The Things Not Named
What's Named And What's Withheld
Beskrivelse
“That's what a storyteller's job is. What do you relay and what do you withhold? And frankly, that's the chronic illness storyteller's mode as well. What am I going to tell this doctor in front of me and what am I going to withhold?” Dr. Michael Stein, author of “A Living: Working-Class Americans Talk to Their Doctor” Michael Stein is a physician, a health policy researcher, and author of 15 books — six novels and nine books of nonfiction. He’s currently Chair and Professor of health law, policy, and management at the Boston University School of Public Health and has also taught at Brown University. Michael is a frequent contributor to The Washington Post, The Boston Globe, and the New York Times. He’s also been featured on NPR’s Fresh Air [https://www.npr.org/2007/02/06/7217658/examining-the-inner-life-of-the-lonely-patient] and in O Magazine [https://www.oprah.com/book/the-addict-by-michael-stein?editors_pick_id=35314]. In his spare time, he is Executive Editor of the Public Health Post [https://publichealthpost.org/]. Below is an edited transcript of our conversation on Substack Live. Transcript: Joshua Dolezal: Welcome back to The Things Not Named. I’m Joshua Dolezal, and my guest today is Dr. Michael Stein. Willa Cather famously said that it’s the presence of the thing not named that gives high quality to fiction, drama, and poetry. So this year I’m asking that question of medicine. How might we all be more attentive to what goes unsaid in the clinic, in popular culture, and in the experience of illness from the patient’s side? Michael’s recent book addresses that question because he’s giving voice to a lot of people who normally don’t get to tell their story in popular culture or in medicine, so that’ll be a treat today. Michael is a physician, a health policy researcher, and author of 15 books — six novels and nine books of nonfiction. He’s currently Chair and Professor of health law, policy, and management at the Boston University School of Public Health and has also taught at Brown University. Michael is a frequent contributor to The Washington Post, The Boston Globe, and the New York Times. And he’s also been featured on NPR’s Fresh Air [https://www.npr.org/2007/02/06/7217658/examining-the-inner-life-of-the-lonely-patient] and in O Magazine [https://www.oprah.com/book/the-addict-by-michael-stein?editors_pick_id=35314]. In his spare time, he’s also the executive editor of the Public Health Post [https://publichealthpost.org/]. Welcome, Michael. Thanks for joining me today. Michael Stein: Josh, thanks for having me. This is great. Joshua Dolezal: I want to get to your latest book, A Living [https://www.penguinrandomhouse.com/books/780358/a-living-by-michael-d-stein/], which you’ve modeled after Studs Terkel’s classic, Working. But first, I’ve talked with almost everyone on this series about craft and how they think of themselves as a writer. And I’d kind of like to start with when you first started thinking of yourself as a writer, what some of your formative influences were, any significant mentors you had that shaped you as a writer. What’s your origin story? Michael Stein: Right, great. Thanks again for having me. So my origin story is — I think the first book that influenced me as a quasi-adult was in my 20s when I read a biography of Robert Lowell. And I thought that was just a fascinating life. And he was obviously a poet primarily, and I was writing poems at that point. And I spent many years doing poetry, which I published all over the place, and came into contact with the famous editor Gordon Lish, who had reached out to me and asked me to send things to his magazine. So I started to send some things to a journal that he was running called The Quarterly. And so I wrote a lot of poems early on. At the same time, around then I had done some work as a journalist, which was not creative writing but an important kind of writing. I had done that in college and I thought of doing a career — I sort of reached the fork of do I do medicine or do I do journalism? And so, of course, being who I am, I chose both. I ended up going to medical school and was still sort of writing journalism pretty much through medical school. I paid for medical school working as a journalist for Nature magazine and went to occasional medical school classes. And I was writing a lot of poetry. Then years passed and I had children, and I started one night — when I was up feeding children in the middle of the night — to write fiction. I wrote six novels, published six novels over the next number of years. And then along the way, I just decided to come and try to start writing about medicine directly. So I went back to writing nonfiction about medicine. My writings have gone all over the place since then. As you said, I’ve written a lot of books — six novels, eight books of nonfiction — and they range from my recent book, A Living, to more straightforward essays, to public health arguments. I wrote a book called Me Versus Us, which explains to people the difference between public health and practicing medicine, because I now work in a public health school. So I’ve flittered. Joshua Dolezal: Well, so coming back to nonfiction is actually coming back to your roots. And I think I had it wrong — I thought you’d started as a fiction writer and then sort of came to nonfiction later. But it sounds like the essay form, personal form, and your journalistic training was really the foundation. Michael Stein: Yes, I think so. But very different, obviously, from journalism. I’ve always taken my nonfiction to be — having gotten to it really through fiction — a more creative form than I ever considered journalism, which I considered a public service as opposed to my personal writing. So a little different. Joshua Dolezal: Here’s an unfair question, and it probably differs because I know you’ve published 400 scholarly articles too, and all these modes are very different. But when you’re thinking more in the literary sense in nonfiction, or perhaps even in fiction, how do you know good writing when you see it? When you hear about craft, what does that mean to you when you’re making decisions in your writing process? Michael Stein: Well, I would have to say it’s a great question, and I probably see what you’re calling good writing differently at different times in my life. I think what I’ve considered good or enjoyable or meaningful to me — I’ve read different things at different times where, when I went back to reread, they didn’t appeal to me in the ways that they had the first time, which is telling me that I probably have a bit of a shifting view. Having written novels, I became much less interested, for instance, in writing — and therefore stopped writing — naturalistic literary fiction. It just wasn’t so interesting to me as a form anymore. It’s not to say that I don’t like stories, but for the moment, I’ve probably read over the past 10 years, when I pretty much stopped writing fiction, fewer novels than I read in the first 20 years when I was writing fiction. It would take a lot unless the fiction I was reading had something experimental or interesting to me. So technical format changes interest me. But I think what’s a satisfying read — which is sort of what you’re asking me at the moment — depends on my goal of what I’m reading it for. Is it just pleasure or is it something that I’m interested in because it’s a subject I’m thinking of writing about and I want to see the lay of the land? But in general, I think like everybody else, I’m interested in tension. I’m interested in pathos. I’m interested in some investment in a character or in solving a mystery. I’m interested in the theme, which is probably what’s going to draw me to something in the first place. And I’m interested in variation. And as I said, usually these days I’ve been interested in technical questions. So all of my books, as you’ve read, have slightly different forms. I try to ask myself different technical questions, which I think I did when I was writing fiction as well. Can I write a mystery and can I write it from backward to forward? I would ask myself these things and then try to set out to do them. So I think I’ve bounced around both in what I consider satisfying and therefore what I consider good. I don’t know that there is a single “good” for me. Joshua Dolezal: Well, I guess we’re all hopefully evolving — we’re not stuck in our sensibility. But so the book we’re talking about today, A Living: Working Class Americans Talk to Their Doctor, is really kind of unique stylistically for your books. I had my suspicions as I was reading it and then discovered in your closing that you did, in fact, intentionally style it after Studs Terkel’s classic oral history, Working, which I think was published in 1974 — people talk about what they do all day. And so in this kind of form, you’re not doing the typical thing that a nonfiction writer does, which is act as a friend to the reader, as Henry James said, as a guide that frames things, contextualizes things, analyzes things. You do that a little bit around the edges. But really, this is a book where your patients tell their own stories in their own voices, much more like a curated or edited oral history form. So I’m curious why you chose that style. What about Terkel’s project felt necessary for you now to revive? And why is your voice so absent from this book compared to all the others? Michael Stein: So let’s put the Terkel comparison and the absence aside for a second and just give you my context for this book. A Living came out in 2025. Four years ago, I wrote a related book with a related structure called Broke. And Broke was similarly about talking to patients about money. So I’m a primary care doctor. I work in an inner city and I see people who are broke. That’s the primary focus of my work. The patient group I’m best known for is taking care of people with HIV or people with addictions. So I’ve naturally grown to populations that are vulnerable and generally poor. And people were just talking to me all the time about money. It was just a constant part of our conversations. And I just thought, nobody writes about how money influences the lives of people. And so here enters two things with Broke. One is I’m in a public health school — poverty is the primary driver of public health in the United States, so there’s a political angle for me. Number two is to go back to your earlier question: I used to write poetry. So I’m drawn to short forms and pith and adjacency of people talking about things that are bouncing from here to there. And like poems, or poetry books in general, I sort of believe in accumulation — which is, while poets will tell you they write books and spend a lot of time organizing their individual poems into some order, the truth is you can dip in and out of a poetry book on any page. The order usually doesn’t matter to the reader. It matters much more to the writer. But what the writer wants, I think, at the end of any of these accumulated books — which I consider Broke and A Living to be its ancestor — is accumulation. They want a sort of overall powerful impact. Okay, so that’s the context. A Living came from Broke. The population of having no money turns out to be, in our world, a population that does manual labor. So a lot of my patients talked about their work, and they do physical work. And I thought, no one ever writes about physical work. And along came — interestingly — two things I wasn’t aware of when I started to write the book. One is that we would have a MAGA movement, which has strong feelings about physical work, and that was an important dimension I didn’t see coming. And the other part I didn’t see coming is what AI would mean, which I think is going to have a profound impact on what we mean by work. And then I happened to read that it was Studs Terkel’s Working 50th anniversary. So I thought, I can get my book out in time to mark his 50th anniversary. So that’s the context — it was sort of a follow-up to Broke, it was a topic that had both health and political interest to me, it was meant to be poetic in its accumulated format, and it happened to fall on the 50th anniversary. So those things are what led me to write A Living. So let me answer the final part of your question, unless you want to interrupt. The other part you asked is why I’m absent. Is there something else you want to ask first, or should I just keep talking? Joshua Dolezal: No, let’s finish that. I mean, I understand you want normal people to tell their own story. These are voices that fit my series — these are the things not named, the people not named. They get these perfunctory social histories. Since the 70s, there’s supposedly been a biopsychosocial method used, but a lot of times it feels perfunctory. You ask a few questions to fill in the section on the chart, but you’re taking a much deeper dive into personal lives that you see as really intellectually linked to health. And so I assume that’s one of the reasons why you pulled yourself back — just to let the reader connect more of those dots, listen to those stories without as much of a filter. But what are some other reasons? Michael Stein: I appreciate your reading of it, thank you. I think you’re right on with that. I guess I would say — and then we could talk about how it’s different from the Studs Terkel book — what I tried to do in A Living was what a primary care doctor does in their office, which is: the story when you come into my office is not my story. It’s your story. My job is to do observation and at some point make a judgment, and then share that judgment with you and then discuss what the options are based on my judgment. And so frankly, there’s very little room for me in the best medical encounters — the doctor’s not there talking about themselves. So it seemed to me, in the representation of people that reflected the actual setting, I should let them talk. And while I could guide them, I didn’t need to have much about me in the book. You’ll get little bits of me guiding the conversations and you’ll have a sense of me from that. But once I start inserting myself with large swaths of judgment, it becomes a very different book. It becomes a memoir, and it wasn’t meant to be a memoir. And so my job was really to take years and years of patients talking about their lives of physical labor, organize them, not really talk about their medical illness at all because it’s not so relevant to the story. And if you’re seeing people with physical labor who have, let’s say, arthritis — a common thing among physical laborers — how many times is it worth me saying this person is here with arthritis? So it seemed irrelevant. I really pretty much removed all medical diagnoses from that. It also helps de-identify the person. And then I just let them talk and guide them. And the job of the writer, therefore, is to create an organizational schema that allows the accumulation. So I divided the book into some themes that people talk about around physical labor — working with their family, what’s the structure of the day, how does physical labor give you identity, et cetera. The structuring was the structuring part. Now the risk — the risk of doing this — so Studs Terkel, first of all, didn’t only do physical labor. He did a lot of office work in that book, which was relatively new in the 1970s when it was coming along. And so mine is just physical labor. His sections are pages and pages long and have much more biographical detail. Mine are what I call scenelets — tiny little scenes. And they’re really just: can you capture the life of a person through their one little story? And so it asks, as you said, a lot of the reader. It says, you have to see why I’m putting these all in one place. And then you have to be interested in some of these people and think, that’s an interesting thing they said, I wonder what that means. The downside to this as a writer and as a reader is that it’s frustrating. You go, I want to know more about that person, and Michael just moved on to the next person. And so I get that frustration, and it asks a lot of the reader to put together a larger story. But to me, it was a form that could hold what I was trying to do. Joshua Dolezal: I appreciate your description of it as like a book of poetry. A favorite point that I used to make while teaching medical humanities is that people are more like poems than they are like puzzles, and getting comfortable with ambiguity is the secret to getting comfortable with people. So to not force homilies or neat takeaways from each of the stories fits with how we interact with people generally. And I like how each of them is self-contained, but then also part of a whole that accretes, that accumulates, that builds up to something bigger. There’s a sense in which this could be a stage performance. I don’t know if you’ve thought about adapting it. Michael Stein: Somebody said that to me afterward. I had never thought of that. But yes, people said, do this as a play, have people come in and speak. Joshua Dolezal: Yeah, or it could be in film, where the scene or the camera changes. I’m curious — and just so if you haven’t seen this book I’ll hold it up — there are these facts that are also in large type. So in this one it says, “In the United States, about half the labor force is employed in working class jobs, defined as manual labor, service industry, and clerical work, and fewer than two percent of members of Congress worked in such jobs before being elected.” So there’s a fact, there’s no real context for it, there’s no real conclusions drawn from it — that’s something the reader is invited to do with what they will more or less. But it does add a little bit of texture as we go. Michael Stein: Yeah, it gives you some sociology, but it doesn’t give you an argument. This is not an argument book where at the end of the day you go rah-rah, here’s what I believe. It’s not meant to do that. Now is there a hint of that through those bits? Yes, because I’m a political person and I do public health. So I took advantage of my platform and allowed myself those bits. I had little introductions to the sections and then I put in these factoids. They’re not meant as arguments. As you said, they’re not even causal. They’re not high science. They’re just notes about the world that you should know when thinking about a group that is pretty invisible to most people of a certain class. And I have the good fortune of working with them and hearing about their jobs. I mean, part of this really had to do with — it’s just interesting to hear people describe what they do. Like, to hear a person describe the making of a sailboat or a wind turbine, or how you actually cut veal from the bone or groom a dog. I’m a weirdo, but that sort of interests me. And it sometimes quite directly affects their health. And sometimes it doesn’t. Sometimes it comes up because as a respectful conversationalist who has the time in an office with people he knows well, it feels like a way of connecting to somebody. If you came in to me and said, I can’t breathe or I have a terrible sore throat, I’m not going to talk to you about your physical labor job — let’s deal with the immediate medical issues. And other times, people come in because they have vaguer complaints, at which point trying to understand who they are is a matter of doing good medicine. And if they spend 10 hours a day working, if you don’t know about their work in detail, I don’t think you can do my job particularly well, or at least part of the job. Joshua Dolezal: Excellent point. Michael, there’s a line in your intro — and I think this provides just that little hint of guidance that a reader needs to make sense of the excerpts to follow — but you’re trying to kind of interrogate what’s lost besides a paycheck when work disappears. And this was something that I hadn’t thought about directly. I knew it because I come from a working class family in Montana. My uncles were loggers. My father was a civil engineer. I’ve done firefighting with the Forest Service. One of my great-grandfathers is in the North Dakota Cowboy Hall of Fame. The typical narrative is that work is hard on your body — that breaks your body down, and that’s the source of all your ailments when you go to the doctor. But you really point out how the absence of work, because work is a source of identity, a source of structure, a source of connection — when you don’t have work, that actually creates pain. The people that are not employed are much more likely to be on pain medication. And it also contributes to illness in ways that are not typically observed. So what else can you say about how these stories taught you about what’s lost besides a paycheck when work is taken away? Michael Stein: I think work is fundamental for most people — some form of work. Obviously people who find work meaningful or have a purpose in their work, that’s very important. Some people don’t find their meaning in their work and do it because they need the money and they’re just getting through the day and doing a paycheck. And I think writing about how people find their work respectable — or not — is a way of respecting them. And I do think that the loss of work for people who have worked their whole lives — because of a change in their industry or an injury to themselves — is devastating. And I try to tell those stories among people who lose jobs. We know from a public health point of view that mental health symptoms are related to not only the stress of work, of which there are many other stresses in life, but that’s certainly one of them. Certainly the loss of work is something that affects people’s mental health dramatically. And that’s often where things land in my office. There are direct injuries from work that one has to deal with. And there are very indirect pieces of life that have to be evoked or brought up in conversations. We talk about medicine as a history and a physical, and the providing of that history is a form of storytelling. And the storytelling of medicine is really about the question of why. So if you come in to me and you have broken your hip — you fell and you broke your hip, maybe at work, maybe at home — the immediate question for most doctors, rightly, is: you broke your hip, now what do we do? Does it need a pin? Does it need a hip replacement? What does it need? That’s so uninteresting — well, it’s important to the patient and it’s the doctor’s livelihood and the outcome is obviously super important. But for the storyteller, the question is, why did you fall down? That’s where the story actually starts. And so until you get into, well, what was the job that you were doing? And, oh, wait, you fainted on the job? Why did you faint? Or, oh, you were drinking before work? At that point, the story is — as in all good stories — what’s relayed and what’s withheld. That’s what a storyteller’s job is. What do you relay and what do you withhold? And frankly, that’s the psychology of chronic illness. That’s the chronic illness storyteller’s mode as well. What am I going to tell this doctor in front of me and what am I going to withhold? I could break my hip and never tell you that I was drunk at the time, but there are going to be consequences to not telling, and you’re not going to be taken care of. But the way we tell a story to a doctor is a way of telling about yourself — how you want to be seen and understood, and what you believe are the laws of cause and effect. And those are important things to know as a doctor and as a human. They are the essential elements of all storytelling in fiction and nonfiction: how do you want to be seen and understood, and what do you believe the laws of cause, effect, and motivation are? To me those are the elements of storytelling. I’m lucky enough to see that with patients, and if you’re open to it and have the time to do it — which we don’t all do. And let me just say, there are plenty of patients who don’t want to tell you these things. And you’re missing their story, and that’s okay. And there are plenty of doctors who don’t have time to take the story. And that’s usually not okay in chronic care. It’s okay mostly in orthopedics, but it’s not great in primary care. Joshua Dolezal: Let’s take one of your characters. Most of them are one-offs — we hear from them once and then they’re gone. Some of them reappear. But one runs from beginning to end and you call him Dennis. Presumably not his real name. And he had this job for many years — I’m not going to be able to pronounce the quahog term or whatever it is, but he was a clammer. He had a boat. And he would bring you clams when he came to see you. And then he loses that — he can’t fix his boat or he hits a series of problems — and so that work is taken away from him. And you seem to be invested in getting him back on the boat, which seems challenging to do. So why did you emphasize Dennis’s story so much in the book? And what do we learn from Dennis that’s representative of the cohort of working class patients the book covers? Michael Stein: Thank you so much for asking that. So there are a couple of things. Let’s talk about the technical part first, then we can talk about Dennis. The technical part is: one of the risks of having 150 people telling 150 stories is, because I’m a reader too, well, what’s the connection across all of this? Give me something I can carry through from beginning to end. People read novels — having written novels, I know — because they want to see a character move from beginning to end. They want what’s called a story arc. And so to me, putting one character in over time gives you a story arc. If you’re interested enough in that character, you’re going to get a little ping every time Dennis comes back. And you’re going to realize that he’s the only one really who’s coming back. The original version of the book, frankly, had nobody’s name in it. And I gave one person a name — Dennis — and then I decided, let’s give everybody a name. It makes it more human. But the truth is that Dennis was a technical, crafty device: give the good reader a narrative arc. So things happen to Dennis. We have a longitudinal timeline. We have things happen within the stories he tells about himself. And one could imagine this book being written as: I choose six Dennises and tell six stories over time. And many books do that. Most classic nonfiction books by journalists always start with a character or a family and carry them over time. Even though you’re interested in eviction as a subject, you better give me four characters who’ve been evicted so that I can humanize it. That’s the classic approach. It’s never been a great appeal to me. So I sort of strip it down to: I give you one character over time. We call him Dennis. So why Dennis? Dennis had a lot of qualities that I personally admired that came out through his work, and as you noted, through periods when he didn’t work and what that did to him. So Dennis was a guy who did quahogging, clamming, and also drove a tractor, and was very dependent on motors and money to actually get into his job. If your snowplow doesn’t attach, you’re not going to make money that snow, and if your motor’s out, you’re not going to get paid. So part of it was that things actually happened in his life over real time. And he had these qualities — he was extremely prideful about his work. He loved his work. He had no sense of that work being problematic at all. It connected him to people in his family. He had no regrets about the work. He was essentially an optimist — as anybody who does fishing, you know, if you throw a line into the water, you’re essentially an optimist. He was a total optimist. I liked that. He was a little confused about himself. He was a bit of an unreliable narrator. He had some self-knowledge. He drank too much at times in his life. So he had obstacles. Between his obstacles, his personal vulnerability, his pride, his ability to do things I didn’t know anything about — and learning about bay water, where you find clams and how one does that and how cold the weather is and how you use a very long rake to get to the bottom — I think there were personal things about him and then also the aspects of change in his life that I could portray in a number of episodes over time. So that’s why I chose Dennis. There were a few others that I could have chosen, but he was the one that appealed to me. Joshua Dolezal: And to link Dennis to some of those factoids that you give — a couple of them that are interesting: 20 million jobs in 1979 in manufacturing versus 12 million jobs now, but 50% more population. So more people, but roughly half the same number of jobs. And then also, in 1950 a third of Americans belonged to a labor union. That became one in five by 1983, and then one in ten by 2019. So these are kind of standalone things. You do teach at a health policy institution, so I’m assuming that you do have arguments to make about these things, but you don’t make an argument in this book, as you’ve said. Would there be changes in health policy that could benefit someone like Dennis? Are you talking about more holistic reforms in labor law? Are you talking about things that average citizens could do? Maybe there’s no cure exactly, but is there any kind of legal or policy change that you think this book could help encourage or inspire? Michael Stein: Well, there are many, and I don’t know that we want to go deep into it, but the simplest one is — unlike every other industrialized, high-income country — we should have paid sick leave. I mean, that’s a simple — well, not simple, because we can’t seem to do it — but paid sick leave would be very good for people. They would not come to work and make us sick because they didn’t want to miss their paycheck, and it would be humane. That’s the simplest health policy piece that’s important. But there are obviously broader issues. The Broke book that I wrote is a bigger issue — I think it’s very clear that poverty is the primary driver of health in the United States. One of the very fascinating and underappreciated things about COVID — which was obviously disastrous in many ways, and which we’ve almost completely forgotten at this point — was that due to federal government policy, we had the lowest poverty rate in 50 years in America. So in the middle of the biggest health disaster on earth, the United States had its lowest poverty rate. There’s this weird silver lining in the middle of COVID. And it was dramatic — childhood poverty went down by something like 80%, which tells you that we have soluble problems in the United States that are very large problems and that drive health — and much else — and that are soluble should you decide to act on them. So these public health problems are problems of public will or political will. Be politically involved. I’m not sure you want this to be a political broadcast, but that’s my feeling about some of these things. And the physical labor book really speaks to — sick leave is the most obvious one. But what’s interesting is I started writing this and watching AI come along. Because what we worry about with AI — or what the AI boosters are telling us — is that the jobs that are going to disappear are white-collar jobs. So it’s interesting that these jobs that we considered most fragile, most difficult, most demeaning are probably going to be the last jobs to be hit by AI. It’s hard to have an AI robot plumber. And that’s interesting to me — that these people will be more secure than my lawyer friends five years from now. Joshua Dolezal: Yeah, well, the jury’s out on that. But a lot of the AI stories also warn of this so-called permanent underclass — if you don’t adopt AI, you’ll be left behind. Michael Stein: Or that there will be no jobs left in America and we’re all going to be unemployed. And what’s the health going to be like then? Joshua Dolezal: Right. Related question, also possibly too big to really tackle. I just wrote last week about the fantastic show The Pitt, which really exposes the burnout problems in American ERs. And also the same thing that pushed me out of higher ed — the corporatization of the university — is plaguing hospitals. So you have an attending physician, the director of the ER, saying, hire more nurses. And then you have an admin, the chief officer, saying the budget comes first. And there seems to be a bottom-line mentality that’s strangling the hospital in the same way that it’s strangling the universities. I don’t know if there’s anything from a policy standpoint that can change there. I don’t understand why it’s so inevitable that we have to be limited by budgets and by this idea of scarcity when the public good is a clear necessity and when the cost of sacrificing the public good is so great. Michael Stein: Yeah, so those are big questions. So let me put on my public health hat. When you’re a doctor like I am who’s worked in the academic medical world for years and then jumps into a public health school — which I did, and eventually became dean of the public health school — it’s a very different world from medicine. So let me take you into the world of public health, because we get very stuck with medicine. We get stuck with it because we have shows like The Pit that tell stories that take place in the world of medicine. It’s very hard to tell public health stories. In fact, I wrote a book about this called Me Versus Us, which explains why we talk about medicine and not public health — why medicine has so dominated the public conversation — whereas, in fact, the only thing that will improve our life expectancy will be public health. So public health is a completely underfunded, underrated, under-discussed ethos, essentially very different from medicine. And the book Me Versus Us explains about nine reasons why medicine has beaten up public health. They’re good reasons and they’re bad reasons. It’s a complicated story. But the notion is this — my analogy is soccer, for those of you who love soccer like I do. Medicine is essentially the goalkeeper. You want a really good goalkeeper, but the game is played on the field by the other ten people. And in fact, if you never have to use the goalkeeper, you’re probably going to win the game. So public health are the other ten players, and medicine is the goalie. Great to have a good goalie, better never to use them. And so if we actually had a public health system, we wouldn’t have these ongoing conversations about medicine. So I always start by taking people away from medicine, because their eyes immediately go to the shiny object of medicine because it’s so much of our economy. And because it’s so much of our economy, the things that you’re talking about — the corporatization of medicine — are really money questions. So if you want to talk about money questions, it gets complicated. In some ways, the answer to medicine and its expense in the United States — which is really driving in part the main issue of medicine in the United States, which is access to care and why 10% of our population doesn’t have access to care — is important. Okay, so it’s a long way around to say: here are the issues. There’s the access issue. There’s public health that prevents you ever from going to a doctor. Okay, now you’re 80 years old and you have to go to the doctor. You want the best doctor at 80 years old. In fact, in America, the best part of our health care is for people who are over 80. If you get to be 80, you want to live in the United States rather than any other country in the world — that’s completely clear to me. Until 80, I’m not sure that you want to live in the United States if you’re the average person in poverty. It’s not so great for you. You’d rather live in 25 other countries than here. And so the issues around the United States really come down to price and economics. If we lowered the price of things in medicine — which is really a price problem, from drugs to ERs — you wipe out the jobs of a lot of people in their communities. So if we take medicine and bring it down to a lower share of our GNP, you’re going to have a lot of unemployed people who now work in medicine, which is the major employer of most cities in the United States. So it’s a complicated question, the interaction. All of that is to say: at the personal level, the doctors who are taking care of you have to make some personal decisions about how they want to interact with you and how they want to deal with being told they have to see people every 15 minutes and rush. That’s a separate question. I’ve always considered it a very personal question — how you deal with the corporatization around you and whether you want to comply with it or not. Joshua Dolezal: That’s good. I love the soccer analogy, and the separation of public health and medicine makes perfect sense. I love your metaphor for that. To wrap up, maybe two questions here. And I want to tie this back to your other recent book, Accidental Kindness [https://www.michaelsteinbooks.org/copy-of-me-vs-us], which we’ve almost entirely run out of time to talk about. But no matter what the limitations are in terms of price or time — when you’re talking about limits and how many patients you can see in a day and so on — the argument that you make in that book is that kindness doesn’t cost more. Kindness doesn’t require more time necessarily. It can be a default setting that is simple and that, for reasons that seem elusive, is not obvious to all doctors. When I was reading Accidental Kindness, which is an argument book very different from A Living, you open with your experience as a medical student and a kind of stoicism that you were taught — this kind of machismo or indifference to cadavers and an almost unfeeling approach that your professor was trying to teach you. And it reminded me of a scene in Patch Adams where the dean of the medical school gives the first-year students a speech about how human beings are not worthy of your trust because they make mistakes and get tired — so our job is to ruthlessly train the humanity out of you and make you into a doctor. And it seems almost identical to your experience, that the humanity was being trained out of you, and along with that was kindness being trained out of you. I don’t know if you would agree with that, but why does that keep happening when kindness remains so essential to effective care? Michael Stein: Oh, we have how many minutes? That’s its own talk, Josh. That’s its own conversation. So let me just say, first of all, Accidental Kindness is a series of essays. It’s much more memoir-y — it’s really about me and some experiences I had where I said things or did things that I didn’t know at the time were either kind or unkind. That’s why it’s accidental, because I didn’t know until after the fact that I had done something that was quite unkind or not. So that’s the framing of the book. I always start by saying I’m a lover of kindness — it’s a spiritual act. But I also want a doctor who’s decisive, efficient, and competent. So I’m not interested in a completely kind person who doesn’t have those other things. Let’s always separate what we call empathy from actual competence, because you can be deceived as a patient where a person’s really nice but just really not a good doctor. So let’s start with that. Does it have to keep happening that kindness is trained out of people? I’m mixed about that. I do think that there is a selection bias — you take certain people into medical school, and most medical schools look for an array of people who are going to do different things in medicine, which require different attributes. So not everybody’s going to be what I would maybe call naturally kind. And then something happens to them in the training, which we know happens to people under great pressure, duress, and sleep deprivation. It changes people. For doctors or clinicians of any kind — social workers, physical therapists, nurses, not just doctors — how much are you able to be vulnerable to others and what they’re saying to you and asking of you? And I think that’s a hard task day in and day out for anybody, even with the best intentions. And I think awareness — am I seeing this clearly? Am I feeling this directly? — is a very important part of the self-awareness game, and we’re good at it sometimes and not good at it others. If you’ve been up all night with your screaming child or you have a child sick at home, you’re going to treat others differently when you have to go to work the next day. I also think that notion of paying attention — that largeness of spirit — is an important and a spiritual act, and we’re all imperfect. And I think patients have to accept this. And I also think they really do want kindness. They remember unkindness, but they really want kindness. And unkindness is never acceptable. But we’re lucky when we get real kindness. And I think that’s true everywhere in life, and unfortunately sometimes true in the office. One of the essays I wrote about is this notion of: can you be overly kind in the office? Part of what I think when you talk about burnout in medicine — I want to put a nice spin on it — is that people who are very compassionate, who are very kind, get fatigued. And that burnout, which we think of as negative, really came from a place of people being involved. You wouldn’t have burned out if you weren’t burning in the first place — I always say that. And that burning is what kindness and compassion is. It’s that tolerance and indulging of other people where you can say to them, and feel it yourself to a degree: a sad thing has happened to you, and I’m here in that sadness with you, and now let’s do some things about it. So that’s what I would say — a complicated, not sentimental, view of these things. One of the essays in Accidental Kindness is: is there any evidence that actual kindness matters to patient outcomes? And it’s very hard to find, frankly, because it’s a hard thing to test as a scientist. But spiritually, it’s the right thing. And as patients, we all love that feeling and that covenant we have with these providers who save our lives. Joshua Dolezal: We don’t have time to dig deeper into Accidental Kindness, but I’ll be sure to include that in the show notes. Final question, if we have time for one more. My series for the podcast is called The Things Not Named. It fits your latest A Living, which is an act of kindness in its own way, listening to these untold stories. So I’m curious — I’m sure you have other book ideas and maybe you’re superstitious like other writers and don’t want to talk about them — but what are some other things not named in medicine that you might explore in future books or that would be worthy of exploration? Michael Stein: Well, I have a book that will be out next year that is tentatively called Will Science Survive?, which is about that question and what we mean by science and what are the attacks on it and what are the unexpected pieces of it. So that’s something I’m writing about in sort of a larger philosophical vein. I’m also interested in this idea of: is health a human right? Which is sort of out there in the world. I don’t quite know what that means, and so I want to try to explore that a little bit. And I have a variety of other projects that I’m in the middle of that I won’t tell you about. But yes, there are lots of things to write about. Joshua Dolezal: We will stay tuned. Michael, thanks so much for joining me. Michael Stein: Josh, thank you. A great pleasure. Joshua Doležal: Michael Stein’s latest books, A Living [https://www.penguinrandomhouse.com/books/780358/a-living-by-michael-d-stein/], and Accidental Kindness [https://www.michaelsteinbooks.org/copy-of-me-vs-us] are available wherever books are sold. You can learn more about his writing at michaelsteinbooks.org [http://michaelsteinbooks.org], and I’ll put links in the show notes. The Recovering Academic is made possible by the support of readers and listeners like you. Thank you. Save the date for my next Substack Live. On Tuesday, May 19, at 1pm Eastern, I’ll speak with Dr. Lakshmi Krishnan [https://substack.com/profile/23703884-dr-lakshmi-krishnan], Assistant Professor of Medicine and Director of Medical Humanities at Georgetown University. That’s the thing not named for today. Until next time. The Recovering Academic [null] explores the messy intersections of medicine, culture, and storytelling. I write three new essays a month, hold live interviews, and produce a podcast about the things medicine leaves unnamed. This is all made possible by paid support from readers like you. More episodes of The Things Not Named ⬇️ This is a public episode. If you'd like to discuss this with other subscribers or get access to bonus episodes, visit joshuadolezal.substack.com/subscribe [https://joshuadolezal.substack.com/subscribe?utm_medium=podcast&utm_campaign=CTA_2]
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