Tuesday, June 4, 2019

Why I, a Physician, Write

“One would never undertake such a thing if one were not driven on by some demon whom one can neither resist nor understand.”
 – George Orwell, “Why I Write”

I remember my first encounter with great literature. Before bedtime, my father would read Great Expectations to me, using different voices for different characters. I remember Pip and Miss Havisham, though I don’t think I fully understood Miss Havisham’s peremptory and eery commandment to Pip to love Stella. I remember the stygian scene with the convict in the graveyard. I also remember reading Sherlock Holmes under my covers, enamored with his brilliance and the game that was afoot. I remember tearing through the Lord of the Rings books and the first few books of Robert Jordan’s The Wheel of Time series. Great stories left a large impression on my childhood. The thrill of diving deeply into an engrossing world still makes me a bit giddy. Even when I read books far more socially complex now, books I would never grasp as a young reader, like Thomas Hardy’s novels, I am reminded of the initial excitement I once felt discovering new stories.

As a child, these stories didn’t remind me of my own life or people in my life, they were just thrilling. I fantasized about writing my own stories one day. I created comic books with different monsters, though my drawing was appalling. I once sat down to hand-write my own epic fantasy story – I don’t think I got very far. I suspect, then, that my desire to write and tell stories was present at a young age. But I lacked the sedulousness to work on my drafts. I would write an essay for school or a story at home and immediately hand it in or toss it aside, assuming that was the end.

Since then, of course, I have written more and learned more. The process certainly has not gotten any easier, especially as time spent writing crowds out time for other things in life like music, friendships, reading, TV shows, and family. Indeed, the time invested has not been trivial. Just as an example, I was covering the intensive care unit one night during my first year of residency and during the few brief quiet moments of the night I was reading a book about the psychology of the Nazi war criminals for an essay for the Jewish Review of Books.

Why do I attempt this seemingly crazy task? It is a question prompted by a recent fellowship interview, when an interviewer asked me: Why do you write? And what drives a physician (and there are many physician-writers) to write?

In 1946, George Orwell explored the reasons for his own writing in an essay entitled “Why I Write.” Orwell explains that there are four great motives for writing: egoism, aesthetic enthusiasm, historical impulse, and political purpose. Writers, he argues, “desire to seem clever, to be talked about, to be remembered after death…. It is humbug to pretend that this is not a motive, and a strong one.” Because of this, serious writers are “vain” and “self-centered.” Of course, there is an element of solipsism in writing. No writer, physician or otherwise, writes without anticipating some kind of audience. It does help give our writing purpose, to know that it affects or influences others. But such an aspiration is not unique to writers, as Orwell concedes. All professionals – scientists, artists, politicians, etc. – desire, to some extent, to be remembered through their research, art, or deeds. No ambitious citizen can deny that this plays some role, large or small, in what he or she does. But the entire writing motive is not necessarily self-aggrandizing: Writers appreciate beauty, “pleasure in the impact of one sound on another, in the firmness of good prose or the rhythm of a good story.” An author, no matter what his or her topic, attends to “aesthetic considerations.” And the content matters, too. Essayists, novelists, political journalists all “desire to see things as they are, to find out true facts and store them up for the use of posterity.” In other words, they aim to portray the world as it is, to draw away the curtains. And there is also a “political purpose” to this. Though writers do want to see things as they are, they also want to imagine the world as it might be or “to alter other people’s idea of the kind of society that they should strive after.” Orwell does not argue that one of these is more important than the other: “These various impulses must war against one another,…fluctuate from person to person and from time to time.”

Most of what Orwell says pertains to physician-writers. For some of them, for instance, politics drives much of their work. Atul Gawande, a surgeon and public health researcher, is a good example. Gawande’s books, like Being Mortal or The Checklist Manifesto, both agitate in some way for reform of our medical system. In Being Mortal, he urges us as a society to rethink the way we take care of the elderly and those closest to death such that we provide them with more independence and choice and less invasive care. In The Checklist Manifesto, he discusses the importance of checklists for the safety of patients in a hospital, in particular during surgeries.

For most physician-writers, however, I suspect that the primary purpose is to reveal to the reader what the world of medicine is like – a world that contains the kinds of riveting stories that fiction offers.

Physician-writers face unpleasant facts; or, rather, unpleasant aspects of life. Most of the stories I relate on this blog are tragic in some way – some of this comes out of a frustrating sense of injustice, but a lot of it comes out of a sense of the inevitability of tragedy and the beauty and rare success coupled to that struggle. Thomas Hardy reportedly said, “The business of the poet and the novelist is to show the sorriness underlying the grandest things, and the grandeur underlying the sorriest things.” The physician-writer shows the sorriness and grandeur underlying our physical life. In that sense, I write with a historical impulse, “to see things as they are.” What is medicine really like? What does it mean to be sick and helpless? What does it mean to be sick and poor? How do physicians react to all of this?

Perhaps the thrill and romance from childhood stories has faded somewhat, but the hunger for nonfiction as a grounding tool has taken their place. This blog provides, among other things, a way to impart the great complexities of medicine and diseases, which are often only understood by other physicians and the victims of those diseases.

I wish I could write a novel with the same flair for storytelling and the same talent for diction and the same eloquence as Dickens or Hardy. That I cannot is unfortunate. But stories about medicine are powerful and the most I can offer. And I am “driven on by some demon” to write about them; a purposeful struggle to put to the page these stories that are filled with meaning, and that might otherwise disappear.

I will never retire this task, whether it’s through this blog or elsewhere. But as my career advances I ought to give myself space to breathe. I start my fellowship in neurovascular disease this summer and have an important specialty board exam this year, both of which require, I think, all of my intellectual energy. So things will be quiet on this blog for now, but look for more in the coming year.

Monday, March 11, 2019

What Makes a Great Physician?

At this blog’s inception nearly five years ago, I asked myself the following question: “When you watch impressive doctors at work, what is it that most impresses you?” In other words, what makes a great physician? I was a third-year medical student at the time and I couldn’t answer the question. At the beginning of training one can hardly keep up with the incoming information, let alone consider the characteristics that make a great physician. I liked and disliked certain doctors depending on the way they treated residents, medical students, or patients. But beyond kindness, their traits varied widely. During residency I have been fortunate to work with many admirable doctors, and consequently my sample size has grown. Seeing what I’ve seen thus far, I think curiosity and humility are the two most impressive characteristics of a great physician.

Galen of Pergamum (AD 129–ca. 216), the Greco-Roman doctor, wrote extensively about how to make physicians great again in his treatise That the Best Physician Is Also a Philosopher. He bemoans the lost art of medicine and the corruption of the profession. He advocates for a temperate lifestyle, arguing that if a physician puts virtue above wealth, he or she will be “extremely hardworking” and will therefore have to avoid “continually eating or drinking or indulging in sex.”

A doctor must also be “a companion of truth.” “Furthermore, he must study logical method to know how many diseases there are, by species and by genus, and how, in each case, one is to find out what kind of treatment is indicated.”

He continues,

So as to test from his own experience what he has learnt from reading, he will at all costs have to make a personal inspection of different cities: those that lie in southerly or northerly areas, or in the land of the rising or of the setting sun. He must visit cities that are located in valleys as well as those on heights, and cities that use water brought in from outside as well as those that use spring water or rainwater, or water from standing lakes or rivers.

Notice that Galen does not endorse brilliance as a required characteristic of a physician. No, he advocates for the intelligent use of one’s faculties. Indeed, he seems to favor curiosity about the surrounding world as a necessary quality for a doctor.

Curiosity, a desire to discover and a desire to know, is inseparable from a great physician. In residency we are often told by our attending physicians that we must be “lifelong learners.” Curiosity naturally creates lifelong learners. Medicine, after all, is not confined to what one learns in medical school or residency. If it were, our doctors would not be very good. One does not see every disease process in residency, one often forgets certain things, and the evidence and guidelines are forever changing and improving. Thus, we must always be looking up the latest evidence on the diseases we see.

Moreover, there isn’t always a clear diagnosis or treatment, and physicians must scour scientific literature for the answer. When, as so often happens, there is a diagnostic mystery, curiosity works against our inclination towards laziness and forces us to stay on our toes, question what we believe and why we believe it.

Curiosity also aids the clinician-researcher. Physicians since Galen’s time have participated in various forms of research, attempting to answer questions that have not yet been answered. For many of our predecessors the questions were quite basic, given the general ignorance about the world of biology. Yet there are still vast areas of medicine for which answers are needed. The most obvious examples in the specialty of neurology concern brain tumors or diseases like Parkinson’s. The lifespan for patients with certain brain tumors is a year and a half – how does one improve treatments for these virulent neoplasms? For Parkinson’s disease, we can only treat symptoms but cannot slow the disease down – what treatments might reverse this pathology or at least stop it in its tracks? Curiosity drives physician-researchers to make discoveries and to seek answers to these questions.

But there is another characteristic, too, necessary in order to be a great physician. The sheer volume of material one must know and understand about medicine as well as the natural world is enormous and infinite. Because of the infinite knowledge they cannot possibly possess, doctors must also confront this world with humility, humility about how much one must truly know and understand in order to be great.

What was true in Galen's life is doubly true today: There is a vast world of knowledge in the realm of medicine. Humility, like curiosity, provides doctors with a sense of the struggle to accumulate a vast amount of knowledge. It helps them confront the possibility of being wrong. And as I’ve written on this blog, doctors are often wrong. Humility makes us more likely to double-check ourselves, to re-examine the patient when we’re unsure, to look things up when we feel insecure in our diagnosis. It makes us more thorough. It urges us to listen to the opinions of other doctors, of nurses, or even of patients.

What, then, when I watch doctors at work, most impresses me? What, then, makes a great physician? Curiosity and humility are necessary characteristics. There is not a single physician I look up to who does not have both of these qualities. These alone may not be sufficient but I have also noticed that other remarkable characteristics tend to accompany curiosity and humility: kindness, self-discipline, intellectual rigor, equanimity.

William Osler
In his valedictory address to the University of Pennsylvania School of Medicine in 1889 (also known as the essay Aequanimitas) Dr. William Osler, one of the original four physicians at Johns Hopkins Hospital and a legendary professor of medicine at the Hopkins medical school and later at Oxford, discusses the quality that he thinks is most integral to being a physician – imperturbability or equanimity. He writes:

A distressing feature in the life which you are about to enter, a feature which will press hardly upon the finer spirits among you and ruffle their equanimity, is the uncertainty which pertains not alone to our science and arts but to the very hopes and fears which make us men. In seeking absolute truth we aim at the unattainable, and must be content with finding broken portions.

What lies behind Osler’s idea of equanimity is an acknowledgement of uncertainty in medicine. And such an acceptance arises first from a humble and inquisitive outlook. Curiosity and humility acknowledge this uncertainty and the need to prepare for it, with equanimity.

Wednesday, January 2, 2019

Medicine as a Vocation

“Hey, doc, come over here!” the patient shouts at me and gestures with a quick wave of his hand as I walk by his room. “I need to show you something. Take a look at this.”

Without waiting for me to ask him what is wrong, he takes out his member and testicles and points at them.

“One of my testicles is swollen. Look! And it’s painful, doc. There’s this shooting pain going up into my stomach. I feel nauseous. Can you get me something for the pain?”

I look at his testicles and feel both of them with my gloved hand. One is certainly larger than the other and the patient winces in pain when I touch them. Though it is close to the end of the day, perhaps ten minutes or so before I sign out to the nighttime physician, I run through the possible diagnoses: testicular torsion (the testicle twists on itself, reducing blood supply and causing intense pain and eventual infarction of the testicle), epididymitis (an inflammation of a certain part of the testicle usually caused by a sexually transmitted disease), a varicocele (the veins of the testicles enlarge due to malfunction of valves within the veins, causing increased pressure and pain), and other, less common pathologies.

At this point, the best next step is to get an ultrasound of the scrotum. This imaging study, which is fairly quick and cheap, gives the physician a sense of the pathological process. Of course, this has to be ordered rapidly because if the patient does have testicular torsion, he needs to be seen immediately by a urologist.

After examining the patient, ordering the test, and calling down to the ultrasound technician to make sure the patient had the imaging study done, it is time for sign-out. But I am in a bit of a bind. It is my responsibility to make sure the patient gets the treatment he needs, but I also have plans with a couple of friends all the way across town. If I leave now, I can make it but will surely be late. If I wait for the study, I will never make it.

I stop by the night physician’s room and let her know that it will be a little bit of time before I sign out because I’m going to follow up on this study. She, understanding my conundrum, tells me to leave and kindly volunteers to take over. Frequently, residents cover for each other in these situations, for we know, given our hectic schedules, how hard it can be to find time to keep up with friends, date, and attend weddings, religious ceremonies or graduations. I jet out of the hospital and just make the crosstown bus in order to show up twenty minutes late.

At the bar my friends and I discuss our respective days at work. And then comes the dreaded question, directed at me: “How was your day?”

I pause as I do when people ask me this question, not because I don’t know what to say, but because there is so much to say I really don’t know where to begin or what is appropriate. Do I tell them how only an hour ago I was examining another man’s penis? Do I tell them about the patient I admitted to the hospital and watched die over the course of five days because his metastatic cancer was so bad that there were no treatment options? How about the time a patient walked into the hallway, pulled his pants down, and pooped on the floor by the nurse’s station?

If I’m honest about the events of my day, I now know the look I’ll receive in return: the eyes widen, the eyebrows go up, the mouth twists in slight disgust and the jaw drops ever so slightly. “Why,” their shocked facial expressions seem to say, “are you telling me this?” The problem is that these stories and experiences not only are a part of work; they become a regular occurrence and a part of life. Resident hours are so long and so intense that, frequently, there isn’t much else to talk about. Anything outside of the hospital feels unnatural to residents; we no longer fit in. Our singular experiences mark us in a sometimes Hester Prynne-like way among our friends and significant others outside of medicine.

Sometimes, too, we mark ourselves not outwardly but inwardly. When I am with friends at a bar or at an apartment sipping on a beer, it will suddenly occur to me that three hours prior, a patient was vomiting on me or dying as I pumped on his chest. The juxtaposition between these two very close moments in time is bizarre.

But even beyond these occasional strange realizations and awkward interactions is something much more expected. When I describe to acquaintances what neurologists do, a typical response goes something like this: “My grandfather is losing his short-term memory — could this be Alzheimer’s?” Or, “my grandmother has Alzheimer’s, are there new discoveries being made on how to cure it?” Some of this is about making conversation related to my job. However, what becomes clear is that you cannot escape the profession. For better and for worse, it follows the doctor everywhere.
In February 2017, Dr. Farr Curlin, the Josiah C. Trent Professor of Medical Humanities at Duke University, wrote a wonderful essay in Big Questions Online about medicine, titled “What Does It Mean to Have a Calling to Medicine?” In it, he explains his hopes that young physicians see medicine as a vocation: “To practice medicine as a vocation is very different [from other professions]; it means putting oneself forward not merely as a physician but in order to become a physician.” And becoming a physician takes “a lifetime of effort.” He compares it to the theological concept of vocation, in which one is summoned or called by God to a certain task. His purpose, I think, is not to portray doctors as gods or medicine as the holiest of professions, but to make clear how absolutely consuming medicine is if taken seriously.

To practice medicine as if it were just another 9-to-5, Dr. Curlin observes, “is akin to play-acting.” One attempts to keep the role at a distance. This is a fool’s errand, as no serious physician can manage it. Any serious approach to the profession necessarily leads to a consuming embrace. I think even of physicians I know who have reached the highest levels of their field, but who still respond to patients’ emails at night after they’ve come home from work; they must be available by phone day and night when they’re on call; they still have to keep up with new research, which they read on their own time; and many even do medical research outside of work hours. This is not to mention the incredible and unsettling statistic that physicians have one of the highest suicide rates of any profession, a rate more than twice that of the general population.

Anton Chekhov via Wikimedia
Dr. Siddhartha Mukherjee, a physician-writer, has considered this dilemma, too. In a stunning essay for The New Yorker, he writes about Anton Chekhov, the great Russian playwright. Chekhov gave up his medical practice to travel to Sakhalin Island, a Russian island in the North Pacific Ocean. At the time it was a penal colony, packed with the destitute and hardened criminals of the Russian Empire. Why would Chekhov travel here? What purpose did this trip serve? Mukherjee argues that Chekhov used Sakhalin “as an antidote.” Chekhov, he claims, had become desensitized to his life as a physician, numb to human suffering as well as to the greater corrupt political struggle in Russia. And it is here, among the detritus of society, where Chekhov discovered sensitivity. This story poses the question faced by all physicians, Mukherjee writes: “What will move me beyond this state of anesthesia? How will I counteract the lassitude that creeps over my soul?”

In one sense, Mukherjee’s essay serves the purpose of encouraging the discouraged, angry, numb physicians. But in another sense it illustrates the point that medicine is a vocation. When patients’ suffering becomes just another task to deal with, physicians falter not just as physicians but as people. Medicine reaches beyond its worker bees and into the hive. It claims physicians as human beings. It claims a part of their souls.

This is not all bad or all good. But it is nearly impossible to dissociate the personal life from the professional life as a physician. Medicine practiced well must be a vocation.