On Becoming a Healer

In can be confusing and even demoralizing for a medical student or resident to understand what’s expected of them when caring for patients with social needs.  They already feel overwhelmed. Are they supposed to now also screen for housing insecurity? Is it their job to intervene to address social needs? And if someone else is doing the screening, what’s their role? And are they also supposed to be advocating for changes to social policies?  Finally, what’s special about social needs as opposed to all the other reasons that, for instance, a patient can’t control their diabetes? A patient may not be able to store their insulin because they are poor. Or they may not be able to administer it because they can’t read the bottle or their fingers are arthritic.  Our guest, Emily Murphy MD, an academic hospitalist, provides her perspective on teaching medical students and residents about SDOH. Co-host Saul Weiner, expresses concern that messages to trainees about their roles are confusing, that the SDOH movement is just the latest buzzword in medicine, like “patient-centered care,”, and that while getting a huge amount of attention the movement could ultimately have little impact on patient wellbeing. He, Dr. Murphy, and co-host Stefan Kertesz discuss these questions and concerns and consider what needs to change.

To commemorate the start of our fifth season, we revisit a conversation we had almost two years ago about the wisdom of Simon Auster, MD. Simon was a family physician and psychiatrist who inspired the conversations we’ve been having with each other and with guests on every episode.  “Simonisms” embody Simon’s insights: pithy observations about the practice of medicine that are never cliché, challenge commonly held assumptions and offer fresh perspectives. We share -- and reflect on -- these pearls because we believe they can help many doctors, those in training, and those who train them, find joy and meaning in their work.  You can learn about Simon, who died in 2020, in an online (open access) essay about his life, published in The Pharos [https://nam04.safelinks.protection.outlook.com/?url=https%3A%2F%2Fwww.alphaomegaalpha.org%2Fwp-content%2Fuploads%2F2021%2F03%2F2020_Autumn_Reflections.pdf&data=05%7C02%7Csweiner%40uic.edu%7C9c29f345ce004b94c15408dcebc4a6a5%7Ce202cd477a564baa99e3e3b71a7c77dd%7C0%7C0%7C638644477066133936%7CUnknown%7CTWFpbGZsb3d8eyJWIjoiMC4wLjAwMDAiLCJQIjoiV2luMzIiLCJBTiI6Ik1haWwiLCJXVCI6Mn0%3D%7C0%7C%7C%7C&sdata=63Bs8rWJe1mH3W1CyYszaVW7hJQS4NqlK3j68Xkj8Xk%3D&reserved=0], the journal of the AOA medical honor society.

The two doctors charged for their roles in the events leading up to actor Matthew Perry’s death were both involved in a “side hustle”: selling ketamine at a big mark-up to make extra money, above what they earned through legitimate practice. One was an internist-pediatrician and the other an emergency medicine physician.  Their cynicism was starkly evident in a text one sent the other about jacking up the price: “I wonder how much this moron will pay. Let’s find out.” It’s easy to write off these doctors as just bad apples; regrettable examples of how difficult it is to prevent a small number of unethical people from making it through medical school and residency.  But what about the profit-making that occurs when thousands of physicians perform procedures, including surgeries, for which there is strong evidence of NO benefit from randomized controlled trials, but with all the risks of pain and complications during recovery and over the long term? From a patient’s perspective is there really a difference between being subjected to predictable harm when you know your doctor is a drug dealer versus these practices within the mainstream of medicine where patients assume their physicians are acting in their best interests?   Which is the greater betrayal?

The term “Narrative Medicine” (NM) refers to a range of activities, including close reading and reflective writing about literature, designed to improve the clinician-patient relationship. What could go wrong?  Our returning guest, English professor Laura Greene, lays out the case for narrative medicine, while co-host Saul Weiner highlights his concern that the challenges and rewards of interacting therapeutically with patients are categorically different from those of a physician interacting with a text.  Unless proponents of narrative medicine articulate these differences explicitly, they risk creating unrealistic expectations about what NM can achieve, particularly in regard to actual healing interactions in the exam room.

There is an idealized version of physician-patient communication that is taught in medical schools, reinforced with acronyms like PEARLS, SPIKES, and LEARN, but what resemblance does it bear to how doctors actually sound in the exam room?  Co-host Saul Weiner leads a research team that has audio recorded and analyzed thousands of medical encounters. In this episode, he and Stefan read a transcript from a typical visit, portraying patient and doctor, respectively, breaking out of role periodically to reflect on what’s just happened. Throughout, the physician interacts with the computer, peppering their patient with questions while conducting data entry. On the one hand, the visit is unremarkable. The physician seems reasonably conscientious. On the other, it is disturbing for their lack of engagement even when the patient shows signs of distress or confusion. What can we learn and teach by studying transcripts of real doctor-patient interactions, warts and all?  Saul has posted over 400 of them, all de-identified, in a federal data repository [https://www.data.va.gov/dataset/Physician-patient-transcripts-with-4C-coding-analy/4qbs-wgct].