance, I’d tell my medical student to page me if I wasn’t out of a talker’s room in 10 minutes in order to create an emergent excuse to leave, no matter what the patient might be saying.

Another emotional survival technique was the ubiquitous gallows humor. Doctors are not the only profession to use this as a coping technique but its dehumanizing qualities certainly do not enrich the doctor-patient relationship. But in the face of repeated futile interventions and the frustrated impotence doctors can experience daily with the chronically ill it’s a relief to see someone as a GOMER (Get Out Of My Emergency Room) instead of a valued human being. Saying a patient needs a dirt nap or a pine box to bedside is so much easier than dealing with the devastating realities of patients’ illnesses and mortality.

These defense mechanisms rolled over into my practice once training was over. It took a long time and a significant change in my work load to transform from a wisecracking, cynical, burned-out physician to one who had the space in her heart to sit down and listen to a patient, no matter how long it took. And the brutal truth is when I start to feel overwhelmed with my work that patience and kindness is the first thing to go. And I don’t think that’s unusual. I think unless you are an automaton the only natural response to constant frustration and stress is to become angry, depressed, and isolated. Exactly the worst kind of person for a frightened, ill patient to be depending on to feel better. No wonder one of patients’ biggest complaints is their doctors don’t spend enough time really listening to them.

So what’s the answer to this problem? Since I haven’t figured out how to make illness, misery, pain, and death any less terrifying or caring for people any less frustrating, I think the answer lies in how we as physicians cope with these situations. Bullying trainees or nursing staff, avoidance, and gallows humor are not the best copying mechanisms; they are detrimental to patients and ultimately ourselves. Anger, helplessness, and isolation lead to depression which can lead to suicide. And physicians have the highest suicide rate of any profession and at least twice the rate of the general population. For our patient’s lives and for ours we need to find better ways to cope.

Like any good lifestyle change model the first thing the medical community needs to do is admit we have a serious problem. As in many other professions that deal with daily traumatic events there is a macho culture of applauding emotional reticence and denigrating emotional expression as weakness-what I like to call a suck it up culture. This needs to change. Doctors shouldn’t have to feel they need to hide in a bathroom to cry when they’ve lost a patient or feel they cannot admit they are overwhelmed by the demands the work puts on them. There should be available regular counseling sessions, incorporating individual and group therapy, starting as early as medical school, so people have a structured outlet for their negative emotional stress. That way we could build healthy coping mechanisms together. Admitting we need this help is the first step. Demanding it be part of our training and our professional lives is the next.

There are logistic challenges in deciding who would provide and pay for these counseling services. Being part of medical school and residency curriculum would be fairly simple to set up but it becomes much more difficult to organize services for all the private physicians out there. However, I think there is a precedent for this. Currently individual states are able to require certain criteria for state licensure, such as CME’s, then perhaps a required amount of individual and group counseling sessions could be instituted as well. It would behoove State Medical Boards to provide these free of charge given the immense benefits to doctors and patients in their state. States already do this with educational material they have prioritized as essential for all license holding doctors to know. For instance, when I worked in Delaware the state required specific training in recognizing and reporting child abuse, educational materials they provided free of charge, before licenses could be granted or renewed. State Medical Boards would just have to recognize physician suicide as the public health crisis it is and prioritize the well being of physicians just like they would prioritize any other health crisis in their state.

But I think one of the larger obstacles to making counseling mandatory for training and practicing physicians is the association counseling has with mental illness and the stigma that carries. In fact, models where counseling is regularly used on non-mentally ill people on a large scale are rarely seen. The only time I’ve observed counseling being regularly set up for a general population is after a specific traumatic event like a school or workplace shooting. And then it’s usually only available to the victims of these events for a short while. It’s a shame we are not providing regular counseling for people encountering emotionally traumatic situations on a routine basis such as physicians, soldiers, EMTs, police, firefighters and any other profession that handles high stress, life and death situations. I think the rates of burnt out, depression, substance abuse, and suicide in all these professions would dramatically drop. And for physicians it might allow them to develop more emotional space to be able to spend time and listen to their patients.

I don’t know the circumstances of the two suicides at my former Medical School but I can speak from my own experience and the behaviors I’ve witnessed from my colleagues. The benefit of having an excellent emotional support system for doctors that includes regular individual and group counseling without any associated stigma would far outweigh it’s cost. And there is a precedent to be able to provide this as a requirement through individual state Medical Boards.  But first the culture of medicine needs to stop asking physicians to suck up their emotional trauma and start accepting the demands of the job require a healthy outlet to ensure physicians and patients can continue to thrive.

Miss Doctor

~ iduncun ~ Leave a comment

I’ve been a Hospitalist for the last 14 years and still encounter sexism regularly at my job. It’s not the big stuff like pay differentials or career advancement. I work with groups that are at least half female and usually led by women so my colleagues or superiors aren’t the problem. The sexism I face is subtle, almost mundane, and it comes from the people I’m pledged to serve. My patients.

Every female physician I’ve ever met can relate to stories of patients mistaking them for nurses or other members of the healthcare staff. In fact, I believe all female physicians are regularly subjected to the casual sexism of mistaken identity. In my experience women of color have the hardest time getting patients to accept their status as Doctor. Younger and smaller women also seem to really struggle. But this phenomenon is not limited to skin color, age, or physical stature. Recently an older, tall, white female co-worker told me how patients at our hospital often complain to nursing staff that they haven’t seen a doctor in days when she’d seen them every morning. This woman has been in practice for decades, wears a white coat with her title and name embroidered on the front, and wears a visible ID badge.

Stories like these range from the offhandedly insulting to the ridiculously comical. I often have the experience of entering a patient’s room and hearing them tell someone on the phone they have to go since a nurse just walked in, even after I’ve been their primary doctor for days. After recently complimenting another hospitalist on her shoes she confided to me she always wears high heels so she’s not mistaken for a student, something she feels happens to her often since she is an Asian woman. One of the most amusing stories I ever heard happened to my former Medical Director. One of her patients complained to their nurse they had yet to see a doctor shortly after she’d left their room. When the nurse pointed out she’d just been in to see the patient they assured the nurse that no one had seen them all day except for a very nice chef in a long white coat. In 14 years I have never heard stories like these from my male colleagues, even the ones that wear no white coat or visible signs of our profession.

Because of this bias I have always gone out of my way to introduce myself as Dr. Walker. I’ve never offered my first name and flinched when patients asked it. If patients called me a nurse or used my first name I’d be quick to correct them. Or at least I used to.

Something has happened to me over the last few years. I’ve noticed a number of my patients starting to call me Miss Walker. Interestingly, it always happens after I feel I’ve made a genuine connection to the patient. It’s as if the more the patient feels at ease and trusts their interaction with me the more likely I am to hear myself called Miss instead of Doctor. And instead of irritation or frustration with the misplaced title I find myself relishing it. I’ve come to realize it means I  somehow transcended the distant role of unknown hospital doctor and became a respected member of that patient’s more intimate community, like a reliable neighbor or a beloved teacher.

Now I consider it an honor when a patient or family member ends our conversation with a heartfelt “thank you Miss Walker.” And it’s made me view how female physicians are treated compared to our male counterparts in a somewhat different light. Yes, we are often mistaken for members of the healthcare team considered to have lower status, but maybe that’s because our ability to communicate, to empathize, to listen, and to understand is not associated with the stereotypical expectation of a doctor. The power gap between the sick patient and seemingly omnipotent physician is immense and scary. I think women are much better at bridging that gap.

I have a three year old niece. When she’s an adult I hope the inherent expectation of what a woman can be will be as vast as that of a man. And I hope if she’s a doctor her patients will afford her the title she has earned. But even more than that I hope this next generation of doctors, both men and women, will be able to lessen the great divide between doctor and patient, will be able to make patients, at their most vulnerable, feel at home. Then no matter how these doctors will be addressed it will always be with affection and respect.

Opioid call to action!

~ iduncun ~ Leave a comment

The other day I was asked how I felt about pain management. It was at the end of a lunch with a potential employer. We were half out of our seats, about to return to the clinic where this primary care doctor had patients waiting. I’d already talked her ear off about everything from the need of PCP’s to focus more on diet and exercise to the need to focus more on end of life planning. And now she asked me about pain management.

As I paused to take a long, anticipatory breath, she explained the need for pain management was very great where we lived. She said this with a knowing look and half-chuckle that could have been interpreted different ways. It might have meant: you know how important and overwhelming the need is because we really should do a better job keeping people pain free. I choose it to mean: isn’t it a ridiculous situation we’ve gotten ourselves into with so many people addicted to prescription opioids. So I opened my mouth.

At the end of our short walk back to her office I realized my interpretation was wrong. And the likelihood of her hiring me was nonexistent. My stance of refusing to give opioids to people with musculo-skeletal pain did not go over well. During my descriptions of difficult pain medicine addicted patients I’d seen in the hospital, who were abusive when I stopped their opioids, her previously agreeable attitude turned uncertain and nervous. She asked what I said to a patient who told me I was being mean. I repeated what I say to all my patients-deaths from prescription opioid overdose are at an all-time high and prescription opioid dependence is linked with current heroin epidemic. That and the fact opioids have not been shown to help in chronic musculo-skeletal pain. The primary care doctor nodded as I talked but the way she squirmed belied agreement. As did her half-hearted handshake when I finally shut-up.

This is an excellent primary care doctor, probably the best in my region. Her praises are sung by patients and doctors alike. Even from our short meeting it was obvious how deeply dedicated she is to providing the best possible primary care. But taking a hard-line stance on the use of opioid pain medication is not in her agenda.

Unfortunately this is not surprising. More surprising is how only now people are finally realizing the truth behind prescription opioid prescribing. It’s not just a handful of prescription mills causing the massive epidemic we’re facing. It’s the everyday primary care doctor that’s just as responsible. And the reason is simple. They care, they want their patients to be happy. They don’t want their patients to be mad or dissatisfied. Just like enabling family members of drug and alcohol abusers they have a hard time saying no to people they care about who are in significant distress. This is especially hard in our current environment where subjective pain is evaluated on a self-reported numerical scale as if it was an objective vital sign such as blood pressure or temperature.

Another not well discussed part of the problem is the ER. The objective of the ER doctor is to move the patient safely and quickly out of the ER, either as an admission to the hospital or as a discharge home. When confronted with a patient complaining of musculo-skeletal pain the quickest way to get them out of the ER is to give large doses of IV opioids and a prescription for pills. In large communities with multiple hospitals pain medicine addicted patients regularly rotate their ER visits, as well as their pharmacies, so the actual amount of opioids they are legitimately receiving is almost impossible to tract. In small communities with just one local hospital these patients are easier to monitor, but in my experience the ER continues to take the path of least resistance-excessively dosing and over prescribing opioids.

Knowing what is happening in the medical community is one thing. What can we do about it? I believe the first step is stop prescribing opioids for musculo-skeletal pain. This includes weaker opioids such as Percocet or Vicoden. A combination of NSAIDs and tylenol with appropriate physical therapy modalities is the best course to take for musculo-skeletal pain. Second step is to better manage the patients who are pain medicine dependent. Instead of feeding their addiction physicians should work with them to slowly come off opioids using inpatient or outpatient drug rehab as needed. Third step is to break the ER cycle of blitzkreig treating. Have good tracking systems to identify pain medicine abusers and social services in place to immediately refer them to rehabilitation facilities.

Patients will be pissed. They will scream, curse, plead, bargain, demand, threaten. They will call doctors every name in the book and transform into frightening, rage-filled monsters. Every family that’s ever dealt with drug and alcohol addiction has seen it. The simplest thing to do would be to give them what they want. But we need to be better than that. We need to give them what they need-help to overcome their opioid dependence.

The Right to Die

~ iduncun ~ Leave a comment

I’ve been trying to figure this one out for some time. My first reaction to physician assisted suicide was negative. After all, I took an oath to do no harm and that’s been hard enough to uphold in my regular practice since every treatment course I’ve prescribed has had the potential to cause harm. Prescribing medication sure to cause death seemed downright unethical.

There’s also the fact the medical community has done everything in its power to keep people from killing themselves. If a person expressed suicidal ideas we stripped them of their basic rights and held them captive in a medical or psychiatric facility until a psychiatrist deemed they had no more desire to end their life, usually after significant medical and counseling therapy. The patient had no right to refuse treatment-they were held involuntarily. The only other way a patient could get released was by a court order. Thus, for all intents and purposes, suicide was illegal.

But aside from the ethical and legal aspects of physician assisted suicide there was something else I’ve struggled to understand. Why did we need physician assisted suicide if we could already provide excellent end-of-life hospice care? No matter what the illness we should be able to keep people comfortable and at their highest quality of life until their natural passing. And wasn’t that the best death we could hope for?

Reading about Brittany Maynard and Jennifer Glass, who was quoted in an NPR article as saying “No one should have the right to prolong my death”, I can now answer my own question. Dying comfortably in hospice is not the best death we can hope for. The best possible death is one we have complete control over. It’s one where we haven’t let our bodies fail to the point we have no ability to carry out basic daily functions such as feeding and toileting, or where our bodies have become so wasted or swollen they are painful for our loved ones to see. It’s one where we can have one last, great day and say, ‘Yep, that was perfect, this is enough, I’m ready now.’ It’s one where the looming inevitability no longer remains a mystery, but something you can plan precisely. Should everyone have the right to die their best death? I think they should.

But I’m still struggling with how. Physicians may be doing more harm to their patients by preventing them from dying their best death, thus my ethical issue is solved, but I’m not confident we understand enough about the dying process to be its best dispensers. As it is we aren’t doing a good enough job preparing people for end-of-life. In a profession so heavily focused on treat-treat-treat with pill after pill after pill will this be just another pharmaceutical plan? And how should we treat patients with chronic major depression recalcitrant to treatment who have been begging us to have their best death for years?

Another issue that bothers me is the permanence of physician assisted suicide. There is no other medical treatment I know that is quite so permanent. The one constant in life is change. We age, we sicken, we improve, all in a never-ending cycle until the unknowable end. But to be responsible for making it knowable and unchangeable-maybe this frightens me most of all. I don’t know if I’m ready for that responsibility.

As the legality of physician assisted suicide changes my hesitancy toward it will also change. I’ve already come to believe we should have the right to die our best death. And even if I’m not convinced doctors are prepared to take on this awesome responsibility right now, one day with the right training and experience we just might be.

Legalize It, Soon!

~ iduncun ~ Leave a comment

Oregon recently became the fourth state to legalize recreational marijuana. There is a momentum behind the legalization movement I hope will mirror the same-sex marriage movement with increasing numbers of states following suit soon. Eventually, just like with same-sex marriage, the federal government will be forced to change its position on marijuana from tolerating its recreational use in states where it is legal to decriminalizing it nation-wide. This is, in my opinion, excellent and long over-due. Especially since the way states have eased restrictions on marijuana use has been by making medical professionals the new drug dealers.

Let me be very clear-I am one hundred percent for the legalization of recreational pot. What has bothered me about its evolution is the involvement of the medical community. Four years ago, stranded in Santa Barbara waiting for my VW bus to be fixed, I was shocked by the number of people I met who had marijuana cards. Actually, I think everyone I met had one. Young bohemian artist/fruit sellers, college students, middle-aged mechanics, yoga instructors, professional coffee shop hanger-outers (you can tell the crowds I traveled in). Up until then I had thought marijuana derivatives, such as Marinol, were only indicated in disease processes where the appetite is significantly diminished or in glaucoma. As far as I knew none of these people suffered from any of these problems. How were they all getting access to medical marijuana?

The answer became clear the more time I spent in California. I began to notice the many advertisements for medical marijuana clinics with young, attractive physicians promising quick and easy service. Then in Venice Beach I approached a very tall, sunglassed Eastern European man holding a huge sign with a pot leaf. He led me down a narrow street off the boardwalk and into a dark, bare store front. Sitting behind a dingy desk was a young woman dressed in club gear. Not your typical professional medical office. She smiled and handed me a sheet to fill out as my Eastern European escort slipped back into the street. Except for the list of medical questions on the sheet the whole experience had the aura of a shady drug deal. I confessed to the club kid I was a doctor just curious about the process and she happily told me the steps to getting a marijuana card. First I fill out the medical form, being sure to focus on the questions about anxiety since this was the most common ailment for which medical marijuana was prescribed. Then I go upstairs and see the physician who’ll read my form and give me a marijuana card. Just like that. I asked if anyone was ever denied a card and she said she didn’t think so.

So basically everyone who came through that back alley store front with enough money to buy their marijuana card got one. Call me old fashioned but that sounds like drug dealing. And it just doesn’t sit well with me. Doctors are educated and licensed to help cure illness, or at least give comfort when they can’t, not provide access to recreational drugs to the masses for money. I have no problem with the real use of medical marijuana, and I have no problem with the recreational use of pot, I just have a problem when those uses are inextricably blurred. In the end, its unethical and fraudulent.

I understand the legalization of medical marijuana is a means to an ends. The medical marijuana dispensaries have allowed legal marijuana farms and distribution networks to be established in the United States laying the groundwork for when recreational pot is legal. But I don’t believe the ends justifies the means. We need to be very careful to maintain the boundaries of what the physician’s role in society is. Unfortunately there are unethical opportunists amongst us, and instead of doing no harm we may be exploiting a situation for our own gain to the detriment of our patients. Marijuana is for most people a recreational drug, not a medication. To rename it as such makes its use a necessity instead of a luxury. And as we find out through more studies, just like another recreational drug alcohol, it is not entirely benign.

Hopefully Oregon’s example will spur other states to quicker action and marijuana will be taken out of the medical purview and put back into the category to which it belongs-a recreational drug to be used at the user’s discretion with full knowledge of all the potential negative consequences. Then the procurement of pot will not depend on compromising the ethics of the medical profession.

Getting Dying Right

~ iduncun ~ Leave a comment

I was at the end of a long week working in an unfamiliar hospital when the ER called me to admit a 92 year-old anemic woman. I took down the information and then immediately asked if she had an end of life plan. The ER doctor became very flustered. She told me the patient was not at end of life. She insisted this was only a reversible anemia and the woman needed to come in for treatment. I tried to explain to the ER doctor how I see every 90+ year-old at end of life, no matter what their acute problems, since my goal in the very elderly is to maximize their quality of life. The ER doctor became angry and defensive and said the patient and her daughter were not ready for that kind of conversation. I wanted to counter back how they should be since it couldn’t be a surprise the patient would not live forever, but the ER doctor had become so upset I knew the argument was pointless. So I dropped it, thanked her for the information and hung up the phone. I was so disappointed one of my colleagues would get upset about addressing end of life with a 92 year-old it was a good ten minutes before I could get back to work. Even then I spent another fifteen minutes venting to the first sympathetic ear I found. Luckily it belonged to a very understanding co-hospitalist who nodded knowingly as I lamented a medical culture that refuses to address death. She agreed that talking about death with patients was still somewhat taboo where we were working. But the sad thing is, it seems to still be taboo everywhere.

For many years I’ve been frustrated by how inadequately elderly people and their families are prepared for death. As a hospitalist many of my patients are nearing their life’s natural end. Instead of being able to spend the end of their lives comfortable in their own home surrounded by loved ones, I see too many bounce in and out of hospitals and rehabs until they die in these unfamiliar clinical settings filled with strangers. Because they are ill-prepared it comes down to me to talk to them about their end of life wishes, a doctor they’d just met in the hospital when they are at their sickest. Sometimes patients are able to tell me they want to go home and just be kept comfortable but many times they are too sick to make their own decisions. Then family becomes responsible for these decisions which puts people in the terrible position of deciding how they want their loved ones to die. And even if a patient has a living will the family could still be in limbo since the language of the living will often does not adequately guide the decision making process in end of life cases.

How could this be? The whole point of having a living will is to ensure a patient’s wishes are met when they are too sick to express them themselves. But here is the real problem-neither patients, their families, nor the legal entities creating these living wills has a good grasp on what end of life is. To be honest, it’s taken years of practicing medicine for me to really understand it. Living wills are written to best address when the patient will be at a point in their disease process that would require advanced medical intervention, such as ventilators and other resuscitative measures, to sustain life. Sometimes living wills will be more expansive to include decisions about less aggressive measures-such as using antibiotics or artificial nutrition-but the language here is usually very ambiguous and open to interpretation. What I’ve come to understand is most end of life experiences cannot be so neatly applied to the directives of a living will.

First of all, I want to define what I mean as end of life. End of life is a time period when the patient will no longer get better overall, instead they will continue to worsen until death. For patients with dementia end of life could be a period of years, for a patient with metastatic cancer it could be a period of weeks. During this time most patients will require multiple hospitalizations to treat the consequences of their underlying illness-for example aspiration pneumonia in demented patients or line infections in patients receiving chemo.

If a living will exists it will answer the question of whether the patient wants to be artificially resuscitated and sustained on machines should they stop breathing or their heart stops. It usually will not sufficiently answer whether artificial hydration and nutrition should be used at end of life. As stated above, the wording in living wills is particularly nebulous about this leaving families with the harrowing decision to continue or stop IV fluids when their loved one can no longer speak. This is the most difficult decision for families since they feel if they stop IV fluids they will be killing their loved one even though evidence shows at end of life patients have less pain and live longer without them.

Other issues the living will does not address are the many things patients endure in hospital settings-from IV’s to multiple blood draws to sleep disturbance to lack of interaction with loved ones. These things make the time the patient has left not enjoyable. The living will does not let healthcare providers know when a patient would want to stop such conventional medical practices or how far a provider should go in treating the different consequences of their illness. Most importantly it does not include the exact circumstances when a patient would want no more medical interventions and just be kept comfortable-such as when to stop all vital signs and nursing checks.

Just determining whether a patient wants to be resuscitated and their life sustained with artificial hydration and nutrition is not enough to protect a patient at end of life. Living wills should be carefully drawn up to try to include all the nuances of the end of life process so nothing will be left to burden grieving loved ones. They should include how much time a patient would be willing to spend in hospital and/or rehab settings, and how early in their disease process they would want their care transferred to a comfort care/hospice setting. I recognize each patient’s case is unique and all contingencies at end of life cannot be predicted, but I think we can start to do a better job with living wills than what we have now. It starts with primary care doctors having very direct and honest discussions with patients and families about their disease process, or their advanced age, and what lies ahead of them as they continue to worsen. That way patients can make their most educated decision about how they want to live at the end of their life and try to ensure their wishes are carried out.

In the case of my 92 year-old, whose anemia was likely to recur causing repeat hospitalizations in the time she had left, a living will that clearly described how she wanted to be treated for this anemia-i.e. to stop hospitalizations once she was showing overall functional decline so she could be kept comfortable at home- would allow her to control what would happen at end of life and give her daughter great peace of mind when she became too weak to advocate for herself. Hopefully one day such specific living wills, written in unambiguous language that directly applies to medical practices, will be readily available for primary care doctors to procure for all their patients nearing end of life.

GMO’s

~ iduncun ~ Leave a comment

I recently read about a letter 10 physicians sent to Columbia asking the university to remove Dr. Oz from his position as vice-chairman of the department of surgery.  Their complaint stated he “has repeatedly shown disdain for science and for evidence-based medicine.” They specifically mention his opposition to genetically engineered crops. Not surprisingly several of these doctors have been national proponents of genetically engineered crops which has shifted the focus away from Dr. Oz’s credibility as a physician to a fight between doctors over GMO’s. And I’d like to join.

I first heard about GMO’s in 1999 at an art exhibit. The gallery was on the second floor of a newly renovated building in Brooklyn. The exhibit felt like an art student’s senior thesis, and it might have been. I think I was there for the free wine. As I wondered around looking at the frightening collages on the walls-grotesque images of mutated corn swirling in a tornado of chemical symbols- I kept coming across these three letters. G-M-O. Finally I admitted my ignorance to the woman passing out the wine.

“Genetically Engineered Organisms,” she said, astonished. “You haven’t heard about them? They’re horrible. We’re all going to end up mutated and stuff.”

I was a medical student at the time and fascinated by science, especially genetic engineering. I was like a nuclear scientist before the bomb, filled with limitless expectations of  how this new technology would improve the world. I distinctly remember thinking how foolish this woman and the artist were to be scared of something that could only make things better.

I can’t remember when my feelings changed. There was never a Hiroshima-esque seminal moment to sway my opinion of GMO’s, although watching Food, Inc.  several years back was very influential. But even before then I was experiencing a profound shift in how I viewed the manipulation of food’s genetic code. And these ideas, just like Dr. Oz’s, were not based on science or evidence-based medicine.  Instead they came from my own life experience.

After years of practicing medicine in the Mid-Atlantic region of the United States I’d seen my patients getting sicker and sicker.  I’d watched the average body size continue to expand and people present younger and younger with adult onset diabetes. Since childhood I’d heard my grandparents bemoan the lack of flavorful vegetables they remembered from their youth only to discover these amazing flavors by buying directly from organic farmers. Paying more attention to my diet made me realize how many processed, sugary and calorie laden foods I was eating, not to mention the average American. Its from my personal experience and the experience of my patients I’ve drawn my conclusions. Food science, especially the modification of sugars and fats, can be bad for you.

The wisest advice I’ve heard on the subject is to eat how your great-grandparents ate.  This makes a lot of sense. The human body has had tens of thousands of years to evolve in harmony with the natural food it ingests. Scientists haven’t had enough time to know all the consequences of the modern processed food diet on our health. So far it doesn’t look good. And to me, even though there is no negative scientific evidence about GMO’s, genetically engineered food fits in the category of food our great-grandparents did not eat.

Perhaps one day science will prove people like me and Dr. Oz right. Maybe not. But I’m not going to wait for science to reach the same verdict as my personal experience and beliefs. I’ll keep eating, as much as possible, the foods my ancestors would have recognized and hope the organic, whole foods movement continues to gain momentum and become affordable for all.

The Importance of Being Honest

~ iduncun ~ Leave a comment

On the small island where I live there is a doctor people speak about fondly and a doctor they do not.  The loved doctor’s kindness, sacrifice, and willingness to tell patients when their problems are beyond her expertise are universally praised.  When they speak of the other doctor they shake their heads, roll their eyes and say he’s likely to make a joke of their concerns.

I’ve met this second doctor.  He is relatively young and has a friendly, open face.  He makes jokes and moves confidently around his patients with a casualness meant to be disarming.  There is something resigned about his demeanor too-the way he falls into a chair and sighs as he writes a prescription, or how he leans against the exam room counter top as if he would fall over without it.  I do not think he is a bad doctor.  In fact I think he is more than competent.  But he is also significantly overworked on an island that does not have enough people for the government-run clinic to justify spending the money to build and staff a true hospital with well equipped emergency services.  Instead he has to make due with limited staff and equipment while still trying to treat the entire spectrum of medical problems-from simple colds to life-threatening traumas- anytime of the day or night.  This impossible situation is enough to wear the best physician down.

But the loved doctor, who shares his burden 50/50, is not perceived as arrogant or belittling.  What makes the difference?  Some of it is just intrinsic personality differences and the ways two unique people cope with stress.  After all, doctors are not automatons.  I think there is something else though, something that makes a bigger difference in their perceived styles.  And to explain it I have to go back to my own experience of becoming a doctor.

I never intended to go to medical school.  I majored in biochemistry because I loved the subject and I loved my other required classes such as organic and physical chemistry.  The pre-med students in my classes seemed only interested in their grade point averages.  I looked at them derisively as they tried to wheedle upcoming test answers from our professors.  Having the right answers was more important to them than actually learning.  Because of this I vowed never to consider becoming a doctor.

That lasted two years.  Through an unexpected series of adventures I found myself in medical school surrounded by the same people I thought myself so superior to.  Luckily I found out how presumptuous I’d been and how good a group of people they were.  But one thing was the same.  Having the right answer remained supreme.

Really this should not be surprising.  Since elementary school we are judged on whether we have the right answers.  If we do we are rewarded with good grades and move onto colleges and universities where we are still tested in an increasingly competitive environment on whether we know the right answers.  Four more years of right answers later, 16 years of acculturation in what determines a smart, capable person behind us, we are worthy to go on to medical school.  And in this most competitive of environments, where students and later residents are vying for a tightly controlled number of specialty training spots, what is judged and valued, you guessed it, are right answers.  There is even a term for being peppered with questions by an attending doctor-being pimped– as if a student’s mind is a prostitute required to perform.  If you don’t have the right answer you are harshly judged and often ridiculed.  One time during residency, after answering a question too vaguely, my chief resident snapped, “That’s a first year medical student answer,” with a disdain meant to deeply humiliate.  The amount of hate he conjured in his face and voice was extraordinary.

In this setting honesty cannot triumph.  I have watched my fellow students and residents blatantly lie about exam findings, patient histories, or even test results to cover up things they did not know.  And this all-consuming pressure to be right does not end with training.  Teachers and Attendings are replaced by colleagues and patients.  The expectation that doctors know everything and are always right is a double-edged sword.  It not only prevents the doctor from being truthful about their limitations, it also colors the way society perceives doctors.  We’ve been promoting our intellectual invincibility for so long it can be very distressing for a patient to hear a doctor admit ignorance.

But here is the dirty secret of medicine.  We don’t know.  This is too simplistic, I know, but there is a lot of truth to it.  New studies come out all the time refuting previous studies that were the cornerstones of medical care.  We see it in the continual pendulum swing of dietary recommendations, recommendations for treating blood pressure, antibiotic usage, etc.  We are still stumbling around in the dark, waiting to see if the treatment du jour will turn out to have significantly negative side effects in 10-15 years.  Treatments that were the cutting edge of their time are barbaric by today’s standards (i.e. lobotomies) and cutting edge treatments of today will be considered barbaric in 50 years.  The sooner we embrace the uncertainties of medicine, like the uncertainties of life, the sooner we can shed our need to be right and start having more honest discussions with our patients.  It will take some time to shift society’s expectations, but slowly we can turn our patients’ need to have the right answer to a deep, comforting trust in our care.

I think this comforting trust makes the difference between the loved doctor on my island and the other.  She takes the time to listen to patients, carefully examines them, and afterward can still throw up her hands and admit ignorance.  Even if she comes up with less answers than her colleague, her patients appreciate her for her honesty and caring and trust her more than a doctor who cannot admit what he doesn’t know.

The Problem with Pills

~ iduncun ~ Leave a comment

A few weeks ago, while I was sitting at a crowded bar on a popular open mike night in my new island home, a man I’d met a few times before started telling me about the problems he’d been having with a new blood pressure medication.  This is not unusual.  Once people find out I’m a doctor, especially if they’re the most peripheral of acquaintances, I’m bound to find out intimate details they’d never tell their friends.  Suddenly I’m craning over the person in the bar seat next to me, shouting over another spirited rendition of Wagon Wheel what I hope is helpful advice.  But also vague advice, because I know nothing about this man’s medical record or his exam.  It ends up being much more than I meant to say, and much more than the poor man is willing to listen to in the midst of swinging drinks and belted choruses.  Because the problem with pills is not so easy.

I’ll start by saying pills are neither all bad or all good.  Millions of people are alive today because of pills.  That said I have strong reservations about how Western Medicine uses pills.  When I went to Medical School there was no emphasis on how exercise and nutrition can prevent and combat illness, and very limited emphasis on how to help people make better lifestyle choices when it came to alcohol, tobacco, or drug use.  There was, however, a pill for almost every disease.  Even if the pill did not cure the disease it could reduce some of the symptoms.

This is not surprising.  Throughout history humans have used various plants, animals, and inanimate objects as ways to help heal.  And human nature seeks an easy fix.  Not to mention, pharmaceuticals are incredibly lucrative.  But after ten years of practicing medicine I know that pills alone are not the answer.  In fact any medication, even a medication as ancient and benign as aspirin, can have life threatening side effects.

There are some people who will always need medications.  Type I diabetics, for instance, who cannot produce insulin.  Or people like a friend I had in medical school whose family history of high cholesterol was so bad two of his brothers had had heart attacks before thirty.  But many of the patients I’ve seen suffer from health problems that could have been prevented or reduced by significant lifestyle changes.  There are so many variables that effect a person’s health-from genetics, to stress, to environment-all of which we have limited or no control over.  In fact, we have little or no control over anything that happens to us.  We do have control over two important things, though.  What we put in our bodies and what we do with our bodies.

Here comes the hard part.  Taking pills is the quick fix we seek.  Changing how we eat and drink and how we exercise is not.  Changing these things takes a significant amount of hard work that can seem overwhelming and impossible.  But it’s not.  Take small steps, challenge yourself, keep going.  You may still end up needing to take pills but I guarantee you’ll need less medication overall.  And its never too late to start to make these changes.  Even small changes like losing 5 pounds, walking twenty minutes a day, or eating less processed foods will give you significant health results.

So that’s what I tried to tell my acquaintance at the bar, a pretty hard sell over half-price cocktails and greasy appetizers.  Preaching health at a happy hour is like promoting abstinence at a brothel.  But that’s my story and I’m sticking to it.  -The Anecdotal Doctor

The Anecdotal Doctor

~ iduncun ~ Leave a comment

I was an Intern scurrying behind my busy Attending as she flew down the hospital corridor, her long white coat snapping at my knees, when I first heard the words anecdotal evidence.  I recognized the term, it included my favorite sixth grade vocabulary word, but I never heard the words until she spit them out of her mouth like spoiled milk.  Anecdotal evidence.   How detestable.  Of zero consequence, not to be trusted.  My love of the short, amusing story squashed under her squeaking clogs.

But I could not let it go.  After three years of residency and ten working the same kinds of heavily waxed hospital corridors I still can’t.  I agree that it is dangerous to try to find the truth based on a single or a few experiences.  The scientific method of experimentation to prove the truth, and repeatedly prove it, has allowed society to advance beyond what our ancestors would have thought possible.  But…I think there’s a place to have an opinion, or belief, or idea that’s based on personal experience.  Is it a fact, is it a truth?  I’ve been a doctor long enough to realize what we thought was truth based on all our available studies can often become disproved with new research.  So I’ll let them keep their evidence-based medicine and I’ll practice my anecdotal medicine on this blog.  I’ll tell stories about myself and people I know and maybe they’ll be helpful, maybe they’ll be informative, but at least they might be interesting and amusing.