Narrative Medicine

New and Selected Essays

Arthur L. Lazarus

• Publisher: Academica Press
• Year: 2025
• Print ISBN: 9781680535815
• eBook ISBN: 9781680535822
• Edition: 0
• Topic: Medicine
• Subtopic: Literary Essays

Narrative Medicine: New and Selected Essays, by Arthur Lazarus, MD, MBA, contains the thoughtful curation of the author's best work alongside new contributions.

The book is divided into two sections:

Section 1: New Essays

In this section, 10 vibrant essays serve as a bridge between reflection and the future of the medical profession. They focus on themes that have emerged since the COVID-19 pandemic and have taken on a new urgency in light of our evolving healthcare landscape.

Section 2: Selected Essays

Here, 50 essays were chosen for their significance and quality, representing the author's finest additions to the discourse on contemporary medical practice. These essays explore a range of topics critical to the medical field: the arduous journey through medical training, the ethical dilemmas doctors face, the rise of artificial intelligence, the importance of mentorship and reflective writing, and the career challenges that can either make or break a physician's resolve.

Within these pages you will find a comprehensive gathering of essays and viewpoints that reflect the complexities of modern medicine and explore the intricate relationship between practice and storytelling, offering insights into how narrative shapes our understanding of patient care.

Table of contents

• Narrative Medicine:New and Selected Essays
• Arthur Lazarus, MD, MBA
• Narrative Medicine:New and Selected Essays
• Arthur Lazarus, MD, MBA
• Academica PressWashington~London
• Library of Congress Cataloging-in-Publication Data 
• Names: Lazarus, Arthur L. (author)
• Title: Narrative Medicine: New and Selected Essays | Lazarus, Arthur L.
• Description: Washington : Academica Press, 2025. | Includes references.
• Identifiers: LCCN 2025934747 | ISBN 9781680535815 (hardcover) | 9781680535822 (e-book)
• Copyright 2025 Arthur L. Lazarus
• ALSO BY ARTHUR LAZARUS
• Neuroleptic Malignant Syndrome and Related Conditions (co-author)
• Controversies in Managed Mental Health Care
• Career Pathways in Psychiatry: Transition in Changing Times
• MD/MBA: Physicians on the New Frontier of Medical Management
• Every Story Counts:Exploring Contemporary Practice Through Narrative Medicine
• Medicine on Fire: A Narrative Travelogue
• Narrative Medicine: The Fifth Vital Sign
• Narrative Medicine: Harnessing the Power of Storytelling through Essays
• Story Treasures: Medical Essays and Insights in the Narrative Tradition
• 21st Century Schizoid Health Care:Essays and Reflections to Keep You Sane on Your Medical Travels
• Narrative Rx: A Quick Guide toNarrative Medicine for Students, Residents, and Attendings
• To my family – my stories, your stories, our stories.
• And to all caregivers dedicated to the healing and well-being of others.
• Contents
• Preface xvii
• Prologue I Was Traumatized by a Patient I Never Met xix
• Section1: New Essays 1
• 1. The Growing Discrepancy Between Healthcare Promises and Practice 3
• 2. Dark Humor Allows Us to See the “Light” in Medicine 7
• 3. What I Discovered While Walking Through the Cemetery 11
• 4. Strategies for Healthcare Practitioners to Re-Engage with Patients 15
• 5. Embracing Mental Health Openness in the Medical Profession 19
• 6. Who Cares for the Healers? 23
• 7. Transitioning from Sick Care to Health Care 27
• 8. Utilization Review is a Crap Shoot 31
• 9. The Last of the Independents 35
• 10. The Big Picture in Psychotherapy 41
• Section 2: Selected Essays: Physician Issues 47
• 11. I Am Not What Others Think of Me 49
• 12. My Biggest Blind Spot is Me 51
• 13. Memoirs of a “Recovering” Peer Reviewer 55
• 14. Call Me In, Not Out, for My Transgressions 59
• 15. Like Many Physicians, I’ve Forgotten How to Relax 63
• 16. Sending in “Tougher Canaries” Won’t Fix the Problemof Physician Well-Being 67
• 17. Burnout On the U.S.S. Enterprise 71
• 18. Autism and Doctors: Strengths, Challenges, and Stories 75
• 19. Your Employment History Isn’t Spotless,So Learn to Master Job Interview Questions 79
• 20. Blues Power: Turning Heartache Into Healing 83
• Selected Essays: Education, Training, and Development 87
• 21. The First Time I Felt Like a Doctor 89
• 22. Breaking Point 93
• 23. Coping With Rejection Requires Resilience 97
• 24. I May Be Old School, but I’m Not Outdated 101
• 25. The Jobs You Hold Prior to Medical School are Important,but Not for the Reason You Think 105
• 26. Faking Your Way Through Medical School 109
• 27. I Competed with My Best Friend in Medical School.It was My Worst Nightmare. 113
• 28. From Resident to Academic Attending: The Challenges Ahead 117
• 29. The Ebb and Flow of Mentorship in Medicine 121
• Selected Essays: Patient Care 125
• 30. Allegory Is a Powerful Tool in Medicine 127
• 31. Treatment Is a Two-Way Street 131
• 32. What Does It Mean When We SaySomeone Has Lied After a Long Illness? 135
• 33. Medicine Has Become the New McDonald’s of Health Care 139
• 34. Spread “Aloha” in Health Care 143
• 35. Appreciate the People in Your Life 147
• 36. How the Time-Honored Tradition ofa Baseball Catch Became a “Test” for a Brain Injury 151
• 37. The Power of “Enough-ness” in Medicine 155
• 38. First Impressions Count in Health Care 159
• 39. Hidden Heroes Who Fought for Women’sReproductive Rights in the 1950s 163
• Selected Essays: Practice and Career Concerns 167
• 40. I Retired After Speaking Out. Now I Can Speak My Mind. 169
• 41. Whatever Happened to Professional Courtesy? 173
• 42. Have You Lost Your Desire to Practice? 177
• 43. When an MBA Degree Meets Medicine:An “Eye-Opening” Experience 181
• 44. Medicine Is a Joke, Except No One is Laughing 185
• 45. Never Ask Me to Be a Medical Expert Witness (Again) 191
• 46. Euthanizing Our Pets Teaches Us AboutProgressive End-Of-Life Care 195
• 47. The Artificially Intelligent Physician 201
• 48. How Should Unethical Legacies in Medical History Be Handled? 205
• 49. I Was Quietly Fired Even Though I Complied 209
• Selected Essays: Writing and Reflection 213
• 50. Narrative Medicine Writing Saved My Sanity 215
• 51. On Juneteenth I Learned the Ugly Truthof My New Hometown. It Restored My Faith in Humanity. 219
• 52. Discovering Self Through Creative Writing and Medicine 223
• 53. A Season of Emotions: Spring, Trauma and Healing 227
• 54. Man’s Search for Meaning is Spiritual, and Relevant to Medicine 231
• 55. Transitioning From Academic Writing to The Narrative 235
• 56. Why Aren’t You Writing? 239
• 57. Kick Start Your Writing with a Surprise 243
• 58. The Real Story Behind Woodstock is Not the Brown Acid 247
• 59. My Journey of Missed Journaling Opportunitiesin the World of Medicine 251
• 60. The Power of Story 255
• Afterword: Live Longer, Die Shorter:The Surprising Health Secrets to a Vital Old Age 259
• Notes and Sources 263
• About the Author 265
• — Paracelsus
• Preface
• In the constantly changing landscape of medicine, where the demands on healthcare professionals continue to intensify, narrative medicine offers a vital lifeline – a way to connect with the human experience that underpins all we do as physicians and healthcare providers. This collection of essays, drawn from a lifetime of observations, experiences, and emotions as a psychiatrist, reflects not only the challenges and triumphs of practicing medicine but also the deeply personal stories that shape our professional lives. They were written at a time when medicine was undergoing major shifts – some brought on by the relentless pressu es of modern healthcare, others by longstanding flaws that have simply deepened over time.
• Fifty of the essays included here have been previously published in one of my earlier volumes, selected as what I consider my most resonant work, representing my best attempts to capture the heart of contemporary medicine. They explore a variety of issues that I believe are critical to understanding not only where we are but also how we, as medical practitioners, might strive toward something better. From the systemic dysfunctions of the healthcare industry to the personal struggles of burnout and moral injury, these essays aim to paint a picture of modern medicine from both a macro and micro perspective: the arduous journey through medical training, the ethical dilemmas we face, the rise of artificial intelligence, the importance of mentorship and reflective writing, and the career challenges that can either make or break a physician’s resolve.
• The ten new essays serve as a bridge between reflection and the future of our profession. They focus on themes that have emerged more recently or have taken on new urgency in light of our evolving healthcare environment. They also address, more personally, my own transformation as both a physician and a patient – someone who continues to grapple with our missed interpersonal con ections, the painful realities of patient suffering, and the moral challenges that arise in this work.
• My journey through narrative medicine began as a way to understand, to critique, and, at times, to simply make sense of this path we walk as caregivers. Writing became a space to reconcile the disillusionment I, and many others, have felt with the often unmanageable demands and new characteristics of the system. It became a way to maintain my own sanity, as I watched systems around me consolidate, deteriorate, and crumble.
• In writing these essays, I have drawn upon my own experiences and those of the countless patients and colleagues who have shared their stories with me. It is through these narratives that we find meaning and connection, allowing us to traverse the most intimate moments of our profession with empathy and resilience. In the spirit of John Fogerty, who “Wrote a Song for Everyone,” I wrote these narratives for everybody who is part of this world of healthcare – whether as a physician, a patient, or an advocate. The stories I share are also for those who, like me, remain committed to the belief that healing can still happen, that cha ge is possible, and that medicine is ultimately about humanity.
• May these essays inspire reflection and dialogue, fostering a deeper understanding of the human condition and the pivotal role we play as healers. As you explore them, I invite you to consider your own narratives and the impact they have on your practice and personal growth. Together, through mutual stories and experiences, we can continue to campaign for a more compassionate and effective healthcare system.
• Prologue I Was Traumatized by a Patient I Never Met
• Soon after midnight, after a busy day on the inpatient psych unit, I slipped into a deep sleep. Then the phone rang in the residents’ on-call room.
• “Dr. Lazarus,” the voice on the other end inquired?
• “Yes,” I replied, half asleep.
• “This is Dr. Hendricks (not her real name) in the ER. Are you the on-call psych resident tonight?”
• “I am,” I answered drowsily.
• Every physician knows that nightly awakenings are part and parcel of being on-call. And like most residents, I had learned how to short-circuit several stages of sleep to quickly attain alertness when paged. But tonight, it was really difficult to wake up.
• “We have a patient down here. I don’t think you need to see him, but I’d like to run the history by you and see if you agree with the treatment plan before we send him on his way.”
• I sat up in bed and said, “Sure. Go ahead.”
• “The patient is in his twenties. He has a diagnosis of schizophrenia, and he lives in a local boarding home. One of the staffe s escorted him to the ER. The patient tells me he is hearing voices, but the voices are not telling him to do anything bad or hurt himself. Do you think it’s okay to increase the dose of his Haldol from 15 to 20 mg a day and set him up with an outpatient appointment in the psych clinic?”
• “Yeah, that sounds fine to me,” I replied, still groggy. There were other aspects of the history that should have been explored, so I added, “Do you want me to come down and see him?”
• “Oh, no. That won’t be necessary,” remarked the medical resident. “He looks pretty good. I’m just not too familiar with Haldol, and I want to know if bumping up his dose by 5 mg is appropriate.”
• “It could go higher,” I explained, “but that can be evaluated further when he is seen in clinic.”
• “Okay, then, Dr. Lazarus. Thanks for your help.”
• “Is it quiet tonight?” I asked before hanging up. That was code for asking whether any other psych cases were pending and whether I could count on a good night’s sleep.
• “Not much happening,” the resident replied. “Thanks again.”
• It took me less than 10 minutes to reverse the sleep cycle. I nodded off with a good feeling, comfortable that I was able to p ovide consultation without having to see the patient. It’s about time I caught a break, I thought, given that it was spring and I was two-thirds of the way through my first year of residency.
• The emergency department was run by the medical house staff, who liberally called upon psych residents to see depressed, addic ed, and psychotic patients, even though these patients were supposed to be transported and seen at the community “crisis center” located at another hospital. I felt I was fortunate to be spared a midnight consultation. I also thought it was admirable tha my counterpart in internal medicine attempted to handle the case herself.
• Suddenly, the phone rang at 3 a.m. I awoke faster than before. “Dr. Lazarus, this is Dr. Hendricks again from the ER. You’re never going to guess what happened!”
• Before I could utter a word, the resident continued in a distressed tone, “Remember the patient from the boarding home? Well, he paramedics just brought him back. He jumped out the third story window and it looks like he broke both legs. We’re going to take him to X-ray now, and he’ll probably need surgery. I just wanted to let you know.”
• All I could say was, “Okay, thanks for letting me know. I’ll make sure the psych consultation team sees him in the morning.”
• This time, I couldn’t get back to sleep. I asked myself how this could have happened. The patient was stable, according to the medical resident. He did not have command hallucinations. He was not suicidal or self-injurious. I lay awake second-guessing myself − and the resident − until daybreak. I should have seen the patient, I bemoaned, rather than take the word of a physician with less experience in my specialty.
• To make matters worse, in the morning, the ER staff notified the consultation-liaison (C-L) team about the incident before I did, and a rumor had spread that I had refused to see the patient in the emergency room. Shame and guilt set in immediately, like an IV infusion. I was interrogated by the upper-year resident on the C-L service. I assured the senior resident and the attending physician of the C-L service that I had offered to go to the ER at midnight, but I was told it was unnecessary. The C-L team appeared to be satisfied with my account but not with my judgment to do a telephone consultation rather than evaluate the patient in person.
• Clearly, the damage was done. The patient had sustained serious injuries. The house staff dubbed him the “jumper,” and I had become infamously associated with him. No matter how many times I replayed the incident, I could not forgive myself for not seeing the patient, even though a face-to-face consultation was never requested. I berated myself, thinking I should have known better, that a bad outcome would ensue.
• I became overwhelmed with anxiety. I began to dread being on-call. I tried to avoid seeing difficult patients. I became depressed, and I had all the symptoms of PTSD. My performance suffered, and it was noted by many of the faculty.
• I sought the help of a senior psychiatrist, who became my therapist. He was a kind and compassionate man who understood what I was going through. He assured me that even a modest improvement in my defenses – unconscious ways of managing conflict and strong emotion – could result in a sizable improvement in my life. But he warned me, “Art, unless you can acknowledge that a patien ’s fate is beyond your control, you will not survive in practice.”
• True to his words, I did not survive. A decade later I left academia for a nonclinical career. Along the way, I learned from my mistakes, and hopefully I’ve learned how to forgive myself and seek forgiveness from those I may have harmed. Most of all, the “jumper” impressed on me that caring for seriously ill patients, and those who have the potential to become seriously ill, can significantly impact our inner lives.
• “The inner life of individual physicians should, to some extent, be brought into the outer life of physicians as a collective,” remarked Dena Schulman-Green, PhD, in a letter to JAMA. In that case, writing about my experience has been long overdue.
• We all have skeletons in our closets that should be excised through writing. Writing about our experiences in a narrative or s orytelling format can help understand and process the events better. The goal of writing in this context is not to dwell on past mistakes, but to understand, learn from, and move beyond them.
• Section 1 New Essays
• 1. The Growing Discrepancy Between Healthcare Promises and Practice
• Pretending that the U.S. system isn’t broken is akin to “health-washing” and “sane-washing.”
• I’m sure you’ve gathered from the Prologue that after my crash at the end of my first year of residency, I began my second yea on a rough note. My underwhelming performance caught the attention of several faculty members. One professor advised me to talk about the situation with my psychotherapy supervisor, cautioning, “Make sure your supervisor doesn’t sugarcoat it.” The professor was aware that my advisor was a very kind and gentle person who might want to avoid discussing the specifics of my performance to avoid causing me additional distress.
• Sugarcoating the reality of a situation lessens the harshness of underlying events and sidesteps problems. But sugarcoating is exactly what we do when we soft-peddle explanations for the disparity between the outward appearance of a commitment to health and well-being and the actual practices or outcomes that fail to support this commitment. It is a growing practice seen across he U.S. in organizations or institutions that present themselves as prioritizing health and well-being, but their actions do not genuinely support or improve health outcomes.
• Such deceptive practices are akin to health-washing, i.e., deceptive marketing strategies that misrepresent a product’s healthiness to consumers. For example, the publisher’s introduction of Dr. Ken Berry’s book Lies My Doctor Told Me states: “The intent of this book is not necessarily to blame individual doctors; rather the purpose is to consider the health-washing of their medical education that has been tainted by vested interests – including the pharmaceutical and food industries – and ideological bias. The more you look, the more you find the agendas of industry and ideology that have affected research outcomes.”
• In extreme instances, health-washing may seem like sane-washing – attempting to downplay a person’s radical ideas to make them more palatable to the general public. You can choose whichever noun seems appropriate – sugarcoating, white-washing, or sane-washing – but the fact is, the gap between the reality of healthcare delivery and the way in which it is experienced by the public is widening.
• For example, healthcare systems may promote themselves as champions of patient-centered care, emphasizing their commitment to high-quality, compassionate services. However, in practice, they might cut corners, underfund essential services, or prioritize profit over patient outcomes, leading to substandard care.
• Insurance companies might market their plans as offering comprehensive coverage and easy access to healthcare. Yet, in reality, they could impose high deductibles, copays, and restrictive provider networks, making it difficult for patients to receive the care they need without significant out-of-pocket expenses.
• Hospitals and clinics might advertise advanced technology and state-of-the-art facilities to attract patients. Despite this, they could neglect basic patient care standards, staff training, or maintenance, resulting in a disconnect between their marketed image and the actual patient experience.
• Pharmaceutical companies might claim to prioritize patient health and innovation in their promotional campaigns. However, they could engage in practices such as excessive pricing, aggressive marketing of drugs with marginal benefits, or withholding negative study results, which undermine true patient welfare.
• Employers might implement wellness programs and promote a healthy workplace culture, yet fail to address fundamental issues such as toxic leaders or excessive work hours that contribute to employee stress and unwell providers.
• Policymakers might publicly endorse healthcare reforms and initiatives that promise to improve access and quality. However, the actual policies may be underfunded, poorly implemented, or designed to benefit special interest groups rather than the general public.
• The discrepancy between healthcare promises and practice is especially problematic in mental health care.
• Healthcare organizations may launch mental health awareness campaigns or programs that look good on the surface but lack substantive support or funding. For instance, a hospital might promote mental health awareness during Mental Health Awareness Month but fail to provide adequate mental health services or support for patients and staff year-round.
• Some institutions might implement minimal mental health resources, such as a token mental health professional on staff or an employee assistance program (EAP). But beyond the limited number of sessions provided by EAPs, there loom long wait times to be seen for therapy in the community, as well as high costs and insufficient and – in some cases – inadequately trained providers.
• Employers in the healthcare sector might promote a culture of wellness and mental health support for their employees, but fail to address the underlying causes of stress and burnout, such as excessive workloads, inadequate staffing, or lack of support for mental health days.
• Healthcare services, both physical and mental, are on the brink of chaos and collapse. Everyday we read about hospitals throughout the country losing millions if not billions of dollars per year. Hospitals are closing urgent care centers, obstetric, pediatric and other services to try to survive. The reduction of services has greatly affected access to all areas of health care, and individuals have lost the ability to get timely appointments, x-rays, and tests. A massive shortfall of staff and dependency on temporary staff has compounded the crisis, resulting in an inability to transfer patients from emergency rooms and other se tings to appropriate facilities.
• A 2024 report of The Commonwealth Fund compared health system performance in 10 countries and concluded: “The U.S. continues to be in a class by itself in the underperformance of its health care sector. While the other nine countries differ in the details of their systems and in their performance on domains, unlike the U.S., they all have found a way to meet their residents’ mos basic health care needs…”
• I hope the Commonwealth Fund report and similar exposés will put an end to over-selling the virtues of America’s healthcare system and prompt meaningful reforms. Our local and national leaders must do more to address these issues.
• 2. Dark Humor Allows Us to See the “Light” in Medicine
• But don’t forget to speak softly and tread carefully.
• During a visit to our daughter and her family in Columbus, Ohio, my wife and I went grocery shopping. I noticed a dialysis cen er nearby and joked, “If we decide to settle in Columbus, I won’t have to go far if my kidneys fail,” given my stage 3b chronic kidney disease.
• My wife didn’t appreciate the humor about my kidneys, despite their stability for the past 20 years. In general, she isn’t fond of dark humor, which has been a recurring point of contention in our marriage. I tend to use it frequently, while she finds it cruel and unkind. As we stood in the parking lot, I explained that I’ve relied on dark humor as a coping mechanism for my heal h and my patients’ health for over 40 years. She insisted it was insensitive and preferred to focus on the positive. I mentioned that medical school had shaped my perspective, but she urged me to change my ways or find healthier coping strategies.
• Once in the car, Bob Dylan’s “Knockin’ On Heaven’s Door” played on the radio, and I couldn’t help but laugh at the irony. I saw it as a form of divine intervention in our discussion about health and mortality related to kidney disease. When I explained my laughter, my wife, initially confused, felt that it was adding insult to injury.
• “The House of God”
• Dark humor, often characterized by its morbid, sardonic, and sometimes shocking nature, is ubiquitous in the field of medicine. It can be heard in the ICU, operating theatre, emergency department, and perhaps for the first time for many aspiring physicians, in anatomy lab. But while often serving as a coping mechanism for medical professionals, it can sometimes cross the line in o inappropriateness, particularly when it is perceived as insensitive or disrespectful to the patient, acting as a barrier to compassion and empathy. (A patient was the brunt of dehumanizing jokes – recorded on his smart phone while sedated and undergoing a procedure – and was awarded $500,000 for malpractice and defamation.)
• Samuel Shem’s novel The House of God, which provides a satirical and often irreverent look at the lives of medical interns in he early 1970s, is filled with instances where dark humor is used to highlight the dehumanizing aspects of medical training and the coping strategies of young doctors. For example, the interns in the novel refer to certain patients in dismissive terms and use acronyms like GOMER (“Get Out of My Emergency Room”) to describe elderly patients with chronic conditions who frequently return to the hospital. While these terms reflect the interns’ frustration and emotional exhaustion, they also underscore the potential for dark humor to devalue patient experiences when used insensitively.
• “M*A*S*H”
• M*A*S*H, a novel by Richard Hooker and later a movie and television series, is a quintessential example of the use of dark humor in a medical setting. Set during the Korean War, M*A*S*H follows the lives of surgeons and staff at a Mobile Army Surgical Hospital. The series is renowned for its ability to blend comedy with the grim realities of war, using dark humor as a means for characters to cope with the stress and trauma of their environment.
• Characters like Hawkeye Pierce and Trapper John McIntyre use wit and sarcasm to deal with the overwhelming challenges they face, such as the relentless influx of wounded soldiers and the constant threat of danger. Their humor often serves as a shield against the emotional toll of their work, allowing them to maintain a sense of humanity amid the chaos. The humor in M*A*S*H is no just for entertainment but serves as a commentary on the human condition, emphasizing the resilience and camaraderie that can emerge in adverse situations.
• COVID-19
• The unprecedented nature of the COVID-19 pandemic, characterized by widespread fear, uncertainty, and significant stress, led many to turn to dark humor as a way to manage their emotions and maintain morale.
• Healthcare workers, in particular, faced extraordinary challenges, including high patient loads, resource shortages, and the emotional toll of treating severely ill patients (see essay 6). Dark humor provided a way for them to express their frustrations and fears in a manner that could help alleviate stress. Jokes and memes about the realities of working during the pandemic circulated widely among medical communities, often highlighting the absurdities and challenges of their daily experiences. This type of humor functioned as a form of coping and bonding, helping to build a sense of community and shared understanding among those on the front lines.
• Preventing Overload
• In the high-pressure environment of medical practice, where decisions can have life-altering consequences, dark humor can help in normalizing the abnormal, making the overwhelming seem more manageable. It offers a momentary escape from the seriousness of medical duties, allowing healthcare workers to distance themselves emotionally, albeit temporarily, from the suffering they wi ness daily. This detachment is not indicative of a lack of empathy but rather a necessary strategy to prevent emotional overload and compassion fatigue.
• However, the use of dark humor in medicine is not without its ethical and legal considerations. It is crucial that such humor emains within the confines of the medical community and is not expressed in front of patients or their families. Tread carefully. Speak softly when walls are thin. Dispense with elevator talk. And don’t forget smart phones are everywhere. Additionally, i is important for medical practitioners to be mindful of the diverse backgrounds and sensitivities of their colleagues, ensuring that humor does not inadvertently contribute to a negative or hostile work environment.
• While it is important to consider the context and audience, humor can be a powerful way to navigate difficult times, offering oth psychological relief and a way to connect with others experiencing similar hardships.
• I believe that dark humor allows us to see the “light” in medicine by capturing its dual role as both a coping mechanism and a means to illuminate the challenges within the medical field. However, my spouse remains unconvinced.
• 3. What I Discovered While Walking Through the Cemetery
• Dark humor, as discussed in the previous essay, can be found in the most unlikely of places.
• There is a cemetery adjacent to our house in Columbus, Ohio. It has a walking path for the public. Having walked through the cemetery many times, I couldn’t help but notice some of the inscriptions on the grave markers.
• My favorite is: “I told you I was sick.” The decedent, Gladys F. Milberg (not her real name), was a 46-year-old woman, an employee at world-famous Toledo Scale Company (now Mettler Toledo), maker of precision instruments across various industries. I could not dig up (pun indented) a lot of information about Mrs. Milberg; her online obituary was sparse, but it stated that she was married to Sylvester T. Milberg (not his real name). Further research revealed that Mr. Milberg passed away 15 years later.⤀
• Mrs. Milberg’s epitaph suggested that she had a sense of humor, even in the face of mortality. This playful and somewhat mocki g message indicated to me that she likely had a witty personality and perhaps a penchant for irony. It could have also implied that she had a strong sense of self-awareness and was not afraid to express her feelings, even if they went unheeded by those a ound her. My guess is that she may have died from an illness that went undetected for some time, and doctors did not take her complaints seriously. After all, even hypochondriacs get sick.
• Her role as an employee at the Toledo Scale Company suggested she was likely diligent and detail-oriented, qualities necessary for working with precision instruments. The fact that she chose such a humorous inscription might also imply that she valued levity and laughter in life, possibly using humor as a way to cope with challenges. The sparse details in her obituary could mean she was a private person, or perhaps her life was more focused on personal relationships rather than public achievements.
• Her stepson, Mitchell P. Milberg (not his real name), was buried next to her. He was only 29 at the time of his death. According to his obituary, which included less information that his step-mother’s, the family suggested contributions to the American Diabetes Association, so I would assume he died from complications of diabetes. On his gravestone are inscribed the words: “Forever in Peace.”
• Mitchell’s inscription, in contrast to his step-mother’s, reflects a tone of serenity and perhaps relief from suffering. It suggests that Mitchell may have faced significant struggles with his health, and his family wanted to honor his memory by emphasizing a peaceful and restful afterlife. The choice of these words indicates a deep love and a desire for him to be remembered in a state of calm and harmony, free from the burdens he might have experienced during his life. Do I dare say that he was “forever in peace,” shielded from his step-mother’s harangue of health complaints?
• There are many other gravesites I have marveled over on my walks through this cemetery. One marker was inscribed, “gone fishin.’” One was etched with hot air balloons. The graves of infants and children were adorned with angels. Some markers dating back to the late 1700s were simply identified as “mother” or “father,” without any personal identification. Others contained loving ributes, such as “sorely missed,” “we will never forget you,” “your smile was like the warmth of sunshine,” and my favorite: “while alive, he lived.”
• The gravestone of an individual who died in 1997 was inscribed “best daddy, husband, bother and son…Go Bucs.” (The Ohio State University “O” insignia was etched in the stone as well.) This individual, a devout Christian according to his obituary, was only 31 years old when he died. His wife remarried and sadly passed away 25 years later at age 56, also beloved and cherished by riends and family, according to her online legacy. Yet she was not interred next to him.
• Together, the inscriptions and short stories paint a picture of a families that valued both humor and peace, facing life’s adversities with resilience and love. Epitaphs serve as a bridge between the deceased and the living, conveying sentiments that range from love and remembrance to humor and philosophy. They often encapsulate the essence of a person’s life, offering a final message or reflection to those who visit.
• For unknown visitors like me, they provide a glimpse into the lives once lived, offering a connection across time that transce ds personal acquaintance. These inscriptions invite me to ponder and fantasize the stories behind the names, reflect on the shared human experiences of joy and sorrow, and appreciate the enduring values that bind generations. As I read these epitaphs, I am reminded of my own mortality and the legacy I wish to leave behind, pressuring me to continue to live with intention and purpose.
• It is not uncommon for epitaphs to express deep love and loss, providing comfort to the bereaved. Others might impart wisdom o life lessons. Dark humor, as I described in the previous essay, was another, albeit less common, element. I saw this in Mrs. Milberg’s epitaph. It seems as though some people literally take their humor with them to their grave, aiming to provoke a smile or laugh, reminding us of the joyful and light-hearted moments shared with them.
• Additional instances where dark humor sees the light of day include the epitaphs of renowned comedian W.C. Fields and statesma Sir Winston Churchill. Fields’ epitaph reads, “On the whole, I’d rather be in Philadelphia,” showcasing his characteristic wit even in death. Similarly, the gravestone of Sir Winston Churchill bears the simple yet weighty words, “I am ready to meet my Maker. Whether my Maker is prepared for the great ordeal of meeting me is another matter.” This epitaph reflects his larger-than-life persona and sense of humor.
• Famous epitaphs often become part of cultural lore, reflecting the personality or achievements of the individuals they commemo ate. A poignant example is the epitaph of Martin Luther King Jr., which features a quote from his famous speech, “I Have a Dream”: “Free at last, Free at last, Thank God Almighty I’m Free at last.” This statement summarizes his lifelong struggle for civil rights and equality, leaving a lasting impact on those who continue to fight for justice – except with one glaring mistake. The most recognizable lines from Dr. King’s speech were misquoted on his tomb. The quotation on his tomb has Dr. King saying, “I’m Free at last,” but in his speech he actually said, “We Are Free at last.”
• Through these inscriptions, epitaphs capture the spirit of the deceased, offering insights into how they lived their lives or how they wished to be remembered. They serve as timeless messages that resonate with the living, providing comfort, inspiration, and sometimes a gentle reminder to cherish the fleeting moments of life. That’s why I enjoy my walks though the cemetery. They provide an opportunity to reflect on my life, compare it to others, and hope it will be remembered as a life well-lived.
• I’m convinced that such reflective walks through cemeteries can inspire healthcare providers to consider the broader implications of their work beyond the clinical setting. These pensive walks underscore the importance of addressing not only the physical ailments but also the emotional and psychological needs of patients, recognizing that health care extends to supporting patien s and their families through the end-of-life journey. By acknowledging the stories condensed in epitaphs and memorials, providers can deepen their understanding of the diverse backgrounds and experiences of those they serve, fostering a more holistic app oach to health care that honors the full spectrum of human experience.
• Still, I haven’t decided what epitaph, if any, I would choose for myself.
• 4. Strategies for Healthcare Practitioners to Re-Engage with Patients
• Attending funerals and strolling through cemeteries may instill empathy and compassion in doctors, but there’s much more that can be done to rekindle emotions.
• “What’s up with this morbid preoccupation with death and dying,” my children wanted to know after I told them about my strolls through the cemetery (see the previous essay).
• My children failed to grasp how walking through a cemetery can bring out “buried” emotions for healthcare providers, offering a moment of reflection on the human life cycle and the inevitable reality of mortality. They didn’t understand how the experience reminded me of the deep connections I formed with patients and how their legacy impacted me after our treatment (psychotherapy) ended or, in rare instances, after they died.
• By contemplating the stories and lives of the deceased, however brief the inscription on the gravestone, I am reminded of the importance of empathy and compassion in our work as healers. The ability to feel for people, even after they are gone, is essential in delivering patient-centered care. It also serves as a moving reminder of the importance of treating each patient with dignity and respect, as the legacies left behind are often shaped by the quality of care they received when they were alive.
• Admittedly, most of what I take away from these walks is left to my imagination. However, cemetery strolls hold therapeutic value. My imagined narratives enrich my understanding of human experiences and reinforce the importance of empathy and compassion, woefully missing in medical practice today. There has been much research on this topic, and it shows that empathy usually begi s to dwindle in medical school. Imagine that! Brilliant and highly motivated medical students start to show emotional fatigue and burn out before they become doctors. Sad, but true. Perhaps they should take a walk through a cemetery now and then.
• This idea is not far-fetched. It has long been recommended that doctors attend their patients’ funerals, although most do not. Attending funerals hits home, reminding doctors of the human side of medicine, frequently lost in the hustle and bustle of modern practice. Funeral services offer a moment of reflection on the lives that have been cared for and the impact of illness and loss. They can also provide closure and a deeper connection to the patients and families served.
• As healthcare professionals, engaging with the memories of former patients and their stories as told by living relatives can help rekindle the empathy that is essential for compassionate care. It encourages us to see our patients as more than their diagnoses, to remember that each individual has a unique story that deserves to be heard and respected. Attending funerals provides a means to hear our patients’ stories as remembered by their loved ones, stories that they were never able to fully narrate in a cold and dank exam room when they were alive.
• Incorporating reflective practices into medical training and ongoing professional development could be a step towards addressi g the empathy gap in health care. By fostering a deeper connection to the human experience, healthcare professionals may find renewed purpose and resilience, ultimately benefiting both themselves and their patients. Here are some tips and practices to help emotionally depleted healthcare practitioners re-engage with patients:
• 1. Mindfulness and Meditation: Regular mindfulness practices can help healthcare practitioners stay present and reduce stress. Short meditation sessions, deep-breathing exercises, or even mindful walking – not necessarily in a cemetery – can enhance focus and emotional resilience.
• 2. Reflective Writing: Keeping a journal to reflect on patient interactions and personal experiences can provide an outlet for emotions and insights (see essay 59). Writing about meaningful moments or challenges can help process feelings and reinforce the practitioner’s sense of purpose. For me, writing has become the best therapy of all.
• 3. Empathy Training: Participating in empathy workshops or training sessions can help practitioners develop skills to better u derstand and connect with their patients’ experiences and emotions.
• 4. Peer Support Groups: Joining or forming support groups with colleagues can provide a safe space to share experiences, challenges, and coping strategies. These groups can foster a sense of community and reduce feelings of isolation. I’m connected with a writing group that serves as much as a support group as it does a group that writes poetry and prose.
• 5. Patient Stories: Taking time to listen to patients’ stories and experiences can humanize interactions and remind practitioners of the person behind the medical chart. This practice can deepen the practitioner-patient connection. At the initial encounter, perhaps it’s better to introduce yourself and say “what do you want me to know about you,” as opposed to directly asking about the chief complaint.
• 6. Regular Breaks and Self-Care: Ensuring regular breaks during shifts and prioritizing self-care activities outside of work can prevent burnout. This includes physical exercise, hobbies, or spending time with loved ones. Because I work from home and can take my work with me, I’ve been able to incorporate frequent, refreshing travel into my schedule.
• 7. Professional Counseling: Seeking support from a mental health professional can provide personalized strategies to manage st ess and emotional exhaustion. If you’re concerned about stigma, a professional coach may be just as effective as a therapist.
• 8. Gratitude Practices: Cultivating gratitude, such as reflecting on positive interactions or moments of joy in the day, can shift focus from stress to appreciation, enhancing well-being and patient engagement. More than ever, I find myself saying, “I appreciate you” (see essay 35).
• 9. Boundary Setting: Learning to set healthy boundaries between work and personal life can prevent emotional depletion. This might include limiting work-related communication outside of office hours or creating a clear transition routine at the end of the workday.
• 10. Educational Workshops: Engaging in continuous learning about communication skills and patient-centered care can refresh approaches and inspire new ways to connect with patients.
• 11. Artificial Intelligence (AI): It seems impossible that ChatGPT can have a better bedside manner than some doctors, but it’s true. The reason it can is that in medicine – as in many other areas of life – being compassionate and considerate involves, to a surprising degree, following a prepared script. In one study, ChatGPT’s answers to patient questions were rated as more empathetic (and also of higher quality) than those written by actual doctors. The researchers felt that further exploration of the application of AI technology is warranted in clinical settings, such as using chatbot to draft responses to patients’ questio s that physicians could then edit.
• By integrating these practices, healthcare providers can nurture their own emotional well-being and foster more meaningful con ections with their patients, ultimately enhancing the quality of care provided.
• 5. Embracing Mental Health Openness in the Medical Profession
• It’s time to break the silence and end the shame and stigma of mental illness in healthcare providers.
• This book is the seventh volume of essays and reflections related to my career as a physician. As a psychiatrist, I’ve been pretty open about my mental health, which is why I reprinted the article about my early struggles with depression and PTSD in the Prologue. I’m not alone. A vast amount of research shows that even medical students suffer alarming rates of depression and suicidal ideation. Approximately one doctor per day completes suicide in the U.S. The two issues at hand are (1) the mental health epidemic in physicians; and (2) whether doctors should voice their struggles with mental illness publicly, including with their patients? This essay deals with the latter issue, which is rooted in both the stigma surrounding mental illness and the traditional expectations of medical professionals. (Essay 6 addresses the epidemic.)
• Historically, the medical profession has been perceived as one of resilience and stoicism. Physicians are expected to be paragons of health and stability, which can discourage them from acknowledging personal vulnerabilities. This culture of silence can lead to a toxic environment where mental health issues are hidden rather than addressed, exacerbating the problem. Openly discussing mental health struggles could help dismantle the stigma that prevents many physicians from seeking the help they need. By sharing their experiences, physicians can normalize mental health issues, demonstrating that these challenges do not detract from their competence or dedication to their profession.
• Moreover, physicians discussing their mental health can foster a more empathetic and understanding relationship with patients. Patients often view doctors as infallible, which can create a barrier between them. When doctors share their own experiences with mental health, it can humanize them and help build trust with patients who may also be struggling. This openness can encourage patients to be more forthcoming about their own mental health issues, leading to better diagnosis and treatment outcomes.
• Adam Rosen, DO, is an orthopedic surgeon who “opened up” after he burned out and became depressed. “I pushed ahead until I crashed,” he wrote, adding, “I suffered a mental health crisis. I couldn’t go to work. I couldn’t get out of bed. I was unable to care for myself.”
• Rosen left work for a year and was treated with cognitive behavioral therapy, meditation, medication, exercise, nutrition and sleep. He also took a course in mindfulness-based stress reduction and became a physician coach. During his recovery, he felt a strong desire to speak up and speak out, to destigmatize mental illness by reaching out to other physicians and letting them know his experience was not unusual. He discussed his journey on YouTube “so that we can all thrive.”
• The noted hematologist-oncologist and author Vinay Prasad MD, MPH (Ending Medical Reversal: Improving Outcomes, Saving Lives) has suggested that doctors should be more transparent about their mental health because that allows patients to seek care from a doctor who is willing to be open to discussing the topic, should patients want that type of doctor. Prasad reasons that physicians could discuss their mental health struggles on social media to attract patients, much like other physicians who have come forward with their special circumstances, e.g., a personal battle overcoming cancer.
• The argument here is that what doctors voluntarily admit online has to be better than the way patients usually choose their physicians, which is basically at random. It is only by chance, Prasad argues, that good chemistry develops between doctors and patients, despite patients’ attempts to select compatible physicians through online search engines and U.S. News and World Report hospital rankings.
• However, there are valid concerns about physicians sharing their mental health struggles. Some may worry about potential repercussions on their professional reputation or fear that patients might lose confidence in their abilities. Additionally, not all patients may respond positively to such disclosures; cultural differences and personal beliefs can affect how mental health issues are perceived. It is crucial for physicians to consider these factors and weigh the potential benefits and drawbacks before sharing their personal experiences.
• Prasad’s coauthor of Ending Medical Reversal: Improving Outcomes, Saving Lives, the distinguished internist Adam Cifu, MD, sums it up this way: “Someday, people will treat medical and mental illness the same way. We will see no difference between hypertension and depression. Patients will be as comfortable receiving a prescription for sertraline as they are for chlorthalidone. Employers will not hesitate to hire an applicant they discover has been hospitalized for 2 weeks with community acquired pneumonia or after a suicide attempt. Patients will be as comfortable visiting a doctor who walks with a cane as one who discusses her lithium dosage on twitter. Unfortunately, we are not there yet.”
• To get there, healthcare institutions need to create supportive environments that encourage open dialogue about mental health. This includes implementing policies that protect physicians who disclose mental health struggles from discrimination and providing resources for mental health support. Training programs should incorporate mental health education, emphasizing the importance of self-care and the normalization of seeking help. Psychotherapy should be seen as a learning tool for physicians, not only helping them overcome anxiety and depression, but teaching them about vulnerability and the trauma of medicine.
• Cifu fears, however, that because many people have negative biases about mental health, classifying them quite distinct from physical conditions, this may leave patients uncomfortable with the thought that their doctor is being treated for anxiety, depression, OCD, or ADHD. “As doctors, our primary responsibility is to make our patients, as many of them as possible, feel comfortable seeing us. I don’t think sharing our mental struggles helps with this,” he opines. Cifu also worries about the careers of younger doctors: “If faced with two equally qualified applicants, it is unlikely that future employers would choose the one who publicizes their mental health struggles.”
• I view the decision to disclose mental health struggles as one that is deeply personal and context-dependent. More than ever, here is a compelling case for encouraging more openness among physicians. By doing so, the medical community can begin to break down the stigma surrounding mental illness, promote a culture of wellness, and ultimately improve the care provided to patients. It is through these efforts that the healthcare field can become not only a place of healing for patients but also a supportive and nurturing environment for those who dedicate their lives to this noble profession.
• 6. Who Cares for the Healers?
• The heartbreaking truth about physician suicide is the fear of reprisal for seeking treatment.
• Lorna Breen, MD, was an emergency medicine physician in New York City. Shortly after COVID-19 struck, she succumbed to the stress of practicing and took her life. Prior to completing suicide, Breen reluctantly accepted treatment at a psychiatric facility near her home in Virginia. Her resistance was not due to the denial of the seriousness of her condition; rather, like many other trainees and practitioners, she feared the professional repercussions of treatment – the fact that therapy could trigger an alarm leading to the loss of her medical license, or at least an event to be reported to authorities who would question her competency and capacity to practice medicine safely.
• Scott Jolley, MD, was also an emergency medicine physician who died by suicide during the coronavirus pandemic. Practicing feverishly and with insufficient help, he broke down and cried to his colleagues, “I can’t do this anymore; it’s not good for me.” Yet Jolley’s insurance only allowed him to receive treatment within his own hospital system, an intolerable embarrassment. Myles Greenberg, MD, MBA, a long-time colleague of Jolley, wrote that in his opinion Jolley “died because of the culture of medicine.” Greenberg and others have pointed out that the medical profession does not allow for weakness. The “culture of not being ‘weak’… fed Scott’s distress,” Greenberg concluded.
• William Ballantyne West Jr., MD, was a 33-year-old ophthalmology resident who ended his life on March 1, 2024. He had a history of depression, but the depth of his despair was unknown to his family, friends, co-residents, and attendings at the time. West’s suicide was made public by his family and discussed extensively in the Washington Post. Here are excerpts from the letter he left behind:
• “Hello All:
• I apologize that this is the best I can do for goodbye. Many of you deserve better but one can’t exactly talk much about this kind of thing in advance so a note will have to do. To those who will be negatively affected by my actions, I’m so sorry. I have simply run out of gas and have nothing left to give.
• To those in a position of authority over residents, a simple reminder that we come to you seeking the possibility of a better life. Some of us with challenges you do not see or backgrounds of which you are not aware.
• There are other residents right now fighting a true life and death battle – one that is waged both inside and out at the clinic/hospital. Often that battle may cause symptoms that look an awful lot like laziness, lack of motivation or waste of intelligence, all unforgivable sins in our profession.
• I hope that an effort can be made to understand, support, and mentor the residents rather than simply to assess and drive them toward their highest potential as doctors.
• To be clear, there are other people at real risk here at GW [George Washington University].
• Thank you so much for being there for me. I wish you all the very best.
• Sincerely,
• Will West”
• The only resources available to West were an Employee Assistance Program that offers up to five counseling sessions; Talkspace, an online therapy platform where patients can text a therapist; and Headspace, a mindfulness app – hardly sufficient to prevent a suicide when someone’s mind is in such a dark, irretrievable space.
• West’s mother told the Post that she hopes his death will lead to progress for others. Hope is what drives her to seek change, and she believes her son wanted that, too. Breen’s family and Jolley’s family felt the same way. They were determined not to let their loved ones’ suicide be in vain. At the urging of Jolley’s wife, Jackie, “Scott’s Bill” was sign into law in Utah two years after his death to ensure that healthcare workers seeking behavioral health treatment will have options to get help outside of their own facility.
• Breen’s family founded the Dr. Lorna Breen Heroes’ Foundation to help support the mental well-being of health workers and destigmatize depression by advocating for a world where seeking mental health services is viewed as a sign of strength rather than weakness. The Foundation’s Caring for Caregivers (C4C) program builds learning communities to assist healthcare organizations, such as hospitals and medical groups, in improving workplace policies and practices that reduce burnout, normalize help-seeking, and strengthen professional well-being. Guided by experts, healthcare organizations participate in three phases of work to implement evidence-informed strategies that go beyond encouraging self-care and individual resilience to focus on operational-level improvements. Their three-phased approach consists of the following:
• 1. Building a professional well-being team to ensure time and resources are committed by leadership to protect, improve, and sustain the mental health of workers. The aim is to embed the necessary knowledge into an organization’s operations without putting the work on a single position or department.
• 2. Breaking down barriers for those seeking help, e.g., by eliminating intrusive, stigmatizing questions on credentialing applications that prevent many health workers from seeking mental health care because they fear losing their job.
• 3. Integrating well-being into operations to ensure that quality improvement projects do not compromise professional well-being. This integration is critical to ensure health workers can provide safe, quality patient care, while limiting administrative and operational burdens.
• It is undoubtedly a tall order to reduce burnout and depression among healthcare professionals and safeguard their well-being and job satisfaction at the same time. Better access to mental health resources, such as regular appointments with a practitioner knowledgeable about suicide and has worked with medical trainees and physicians, and access to medication without fear of rep isal could help dramatically.
• In his final words, true to his character, West wanted to protect other medical students and residents dealing with mental health challenges. His family did not want other families to suffer similar tragedies; they wanted more good people to make it in the medical profession without having to sacrifice themselves in the process.
• To honor the legacies of West, Jolley, Breen, and countless others – approximately 400 physicians die each year by suicide – we must be unwavering in our commitment to reducing physician suicide. Physicians spend their lives caring for others yet they commonly fail to care for themselves Doctors must have a solid, reliable answer to the question, “Who cares for the healers.”
• 7. Transitioning from Sick Care to Health Care
• A diagnosis isn’t the first sign of disease, it’s one of the last. If we wait until a doctor is able to diagnose a disease, we may have missed a powerful opportunity for prevention. Consider:
•  The heart attack at age 50 began at age 20
•  The Alzheimer’s disease at 70 started at 40
•  The loss of independence at 80 began at 30
• In 2018, data from the following sources were analyzed: (1) Nurses’ Health Study (1980–2014; n=78 865); and (2) Health Professionals Follow-up Study (1986–2014; n=44 354). Combining these two data sets allowed the researchers to analyze results from more than 123,000 participants for up to 34 years. The title of the paper perfectly reflects the purpose of the study: “Impact of Healthy Lifestyle Factors on Life Expectancies in the U.S. Population.”
• What did the researchers find?
• “We estimate that adherence to a low-risk lifestyle could prolong life expectancy at age 50 years by 14.0 and 12.2 years in female and male U.S. adults compared with individuals without any of the low-risk lifestyle factors. Our findings suggest that the gap in life expectancy between the United States and other developed countries could be narrowed by improving lifestyle factors.”
• The salutary lifestyle they studied (no tobacco; moderate alcohol consumption; nutritious food; ≥30 min/d of moderate to vigorous physical activity; and maintaining a body-mass index of <25 kg/m2) was worth an average of 13.1 years of “extra” life. That’s more than 4,500 sunrises!
• Another large, longitudinal study conducted at Harvard University also drives this point home. In this naturalistic study, referred to as the Grant Study, researchers followed the health of men for nearly 80 years. The study’s goal was to understand what makes a good life and how to predict health and well-being in later life. Among the main results were: (1) Physical aging after age 80 is determined more by habits formed before age 50 than by heredity; and (2) Positive relationships keep us happier, healthier, and help us live longer.
• The scientific literature about lifestyle medicine makes two things very clear:
• 1. Detrimental behaviors strongly correlate with negative outcomes.
• 2. Beneficial behaviors strongly correlate with positive outcomes.
• So, the aging that we want tomorrow in large part depends on the privileges we have today. While we should make good choices, he notion that all our illnesses are the direct result of bad ones is not only wrong but also psychologically damaging. Some people feel guilty because they believe that any small illness they get is a result of some wrong choice when, in fact, they do not have the means to achieve good health. I’m referring here to social determinants of health: non-medical factors, such as socioeconomic status, education, neighborhood environment, social support networks, and access to healthcare, that influence an individual’s health outcomes and quality of life.
• Moreover, healthy living is a noble aspiration, but medical advice changes quickly. What was common practice 30 years ago, like margarine being good or eggs being bad for you, can turn on a dime. Cigarettes were considered healthy 60 years ago! The long-term effects of sun damage were not evident several decades ago. If I had known, I would have worn a hat to cover my bald head during all those years spent at the beach, possibly preventing widespread actinic keratitis on my scalp and an episode of squamous cell carcinoma.
• The aging you want tomorrow begins with the choices you make today.
• 8. Utilization Review is a Crap Shoot
• The gamble of medical necessity determinations.
• The Case:
• A 33-year-old man has Fragile X syndrome including an intellectual and developmental disability (I/DD). He is prone to wandering from his house, which is situated on a busy street. The family desires a full security alarm system to monitor the patient’s behavior in the home and alert the family to elopement attempts. The health insurance policy has an “innovations waiver” that covers procedures, products, and services when they are medically necessary. Should the insurance company approve the request for the security alarm system?
• The request for a security alarm system can be argued as medically necessary for several reasons:
• 1. Safety and Prevention of Harm: The primary goal of the security system is to ensure the safety and well-being of the patien by preventing elopement, which could lead to dangerous situations, such as traffic accidents or getting lost.
• 2. Monitoring and Supervision: The alarm system would aid the family in effectively monitoring the patient’s movements within he home, providing an additional layer of supervision that is crucial for individuals with tendencies to wander.
• 3. Quality of Life: By reducing the risk of elopement, the security system can alleviate some of the stress and anxiety experienced by both the patient and the family, thereby improving their overall quality of life.
• 4. Support for Behavioral Challenges: For individuals with Fragile X syndrome, environmental modifications, such as a security system, can be part of a comprehensive approach to managing behavioral issues.
• Essentially, the alarm system provides indirect benefits, mainly ensuring peace of mind for the family, but it can be considered integral to maintaining the patient’s health and safety, justifying the request for coverage under the “innovations waiver.”
• However, there are several factors that may lead to the denial of such a request:
• 1. Definition of Medical Necessity: Insurance companies typically define medical necessity in terms of direct medical care, treatment, or interventions that address a specific health condition. A security alarm system, while beneficial for safety, might not be considered a direct medical intervention or treatment.
• 2. Scope of Coverage: The waiver might be intended for items and services that have a direct therapeutic or medical impact, such as medical devices, therapies, or treatments that directly address the patient’s condition. A security system, being more of a preventive or environmental modification, might fall outside this scope.
• 3. Alternative Funding Sources: Insurance companies might argue that security systems are more appropriately funded through other means, such as social services, community support programs, or government assistance programs, rather than health insurance.⤀
• 4. Precedent and Policy Consistency: Approving such a request could set a precedent that might lead to an influx of similar requests for non-medical interventions, potentially straining the insurance resources and requiring broader policy changes. What happens when this patient turns 65? Will a bathroom remodel be requested? What about patients with Alzheimer disease? Is the expectation that home security systems will become standard coverage for them?
• 5. Cost Containment: Insurance companies need to manage costs to keep premiums sustainable for all policyholders. Approving requests for home security systems could lead to increased costs that might not align with the company’s cost-containment strategies. The costs may be passed on to other insureds in the form of higher premiums.
• 6. Availability of Alternative Solutions: The insurance company might propose or suggest other solutions that are more in line with traditional medical interventions, such as behavioral therapies or other support services that could address the underlying issues of wandering.
• Ultimately, while there are valid reasons for both approval and denial, the correct course of action should prioritize patient safety and align with the insurance policy’s provisions and the spirit of the “innovations waiver.” If the alarm system is crucial for preventing harm and no other measures suffice, advocating for approval would be appropriate.
• But who is the advocate? The obligation of a reviewing health insurance physician primarily lies with the insurance company, as they are employed or contracted by the insurer to evaluate claims based on the terms of the policy and applicable guidelines. Their primary role is to ensure that the insurance company’s resources are utilized according to the policy agreements and to maintain the financial sustainability of the insurance plan.
• However, this does not mean that the health insurance physician has no responsibility toward the patient. They must conduct their reviews ethically and fairly, ensuring that decisions are made based on accurate medical information and consistent with the standards of care. They should also consider the patient’s health needs and circumstances within the framework of the policy.
• Ultimately, while the reviewing physician’s formal obligation is to the insurance company, they must balance this with a commi ment to ethical medical practice, which includes consideration of patient welfare in their decision-making process. They should not forget the (Hippocratic) oath they took in medical school.
• It all boils down to a crap shoot. Clinical judgment is involved in virtually all UR decisions. Each patient has unique circumstances. Many UR decisions, as seen in this case, can go either way, despite guidelines. Also, consider that the majority of adverse decisions are overturned on appeal and that UR wastes precious healthcare dollars and heavily burdens physicians and patie ts.
• The use of artificial intelligence (AI) has been suggested to improve the accuracy of UR, but there are concerns and challenges using AI for this purpose. AI systems may perpetuate biases and inequities if they are trained on flawed datasets that lack diversity or are missing key information for marginalized populations. AI might inadvertently flag certain groups for denials or faster approvals based on these biases. Complete transparency in the use of AI for UR decision-making is often lacking.
• Because AI-enabled UR has yet to prove it can optimize both cost savings and patient outcomes, and lawmakers will probably never allow it to operate unfettered without a doctor at the helm – states are already beginning to introduced bills that would regulate how health insurers can use AI for their utilization review process – we are still at square one in terms of knowing what treatment is best for the patient.
• I prefer to wager on the judgment and knowledge of the treating physician every time. I am not fond of gambling, especially when a patient’s welfare is on the line.
• 9. The Last of the Independents
• We must fight to preserve the human touch that defines the practice of medicine.
• Di Bruno Bros. Italian specialty stores (five in all) in Philadelphia, Pennsylvania, were recently acquired by a large conglomerate of food chains, including the hallmark Di Bruno Bros. store founded in 1939 in the Italian market (think: “Rocky”). Small grocery stores, like many other types of independent retailers, are part of a broader group of businesses that represent the “last of the independents,” where small, community-centered trades like Di Bruno Bros. once thrived but are now increasingly being replaced by larger corporations and online platforms.
• One of my daughters reminded me of this disturbing fact when she shared a cherished memory. When she was very young, about 4 o 5, my daughter and I spent a couple of hours at an independently owned book store. We mutually selected several books off the shelf – she, by the illustrations, and me, by the content – and I read them to her in a specially designated reading room. Late , we sat in a ring with other children and parents and listened to a professional reader. My daughter and I have long forgotten the titles of the books we viewed, but the memories of that afternoon remain – sharing the excitement of finding great, easy-to-read, books and bonding over children’s stories with kittens and puppies prominently on display.
• Now with her own two young daughters, my daughter frequents the last remaining “indie” bookstore in Columbus, Ohio. She usually times those visits for when my wife and I are in town, so all of us can soak in the experience of rummaging through an enormous variety of books housed in a labyrinth of 32 rooms (the store stretches a city block and is comprised of pre-Civil War era buildings that once were general stores, a saloon, and a nickelodeon cinema).
• I usually leave the book store with two distinct yet very different thoughts. First, visualizing the vast numbers of books reminds me how difficult it is to become an established author. (It’s even more overwhelming when you browse the offerings on Amazon, which lists over 33 million books across its categories: physical books, eBooks, and audiobooks.)
• The second thought, and certainly the one that is more relevant to health care, is that private practice physicians, like independent book stores, are vanishing. Approximately 80% of physicians today are employed by health systems. In the not-so-distant past, however, the private practice physician dominated and was a cornerstone of the healthcare system, much like the independe t bookstore was a cherished hub of the literary world. Both professions were defined by their personal touch, community engagement, and deep sense of autonomy. We are witnessing the slow disappearance of these once-revered institutions, as corporate consolidation and technological disruption reshape the landscape.
• The Rise and Fall of Private Practice Physicians
• Private practice physicians were, for much of modern medical history, the backbone of patient care. Doctors were not only healers but also small business owners, managing their own clinics, hiring staff, and cultivating long-term relationships with patients. They enjoyed the freedom to set their own schedules, design personalized care plans, and develop strong connections with the communities they served. However, the rise of hospital systems, insurance giants, and healthcare corporations has marginalized the independent physician. Several factors have contributed to this shift:
• 1. Financial Pressures: Reimbursement rates from insurance companies have dwindled, while the cost of running a practice – liaility insurance, electronic health record (EHR) systems, and regulatory compliance – has soared. These mounting costs make it difficult for private practice physicians to remain financially solvent without joining larger healthcare networks.
• 2. Administrative Burden: The increasing bureaucracy of modern health care, from billing codes to complex insurance regulations, has placed a tremendous administrative burden on independent physicians. Many find that they spend more time managing paperwork than they do caring for patients. Large healthcare systems offer relief by handling much of this administrative work, but at the cost of professional autonomy.
• 3. Consolidation of Care: Hospitals and healthcare networks have pursued aggressive acquisition strategies, purchasing private practices and absorbing physicians into salaried roles. While this offers doctors some stability, it reduces their independence and often pushes them to meet productivity quotas, limiting the time they can spend with each patient.
• 4. Private Equity: The reach of private-equity (PE) physician practices is growing at an alarming rate. This trend has led to cost-cutting measures, increased pressure on physicians to see more patients in less time, and greater management oversight. As a result, many practices lose autonomy, and doctors experience increased burnout and reduced job satisfaction, with decisions about care often influenced by financial stakeholders rather than medical professionals. PE ownership is linked to worse patient outcomes and higher costs to patients and insurers.
• The Human Element: What We Lose
• Patients of independent physicians often speak of the comfort of seeing the same doctor for years, sometimes generations. These doctors knew their patients as people, not just charts or appointments. Similarly, independent bookstores offered something intangible: a curated selection based on deep literary knowledge, a sense of discovery, and the warm atmosphere of a community hu.
• As corporate healthcare systems and online booksellers have taken over, something fundamental has been lost: the human touch. The face-to-face interactions that foster trust, understanding, and empathy are being replaced by impersonal, algorithm-driven solutions. Telemedicine, while convenient, cannot replicate the intimate doctor-patient relationship of a private practice. Similarly, online book recommendations, driven by customer algorithms, lack the nuance of a conversation with a well-read bookseller.
• The loss of the human element can be seen in industries other than medicine and book publishing. During the banking consolidation era of the 1980s, a college professor wrote a book titled The Human Side of Mergers and Acquisitions. I congratulated him and asked, tongue-in-cheek, “Is there really a human side to mergers and acquisitions, or are there several hundred blank pages i your book?” He laughed and graciously agreed to write a chapter for a book I was editing on managed health care.
• The chapter I designated for the professor was: “Does Consolidation in Health Care Mean Bigger is Better?” He waivered in his answer, concluding “that many of the key problems and barriers in health care alliances are as much organizational and behavioral as they are strategic and financial.” Even “friendly mergers,” he noted, come with intrigues, cultural clashes, hostilities, and tensions. Unless the human element is properly managed, the merger will fail to meet its expectations.
• The Path Forward
• While the future may seem bleak for private practice physicians and independent bookstores, there is still hope. Both industries are seeing a resurgence of interest in localized, personalized service as a response to the cold, impersonal nature of corporate behemoths. Some doctors are moving to “concierge” and “direct primary care” models, where patients pay a premium for greate attention and better access to their physician, bypassing the bureaucracy of insurance. Independent bookstores are finding creative ways to stay relevant, hosting author events, offering coffee shops, and focusing on building strong community ties.
• Moreover, there is growing recognition of the need to preserve these institutions. Patients are beginning to realize the value of personal relationships in health care, just as readers are rediscovering the joy of wandering the shelves of bookstores both large and small, including three generations of our family. Both independent physicians and booksellers represent a deeper tru h about human interaction – one that cannot be replaced by technology or corporate efficiency. They remind us that, at its core, both health care and literature are about people, relationships, and the shared experience of healing and storytelling.
• 10. The Big Picture in Psychotherapy
• A different way to conceptualize emotions and their management.
• I had a brief email exchange with one of my former mentors, a great psychotherapist and teacher, now retired. He was responding to one of my essays in this book (essay 48) and wrote, “When I was still teaching, I tried always to get residents and students to see the ‘bigger picture’ for both themselves and whom they were caring for.” I know this to be true, because he was one o my psychotherapy supervisors when I was a resident.
• One unforgettable patient we discussed reminded me of my mentor’s “big picture” mentality. The patient was a man in his 30s wi h severe anger issues leading to verbal outbursts, and his temper had cost him two jobs. People naturally felt threatened by him, although his anger had never erupted into physicality. My mentor suggested that I relate a metaphor to the patient, one that helped both me and my patient see the bigger picture. My mentor said, “Art, tell your patient that anger is like gasoline. You can set a match to it and watch it explode, or you can put it in your gas tank and get mileage out of it – it all depends on how you use it [your anger].”
• Wow! That was really helpful, to view anger in an emotionally constructive light as opposed to its usually destructive context. Of all the emotions, anger is probably the most negatively perceived. However, my mentor’s metaphor transformed my understanding of it, highlighting the potential for anger to be harnessed as a powerful motivator for positive change. This perspective no only offered my patient a new way to conceptualize his emotional experiences but also provided a therapeutic framework to channel his anger productively.
• In psychotherapy, helping patients reframe their emotions is crucial. Anger, when understood and managed properly, can be a ca alyst for setting boundaries, advocating for oneself, and initiating necessary life changes. For my patient, this meant recognizing that his anger was a signal rather than just a problem, prompting him to explore underlying issues and unmet needs.
• Through discussions with my mentor, guided by his wisdom and experience, we worked on strategies to redirect my patient’s ange towards productive outcomes, such as improving communication skills and developing better coping mechanisms. This approach not only helped him retain his employment but also improved his relationships, as he learned to express himself assertively rather than explosively.
• Reflecting on this experience, I am reminded of the great impact a mentor can have on both personal and professional growth. My mentor’s emphasis on seeing the “bigger picture” continues to influence my thinking, encouraging me to guide individuals towards self-awareness and empowerment. His teachings underscore the importance of viewing emotions not merely as obstacles but as opportunities for growth and transformation.
• In this particular case – comparing anger to gasoline, with the potential to either explode or propel – symbolic imagery is used to convey a broader lesson about the constructive and destructive potential of emotions. This “big picture” approach helps both the therapist and the patient see beyond the immediate emotional experience to understand its potential for positive transfo mation. It involves helping patients gain a broader perspective on their emotions and experiences, encouraging them to look beyond immediate concerns to understand the underlying patterns and potential for growth. This technique can be applied to various emotions and issues – not only anger – offering patients a more comprehensive understanding of their psychological gestalt.
• Gestalt Psychology
• In psychology, gestalt refers to a concept that originates from Gestalt psychology, a school of thought that emphasizes the human ability to perceive patterns and wholes, rather than just the sum of individual parts. The word “gestalt” itself is German, meaning “shape” or “form.” Gestalt psychologists argue that our minds tend to perceive things as unified wholes rather than simply as collections of components.
• A key principle in Gestalt psychology is that “the whole is greater than the sum of its parts.” This means that when we experience objects or situations, we don’t just see the individual elements (like lines, shapes, or sounds), but rather an integrated form or pattern.
• For example:
•  When you see a series of dots arranged in the shape of a circle, you perceive the whole circle rather than the individual do s.
•  In therapy, Gestalt principles can be applied to understanding how individuals integrate their experiences to form their perceptions of reality and self. Can they see the “big picture?”
• Gestalt therapy, developed by psychiatrist Fritz Perls (1893-1970), builds on these ideas, emphasizing awareness, personal responsibility, and the importance of the “here and now.” It encourages patients to focus on their present experiences and emotions, often using techniques like role-playing or focusing on body language to bring subconscious feelings to the surface. In esse ce, the “gestalt” in psychology is about understanding how we naturally organize and interpret information as whole patterns, and in therapy, it’s about fostering self-awareness and personal growth through understanding one’s current experiences, assembling them into a bigger picture. Here are some examples:
• Anxiety
• For patients struggling with anxiety, the “big picture” approach can help them see their anxiety not just as a source of distress, but as an indicator of areas in their life that may need attention or change. By understanding anxiety as a signal, patients can explore underlying fears or unmet needs, and use this insight to develop coping strategies and make positive life adjustments. Therapists can work with patients to identify triggers and patterns, encouraging them to consider how addressing these can lead to greater overall well-being.
• Depression
• In the context of depression, seeing the “big picture” can involve helping patients understand the recurrent nature of their depressive episodes and the factors that contribute to them. This approach can encourage patients to identify small, actionable steps that align with their values and goals, fostering a sense of purpose and direction. By reframing depressive thoughts as opportunities for insight, patients can explore what their feelings reveal about their current life situation and what changes might be necessary to improve their mood and outlook.
• Grief
• For those dealing with grief, the “big picture” perspective can assist patients in recognizing the natural process of grieving and its role in personal growth and healing. By acknowledging the depth of their loss and the range of emotions involved, patients can be guided to explore how their grief might lead to new understandings of life, relationships, and personal priorities. This approach can help patients integrate their loss into their life story, finding meaning and resilience in the process.
• Relationship Issues
• When addressing relationship issues, the “big picture” approach can help patients consider the dynamics at play and the roles hey and their partners assume. By stepping back to evaluate relationship patterns and communication styles, patients can gain insights into how their interactions contribute to conflicts or misunderstandings. This broader perspective can lead to more effective communication, empathy, and problem-solving strategies, ultimately fostering healthier relationships.
• Conclusion
• Overall, the “big picture” approach in psychotherapy is about empowering patients to view their emotions and experiences as pa t of a larger narrative of personal growth and development. By encouraging this broader perspective, therapists can help patients gain insights that lead to meaningful change and a deeper understanding of themselves and their lives. This approach not only aids in symptom relief but also promotes long-term resilience and well-being.
• However, because psychotherapy takes time to work, it is imperative not to delay interventions that may help alleviate acute suffering. Patients should be provided immediate, actionable strategies that can offer relief and help them regain a sense of control, e.g., physical activity, journaling, and deep breathing and grounding techniques. They should be encouraged to reach out o friends, family, or support groups to share their experiences and receive emotional support. These and other strategies, plus psychotropic medication when indicated, can offer a short-term respite while paving the way for deeper exploration and healing through visualizing the “big picture.”
• Section 2 Selected Essays: Physician Issues
• 11. I Am Not What Others Think of Me
• You don’t need to prove others wrong to cast away self-doubt and believe in yourself.
• The combination of hard work and determination paved my way into medical school. Compared to many of my peers in the 1970s, who either went to medical school abroad and languished for several years before they were accepted to a U.S. school, or abandoned their dreams of becoming a doctor, I suppose I was fortunate.
• However, along the way, I lacked confidence, and the need to prove people wrong became a source of motivation for me. It helped me excel in medical school, residency, and beyond. By continually displaying my skills, I was able to disprove my critics who thought I wouldn’t amount to anything – count my premed adviser among them. But trying to prove people wrong all the time was exhausting, and it spurred me into academic and professional competitions so intense that I lost friendships and relationships (see essay 27).
• Think about it: in the thrill of proving people wrong, you probably find satisfaction in getting back at the naysayers. Now, suppose you become a doctor without having a genuine interest in medicine. You will regret your career choice and may not treat your patients well. Here is yet another reason for someone to prove you wrong and demoralize you. Nevertheless, seeking revenge on doubters and non-believers is constantly played up in the media and songs and movies, as if it were a good thing.
• Where does the desire to prove people wrong originate? Most experts agree it’s during the early school years – experiences with difficult teachers and interactions with peers who tease and taunt. I endured hurtful name-calling in high school due to my weight. It’s no wonder the dour outlook proffered by my pre-med adviser rekindled painful memories and shaped a future in which I felt destined to prove everyone wrong. My professor’s pronouncement was my main drive to succeed, and it worked.
• The important question, however, is whether the end justifies the means? Is proving other people wrong healthy or harmful to your psyche? My training in psychiatry suggests you shouldn’t get your energy from negative people, because it’s easier to use other people’s negativity as fuel than it is to search within yourself and hone your native abilities. It’s more difficult to ove come feelings of insecurity and build confidence from a foundation of strength than it is to want people to like you for what you’ve achieved.
• Over time, I gained confidence by writing and publishing articles and books, speaking at professional organizations, and being elected to leadership roles in medical societies. I rose to the rank of professor. As I became surer of my talents, abilities, and accomplishments, other people’s opinions didn’t matter that much to me, and the need to prove them wrong dissipated.
• I’d like to think I’ve paid it forward to students and residents by mentoring them and furthering their self-actualization, thus sparing them the anguish I suffered early in my career. I advise them that if they simply exist to negate others’ opinions, it serves as a vital clue that they probably have some work to do in terms of valuing their self-worth.
• Chances are, there is (or was) a lingering negative force in your life. It may be human nature to want to prove people wrong, but making someone else wrong doesn’t necessarily make you right. Perhaps the greatest motivator of all is to succeed for yourself on your own terms. Prove to yourself – not to others – that people are wrong about you and in the process help them find their own motivation to change.
• (June 25, 2021)
• 12. My Biggest Blind Spot is Me
• Personal and clinical insights help to close the holes in our psyches.
• I tend to size people up pretty quickly. Adult ADHD? I can diagnose it in about two minutes. Borderline personality disorder? About one minute. Bad actors on the Dr. Phil show? About 30 seconds (with the benefit of Dr. Phil’s preamble). I can’t help it. I attribute my habit of analyzing people to my training and practice in psychiatry. After a 40-year career in medicine, I can o longer delineate the psychiatrist from the private citizen. I don’t even try.
• Physicians occupy a lofty perch in society, or at least they used to. Given their status and power, their transactions with people tend to be one-sided. Until social media arrived on the scene, doctors rarely received feedback about themselves. One of my mentors founded a utilization review (UR) company in the 1980s and was so bold as to name it TAO (pronounced T-A-O). The acronym stood for transaction organization. Naturally, the transaction flowed irreversibly from the doctor to the patient: the UR doctor either approved or denied treatment.
• When I was a resident, I discovered a lot about myself. Psychotherapy was all but mandatory for psychiatric residents. This was fortunate, because therapy provided me insight and allowed me to adapt my persona to a range of patients with varying psychopathology. Still, due to the unilateral nature of the doctor-patient relationship, I felt beyond reproach. Also, as a psychiatris , I could write off any interpretation about my behavior as “transference.” I could simply inform my patients they were misdirecting their unconscious feelings and desires retained from childhood, which only strengthened my defenses and made me more impe vious to other people’s views of myself.
• My pomposity was eventually exposed by a patient. I thought the initial session went quite well, and I suggested we meet the following week. She paused and replied, “I don’t think I can see you again.” I was shocked and inquired further. “Look at your plants,” she said, pointing to several of them wilting in my office, in desperate need of water. “If you can’t take care of your plants, how do you expect to take care of me!”
• Thank goodness there were additional people in my life who gave me accurate feedback about how I came across to them – behavio s I didn’t have a clue, so-called blind spots. Sensitivity to others was once considered a prerequisite for a career in medicine. Somewhere along the way, in some of us, soft skills have taken a back seat to hard skills that enable us to endure medical t aining and the daily challenges of our profession – for example, competitiveness, perfectionism, and other “type A” traits. Medical training often comes at the expense of compassion and empathy, and we tend to over-compensate for our emotional deficits by elevating ourselves above our patients.
• Medical bloggers who respond to my op-eds have provided me with a significant amount of personal feedback, and they typically don’t hold back in their comments. When I bemoaned the lack of professional courtesy, as I discuss in essay 41, some physicians claimed I was entitled. When I wrote in the previous essay that proving other people wrong can sometimes be a source of motivation to succeed – a strategy I used to gain acceptance into medical school – a physician replied that he “pitied” me. Another physician commented that proving others wrong initially demonstrated that I did not have what it takes to succeed in life – ambition, motivation, and perseverance. And when I wrote about some of my experiences working for health care organizations, specifically my fear of speaking out against my employer (see essay 40), one physician commented, “Dr. Lazarus, you did it to yourself. You sacrificed your independence for a paycheck and became a proletariat.”
• While hard-hitting comments from colleagues were difficult to swallow, I knew they deserved my attention. It is well known tha physicians have blind spots to the business of medicine, especially their employment contract options, but it is rarely appreciated that people from all walks of life know a significant amount about us yet we are in the dark. Many physicians recognize when their patients are noncompliant with treatment, but they may be incapable of recognizing faults in their own behavior. Common blind spots in physicians include:
•  Cutting patients off before they are finished speaking;
•  Lecturing patients without letting them get a word in; and
•  Multitasking when they should be listening.
• Doctors with large blind spots have very little insight about themselves and their impact on patients. They may be able to make decisions and act quickly, but with little concern for the effect of their actions, and even less thought given to introspection. On the other hand, doctors with relatively small blind spots are practiced at noticing things about themselves and have a good bedside manner. It is important for physicians to connect the insight they have about themselves with the self-awareness they have gleaned from their patients and colleagues in order to maintain a balanced perspective on patient care.
• I shared the content of some of my contentious online exchanges with a colleague. He nodded knowingly. “My biggest blind spot is me,” he jokingly remarked.
• (November 7, 2021)
• 13. Memoirs of a “Recovering” Peer Reviewer
• I drank the managed care Kool-Aid, but I survived.
• In theory, the application of evidenced-based guidelines assists in reducing unwarranted variation in clinical practice and improving the quality and cost of care. Guideline developers, health plans, and their benefit managers contend that utilization management programs based on medically proven guidelines will transform the health of our communities, one person at a time.
• Utilizing the services of physician (and nurse) advisers, guidelines are deployed in the medical review of complex, controversial, unusual, new, or experimental medical services involving proposed surgery, imaging, pharmaceuticals, devices, and various procedures. The length and level of service – for example, hospital, skilled nursing facility, outpatient treatment, and the like – are also subject to review. All this activity falls under the umbrella of utilization review (UR).
• UR companies cannot exist without physician advisers (even with artificial intelligence substituting for physicians). It is generally accepted, and in some instances mandated, that only a physician can deny medical services (technically, medical benefi s). And therein lies the rub. Most practicing physicians detest being subjected to UR procedures – completing forms and responding to time-consuming peer reviews. An American Medical Association (AMA) survey found that, on average, physicians and their staff spend 13 hours per week (nearly 2 business days) completing prior authorization requests, which represent only a subset of UR functions.
• No one knows the number of U.S. physicians working for utilization management organizations, but it is becoming increasingly popular because companies offer flexible hours and remote working opportunities. The work can be full time or as a contractor, leaving time to continue to see patients.
• I used to believe strongly in the importance of UR and the tenets of utilization management – increased quality and decreased costs. I even worked for a few organizations earlier in my career. I left because I could no longer support the premise that managed care was better than care as usual, and because I questioned my right to tell another doctor how to practice medicine. The more I sympathized with my colleague on the other end of the telephone line, the more I tried to help them fulfill their request for services for their patient, regardless of the UR criteria.
• One doctor thanked me for helping him document the clinical rationale necessary to extend time in the hospital for his patient. He called me an industry “insider.” He said it was meant as a “complement” because he was amazed I still cared about patients. This doctor’s “complement” implied he no longer perceived me as a healer, that I was no longer worthy of helping those in need. I believe that most individuals who become doctors do so with a deep desire to help people recover. Yet, in my case, my purpose had become lost upon my colleague, and perhaps myself as well.
• Another issue that plagued me was my psychiatric training, which qualified me to review mainly patients with psychiatric and substance use disorders. Nowadays, there are a host of companies contracted by payers to conduct specialty reviews in diverse areas ranging from behavioral health to orthopedic and spinal surgery to oncology treatment.
• Shouldn’t physicians who sub-specialize in a particular area of medicine be reviewed by equally qualified physicians? Matched specialty review has become a highly controversial topic. Specialty matches are usually required upon appeal of an adverse medical determination, but not for the first level of review. Still, I doubt that a cardiothoracic surgeon would have wanted me denying – or even approving – her proposed treatment.
• Discussions with treating providers to clarify clinical information caused me considerable anxiety. I cringed at the thought o having adversarial peer-to-peer calls with other physicians. I also had misgivings about HIPAA when it was enacted. Although peer review conducted through the proper channels falls into the exception for healthcare operations, common pitfalls exist that may expose physicians to HIPAA liability.
• Indeed, one physician challenged my authority to conduct peer review. Nevertheless, he complied with my request for clinical i formation. Subsequently, he filed an ethics complaint with the American Psychiatric Association (APA), claiming my role as a peer reviewer was unethical because I did not have his patient’s permission to discuss the case. So why did he divulge the information in the first place? I was exonerated by the APA, but the experience opened my eyes to the fury of my peers.
• It is not uncommon for treating physicians to intimidate reviewing physicians by asking for their credentials and licensing inormation and reporting them to state medical boards. Although hospital quality assurance peer review committees operate under privilege afforded by law, the same is not true for UR activities conducted by commercial entities. To the extent that such activities are tantamount to the practice of medicine, physician advisers could face licensure sanctions – for example, if they fail to competently review the medical record, behave unprofessionally, or review a case in “bad faith,” i.e., with extreme prejudice or malice (see essay 45).
• UR jobs can be rewarding for some physicians. The excitement stems, in part, from the importance and critical nature of the physician adviser role, especially in utilization management companies scaled to impact millions of patients. The role caters to individuals interested in population health. And when you add UR companies’ marketing pitch – working virtually or on-site in a ast-paced environment that favors individuals who are able to learn quickly, be hands-on, handle ambiguity, and communicate effectively with people of different backgrounds and perspectives – UR jobs seem like an ideal fit for physicians seeking a career change.
• Unfortunately, physicians who drink the Kool-Aid soon realize UR jobs are a dead-end. There is little opportunity for upward mobility in large healthcare organizations dominated by the “suits,” where business executives value physicians for their ability to save the company money by denying care to patients, and where women face a significant glass ceiling to advancement.
• I believe fewer physicians would work for UR companies if they fully understood the burden of UR on practicing physicians and heir patients and employers. The aforementioned AMA survey found that prior authorization requirements substantially delay treatment, force physicians to abandon treatment, and negatively impact clinical outcomes including patients’ work performance. I recommend physicians think twice about drinking the beverage they’re served.
• (July 6, 2022)
• 14. Call Me In, Not Out, for My Transgressions
• Respectful conversations can help physicians overcome implicit bias and improve patient care.
• I lost my patience when the food-delivery driver called me and said she could not find her way to our house. Our home is newly constructed and does not appear in some GPS systems. Sometimes it guides people to a wrong location near where we live. Unfortunately, this malfunction includes the GPS system used by delivery drivers who work for a certain online food ordering company.
• Although the driver was lost, she was in my neighborhood – I could tell because I recognized the names of the streets she was eading aloud as she drove past them. The driver’s English was limited, which was somewhat unnerving. I was able to guide her to our home, but my tone was gruff, perhaps because she interrupted my viewing of the nightly news, or because I was “hangry” – our dinnertime meal was 25 minutes late. My anger also stemmed from the fact that I had quite a bit of difficulty communicating with her.
• I met the driver at the curb, waving her down as she approached our house, in fear she might overshoot it. She stepped out of her compact car – a car that had obviously seen better days – and handed over the meal. I composed myself and thanked her.
• “Where do you come from,” I asked?
• “Ukraine,” she replied.
• My heart sank. I was suddenly ashamed of the way I had treated her over the phone. The nightly news that she interrupted? Lester Holt was giving an update on casualties in Ukraine from extensive bombing that day.
• “You know there’s a problem with the GPS system you are using,” I said in a conciliatory tone. “Here, let me show you a better app for directions,” as I introduced her to ‘Waze’ on my iPhone.
• Now collected, I was less bothered by her meager English as she explained that online orders through the delivery app are automatically linked to their GPS system. However, she took note of the “Waze” application as a back-up and said she would use it in the future, if necessary.
• I took our dinner inside, but I had lost my appetite. I couldn’t come to terms with my initial unfriendliness. It was uncharac eristic of me. In my mind, there were inciting factors for the way I behaved, yet they were clearly based on prejudice and couldn’t justify my disrespect of the driver or undo the interaction.
• I became engulfed by my thoughts: was I guilty of microaggressions with patients before I retired from practice? How many patients may I have offended or incensed due to biased thinking? Surely, I saw many patients who spoke English as a second language. Was I negatively predisposed to all of them?
• I flashed back to my years spent in training and clinical practice in Philadelphia. The diversity of people living there enriched my education. English as a second language – or no English spoken – was never a problem. We had interpreters on staff. On one occasion (before HIPAA) I enlisted the corner hot dog vendor to help me translate for a patient who only spoke Greek.
• I was outraged when Joseph (“Joey”) Vento, the owner of a local eatery and shrine – Geno’s Steaks – slapped a sign in the window declaring that only English-speaking customers would be served. It read: “This is AMERICA. When ordering, speak English.” The sign attracted national attention, and legal attempts to remove it were unsuccessful. The sign was voluntarily removed in 201, a decade after it was posted. I protested by ordering from rival “Pat’s King of Steaks” across the street.
• My thoughts also reverted to the 1970s and the era of Frank Rizzo – the former Philadelphia police commissioner turned mayor turned radio talk-show host. Rizzo was known widely for his racist and anti-gay views, leaving a legacy of unchecked police brutality.
• The aggression exhibited by Vento and Rizzo was at the “macro” level. On the other hand, my emotional response to the driver delivering my food was more subtle – a microaggression. Microaggressions are flash-in-the-pan behaviors that stem from implicit biases toward people unlike ourselves.
• Implicit biases are unconscious stereotypes, assumptions, and beliefs held about an individual’s identity. They affect our understanding, actions, and decisions, and increase health disparities. The important point is that implicit biases influence diagnoses and patient treatment even in the absence of a physician’s intent or awareness, because ingrained biases are never truly extinguished – they leave a “mental residue.”
• Learning how to identify and overcome implicit biases is essential to improving the delivery of health care to diverse populations. The first step is to look for stereotyped descriptors in the electronic health record. A study found that, compared with white patients, Black patients were two and a half times more likely to be described in negative terms – for example, “non-compliant,” “agitated,” and “refused.” The authors concluded that providers may not be able to change their belief systems without self-awareness and/or training on potential biases.
• Such training may take the form of a patient-centered approach to cross-cultural care, cultural competency training, and other types of education aimed at recognizing stereotypical thinking. The key is to learn how to replace biases and assumptions with accurate representations of patients free of racial and ethnic context, and increase opportunities for positive contact with geographically and socioeconomically disadvantaged patients.
• Loretta J. Ross, associate professor at Smith College, adds that when microaggressions occur, shaming people is a natural impulse but not necessarily the correct option. It is better to call people in rather than call them out, she says. Calling in is similar to calling out, but it’s done privately and with respect. Calling in involves conversation, compassion, and context. Ross remarks, “...take comfort in the fact that you offered a new perspective of information and you did so with love and respect, and then you walk away...” The calling-in practice entails reserving a seat at the table for transgressors if, at first, they are not receptive to your kind gesture but later decide to join the conversation.
• So, to all my former patients – and any other individuals I may have transgressed against – I humbly seek your forgiveness and ask that you call me in rather than call me out.
• (August 23, 2022)
• 15. Like Many Physicians, I’ve Forgotten How to Relax
• “Sorry, no WiFi for U.”
• Here I am, on vacation at a luxury resort in Hawaii with my wife and two of my four children and their three children. It’s 10 p.m. and I’m beginning to write this essay while everyone is snug and tucked away for the night. Earlier in the day, sitting around the swimming pool, I’m glued to my iPhone. My son, who resides in Honolulu, comments, “Dad, you’re so wired in. Play with he kids (my grandchildren) in the splash zone. Take them on a ride down the lazy river. Relax with us.”
• But like many physicians, I’ve forgotten how to relax. Patient care has been front-and-center since the pandemic started – in addition to the usual crises and emergencies – and we’re increasingly burned out or using substances to cope. Our clinical performance has diminished, resulting in increased errors and other quality concerns.
• The one thing we’ve been good at, it seems, is neglecting our own health. Researchers found that physicians who were wedded to their jobs experienced lower quality of sleep, greater levels of depression, and lower levels of general well-being. Plus, they exhibited more stress at work.
• Everyone knows that doctors need to take time for themselves and relax in order to stay healthy. Providing doctors with opportunities to relax is correlated with better health outcomes for themselves and their patients. Trips to far-away or exotic locations can be helpful but are not guaranteed to afford relaxation. Sometimes simply walking 30 minutes each day, partaking in a hoby, meditating, and other activities are all that is needed to recharge your batteries.
• However, some doctors find it difficult to engage in relaxing activities. I admit, I’m one of them. I have a collection of several hundred DVD concerts; approximately half are unopened and waiting to be viewed. I’ve purchased dozens of books not yet read. What makes it difficult for doctors like me to sit down, relax, and watch a DVD or read a good book? The answer, according to experts, lies in our brain chemistry and conditioning.
• Our brains want a dopamine rush, and our sympathetic nervous system is stuck in overdrive. Physicians rely on a steady diet of distressing news, disturbing deaths, and clinical disasters. After years of medical practice, excitement fades, replaced by boredom and panic. Our brains seek a quick chemical hit to rekindle. Rarely do we have a chance to debrief over critical incidents and reflect on what happened. We just move on, tense and stressed out, always in a hurry to “get to the point,” bypassing important cognitive ramifications of our work.
• In terms of conditioning, we’ve been primed, prepped, and propelled toward academic and career success since high school, perhaps earlier. Along the way, we’ve been challenged by automatic negative thoughts: “I’m going to flunk this test,” “I can’t handle the work load,” “I don’t measure up,” “I’m an imposter.” Automatic negative thoughts can result in fatigue, depression, anxie y, and symptoms typically associated with trauma, especially hyperarousal, which contributes to our inability to relax. Anyone who grew up thinking they had to be the “best” is likely programmed for stressful perfectionism incompatible with relaxation.
• I first noticed difficulty relaxing while in medical school. Absorbing the basic sciences was like taking a drink from the proverbial firehose – a tsunami of new information crashed upon me as soon as I felt up-to-date. During clinical rotations, I was anxious and on guard, waiting to be pimped by a senior resident or an attending. I invested energy in all clerkships. In reality, no specialty other than psychiatry appealed to me. I became chief psychiatry resident thanks to my unsurpassed achievements and devotion to training. However, the work involved “staying ahead” of my peers and precluded relaxation.
• When I started practicing, I expected my nerves to calm, but they didn’t. I read The Relaxation Response, but the helpful advice it offered was overshadowed by my own stressful quest to “find the way to myself,” a purpose championed by Emil Sinclair, the protagonist in Hermann Hesse’s Demian. Sinclair sought to understand why it was so challenging “to live in accord with the promptings which came from [his] true self.” Our pursuit of meaning is an exhaustive process filled with uncertainty and fear. How could anyone relax under such circumstances?
• I identified with Sinclair, especially the passage in Demian in which he realizes that “[man’s] task was to discover his own destiny – not an arbitrary one – and to live it out wholly and resolutely within himself. Everything else was only a would-be existence, an attempt at evasion, a flight back to the ideals of the masses, conformity and fear of one’s own inwardness.” I certainly didn’t want my existence to be “arbitrary.”
• So, I embarked on a journey of self-discovery with the help of a wise and compassionate psychoanalyst. He provided expert guidance for my travels. However, even after therapy, I was consumed by free-floating anxiety. I never felt totally relaxed, and even to this day, at a time when I consider myself semi-retired, I’m always looking over the horizon for the next challenge, the next big fix, the next accomplishment, the next op-ed to write.
• Apparently, patience is not a virtue of many doctors. I’ve read stories about physicians in various specialties – not only psychiatry – who have struggled to relax when off work. Only 60% of doctors report feeling “happy” outside of work. Fortunately, some physicians have managed to compensate for their unhappiness and restlessness.
• An emergency medicine physician finds bicycle riding a great way to decompress. He becomes “lost” in his thoughts as he rides, sometimes forgetting specifics along the route.
• A family medicine physician turns to prayer and religion to relax. Other activities such as walking on nature trails and even sitting by the fireplace remind her there’s more to life than practicing medicine.
• An otolaryngologist who specializes in head and neck cancer surgery engages in outdoor activities like camping, boating, and fishing with his family. His stress is reduced by working with his hands, enjoying hobbies such as woodcarving and tinkering with cars.
• A pulmonologist and critical care physician paints and makes craft projects with her son. Yoga and cooking are her favorite ways to unwind.
• I’m thinking about leaving my computer and smart devices at home the next time I take a vacation. I informed my son of my inte tions. He took me to his favorite coffee café. “Everyone’s connected and engaged here,” he said, pointing to a sign that read: “Sorry, No WiFi 4 U.” A smile crossed my face. I began to relax.
• (January 29, 2023)
• 16. Sending in “Tougher Canaries” Won’t Fix the Problem of Physician Well-Being
• A three-pronged approach aimed at medical education, training, and practice is the solution.
• Many surveys and reports have acknowledged that physicians are unwell, and their numbers have reached crisis proportion. “We a en’t going to fix this problem by noting that canaries are dying in the coal mine and … sending out for tougher canaries,” remarked Gary Price, MD, an attending surgeon at Yale-New Haven Hospital in Connecticut and president of the Physicians Foundation, a physician empowerment organization.
• Price’s remarks were actually in response to a survey of medical and nursing students in the headlines recently. That survey reported that students were exposed to high-stakes pressures, including the financial burden of school, their first exposure to the clinical setting, and the current dysfunction in those settings. By the time those students enter residency and practice, mo e than half will be burned out, according to various sources. However, that’s where most surveys miss the mark on what to do about physician well-being: they’re either silent or don’t know how to fix it. I have a three-pronged approach.
• The first thing to do is totally revamp medical education. We take students who want to be doctors and lock them away in study groups and libraries with endless review videos and flashcards full of useless details. Then we submerge them in “simulations” and send them into patients’ hospital rooms unsupervised and without contemporaneous feedback about their interactions with patients. After they see patients, students are left alone to process their emotional experiences and any trauma associated with their visits. They are forced to wear a false bravado as they are pimped and put down by residents who, themselves, are psychologically distressed, even damaged. The system of learning is insufferable for medical students. Should we be surprised that many come out depressed, having lost interest in serving patients, and pessimistic about their future?
• Next, we need to redo the system for training residents. Clinical training based on hands-on attentive care of the patient, under close supervision by very experienced clinicians, has all but evaporated. Attendings who have shied away from extensive rounding with students and residents, or have faded into the fabric of research and pharma consulting, or simply would rather be elsewhere – anywhere other than at the patient’s bedside – explains why trainees fail to fully grasp the concept of doctoring and why medical care today is so disjointed, patient-unfriendly, and often riddled with errors and failed oversight. Only altruistic physicians who are dedicated to full-time academic teaching – and are fairly compensated for it – need to show up.
• I’ll never forget my first night on call during my junior clerkship in surgery. I was assisting a fifth-year resident in the operating room as he repaired several lacerated tendons in a young woman’s hand (her “boyfriend” brandished a knife and cut her during an argument). The surgery took place roughly between 2 and 4 a.m. Several hours later, the attending arrived for morning rounds, only to discover the resident had operated without his knowledge – that is, the attending’s knowledge; there was no one to pass judgment about the resident’s knowledge of intricate hand surgery. The attending went berserk, scolding the resident for not being notified prior to performing the delicate procedure. The attending said he would have come in from home to assist the resident had he known. We need more of those attendings!
• Finally, we need to restore pride to the medical profession. Doctors used to go into medicine for several reasons. They wanted to take care of patients because they liked people, they loved helping others, and they welcomed the challenge of making diagnoses, performing procedures and surgery, and especially, for psychiatrists, doing psychotherapy, which is now a lost art abrogated to non-medical therapists. Physicians liked the autonomy and collegiality of medicine, and they knew they were going to make a good living at it. All this while essentially making their own hours, working on their own terms, and withstanding the challe ges of – even looking forward to – being on call. What happened?
• What happened was government interference, overburdening physicians with ridiculous documentation mandates and infrastructure issues, and the corporate domination of medicine forcing private physicians to be employed, among other woes of transitioning to the medical-industrial complex. This took away physician’s autonomy and their earned status to the point of simply being another hospital employee or employee of a large health system. This caused physicians to not just be responsible to patients but to corporate entities and the government. This total conflict of interest places physicians between medicine and management, where they do not belong. There is no reason to treat smart, ambitious doctors this way. (Jerry, I hear you singing: “Don’t wanna be treated this a way …”)
• On top of treating doctors shabbily and with disrespect, physicians were forced to accept increasing liability and were expected to perform with perfection, so that now huge malpractice settlements deter organizations from hiring doctors – and God forbid lawyers should let physicians apologize to patients and families for mistakes. Also, continued cuts in Medicare and other heal h insurer’s fees signaled that physicians were not valued. It all seems so surrealistic – a bad nightmare and no longer worth the price of admission to practice. Many physicians are leaving the profession in droves, and scores intend to exit over the nex several years. Why should anyone be surprised that 25% of medical students intend to use medical school as a stepping stone within – or outside of – medicine rather than practice it (refer to essay 42)?
• Virtually everything I’ve read when it comes to medical students, residents, and physicians attaining well-being puts the problem squarely on them, holding doctors accountable for making the necessary changes – for example, ensuring work-life balance; encouraging healthy eating and regular exercise; practicing mindfulness; implementing regular work breaks and resilience programs; building a supportive culture; regularly assessing well-being, etc. We’re too frigging busy to “build” anything. There is nothing “regular” about the practice of medicine that we should take for granted. I want to gag myself with a spoon every time I read this crap.
• I see the same BS in articles suggesting structural solutions to making physicians well again, such as changing workloads and schedules; streamlining administrative tasks; enhancing team-based care; addressing financial pressures; improving workplace culture; and advocating for policy changes. Who’s going to do that? Politicians and lawmakers? Hospital MBAs? They’re the reason we’re in this mess! Measuring physician “burnout” and holding health systems accountable for reducing its incidence is a somewhat novel idea, but let’s face it, the only thing health systems are really accountable for are their bottom lines and those who back their equity.
• It’s time to end the rhetoric and stop pretending that coaching and coddling physicians will make them better. Broken physicia s won’t get fixed by sending in tougher canaries. Broken physicians may get better by breathing in fresher air.
• This profession we call medicine is a sailing ship to the Devil’s Triangle. Unless a course correction is imminent, unless we ight the ship, there will be no more canaries to send in.
• Send in the clowns.
• (November 11, 2023)
• 17. Burnout On the U.S.S. Enterprise
• There is a reason why writers invented Hollywood endings.
• The original Star Trek television series, in my opinion, stands out as the best of the bunch. It lasted only three years (1966-1969), but it has retained a cult following. Among its many television “firsts” were the initial inter-racial kiss (between Captain Kirk and Lieutenant Uhura) and perhaps the first depiction of burnout, as seen in the two-part episode “The Menagerie.”
• Originally intended as the pilot, “The Menagerie” was postponed to the 11th episode of the first season. It featured Christopher Pike as the U.S.S. Enterprise’s captain before James T. Kirk assumed command. Mr. Spock served as Pike’s science officer, and Dr. Phil Boyce played the role of the starship’s medical officer.
• In the episode, Spock usurps control of the Enterprise and sets in on a course to the forbidden planet of Talos IV. It’s not u til part 2 that we discover Spock’s motive for the journey, and in doing so, risking the death penalty: it is to provide Pike with a semblance of a normal life after a tragic space accident left Pike disfigured and unable to move or speak (the Talosians are capable of restoring Pike’s appearance through their power of illusion).
• One of the most poignant scenes in this classic adventure, written by Gene Roddenberry, the creator of Star Trek, occurs in pa t 1. Captain Pike asks to see Dr. Boyce for a second opinion about whether a distress signal coming from Talos IV is real or fabricated by Spock. Boyce enters Pike’s room with his doctor’s bag, and the following conversation (condensed) ensues:
• PIKE: What the devil are you putting in [that glass], ice?
• BOYCE: Who wants a warm martini?
• PIKE: What makes you think I need one?
• BOYCE: Sometimes a man will tell his bartender things he’ll never tell his doctor. What’s been on your mind, Chris, the fight on Rigel Seven?
• PIKE: Shouldn’t it be? My own yeoman and two others dead, seven injured.
• BOYCE: Was there anything you personally could have done to prevent it?
• PIKE: Oh, I should have smelled trouble when I saw the swords and the armor. Instead of that, I let myself get trapped in that deserted fortress and attacked by one of their warriors.
• BOYCE: Chris, you set standards for yourself no one could meet. You treat everyone on board like a human being except yourself, and now you’re tired and you …
• PIKE: You bet I’m tired. You bet. I’m tired of being responsible for two hundred and three lives. I’m tired of deciding which mission is too risky and which isn’t, and who’s going on the landing party and who doesn’t, and who lives and who dies. Boy, I’ve had it, Phil.
• BOYCE: To the point of finally taking my advice, a rest leave?
• PIKE: To the point of considering resigning … There’s a whole galaxy of [other] things to choose from.
• BOYCE: Not for you. A man either lives life as it happens to him, meets it head-on, and licks it, or he turns his back on it a d starts to wither away.
• PIKE: Now you’re beginning to talk like a doctor, bartender.
• BOYCE: Take your choice. We both get the same two kinds of customers. The living and the dying.
• “We both get the same two kinds of customers. The living and the dying.” What a terrific analogy between doctors and bartenders. How true! It makes a great joke: “How are doctors and bartenders alike …”
• This scene is also a great backdrop for understanding burnout. Pike believes he is omnipotent. He sets personal standards that are too high. He blames himself for not achieving them. He begins to imagine there is a better life elsewhere, far away from the Enterprise, where he can participate in activities that once were pleasurable, or at least pursue ones that hold promise – and Pike has a whole galaxy to choose from.
• Burnout is defined in the 11th edition of the International Classification of Diseases as an “occupational phenomenon” rather han a mental health disorder. The syndrome is conceptualized as resulting from chronic workplace stress that has not been successfully managed. It is characterized by three dimensions:
• 1. Feelings of energy depletion or exhaustion.
• 2. Increased mental distance from one’s job, or feelings of negativism or cynicism related to one’s job.
• 3. Reduced professional efficacy.
• It is important to note that burnout refers specifically to workplace issues and is not considered a mental health disorder, although seeking professional help is crucial if symptoms of burnout persist or lead to feelings of depression or anxiety.
• When Star Trek was being filmed in the 1960s, the concept of “burnout” in the context of psychology did not exist. (The term “burnout” was first coined by the American psychologist Herbert Freudenberger in 1974.) Thus, Dr. Boyce’s advice to Captain Pike – to “meet life head on,” insinuating he should suck it up and continue doing his job – made sense for the time period (forgetting that Star Trek took place in the 23rd century). Plowing through burnout in the 1960s was the obvious way to go. Now we know better, and there are options to deal with burnout, including exploring different career paths.
• Who knows what would have become of the Star Trek series had Captain Pike disregarded Dr. Boyce’s advice and resigned his posi ion. After all, it was Captain Pike’s tragic accident – an accident he sustained after Dr. Boyce convinced him to remain as captain of the Enterprise – that effectively ended Pike’s career. It proved to be Kirk’s good fortune, however, since Kirk was able to succeed Pike as captain and give us two more glorious seasons of Star Trek.
• I guess that’s why writers invented Hollywood endings – “to boldly go where no man has gone before.”
• (December 8, 2023)
• 18. Autism and Doctors: Strengths, Challenges, and Stories
• A lifetime struggle for The Good Doctor.
• Dr. Shaun Murphy (played by Freddie Highmore) starred in ABC’s The Good Doctor, a television drama that centered around an au istic surgeon whose job at the hospital was frequently threatened and would be lost if it were not for the practical and emotional support from the hospital president. (The Good Doctor aired over seven seasons, between September 25, 2017, and May 21, 2024.)
• I don’t know how many “Doctor Murphys” practice medicine in real life – autism spectrum disorder (ASD) prevails in about 1% to 2% of the general population – but I do know that ASD is a complex neurodevelopmental disorder characterized by two main types of symptoms:
• 1. Social communication and interaction challenges: People with ASD often have difficulty with social aspects of communication and interaction. This can include:
•  Difficulty with social-emotional reciprocity, such as initiating or responding to social interactions.
•  Challenges in nonverbal communicative behaviors used for social interaction, like eye contact, body language, or understandi g and using gestures.
•  Difficulty in developing and maintaining relationships appropriate to the developmental level.
• 2. Restricted, repetitive patterns of behavior, interests, or activities: People with ASD may display behaviors, interests, or activities that are restricted and repetitive. This can include:
•  Stereotyped or repetitive motor movements, use of objects, or speech.
•  Insistence on sameness, inflexible adherence to routines, or ritualized patterns of verbal or nonverbal behavior.
•  Highly restricted, fixated interests that are abnormal in intensity or focus.
•  Hyper or hypo reactivity to sensory input or unusual interest in sensory aspects of the environment.
• The severity and combination of symptoms can vary widely among individuals with ASD, hence the term “spectrum” was added to the diagnosis of autism in 2013. Symptoms of ASD are typically recognized in the early developmental period, but they may not fully manifest until social demands exceed the individual’s capacities. Symptoms can also be masked by learned strategies in later life, but individuals may suffer from the stress and effort of maintaining a socially acceptable façade.
• This last point, i.e., symptoms may be masked in adulthood, weighs heavily, because I can see myself as an outlier on the autistic spectrum. Not too long ago, a colleague who knows me well suggested half-kidding that I may have had autism as a child.
• “No way,” I said
• “Think about it,” she replied. “You don’t socialize much, you have rituals (two showers a day), you’re rigid and set in your ways, and you’re fixated on your hobbies. I bet if we gave you the ADOS-2 (Autism Diagnostic Observation Schedule, Second Edition), you’d come out on the spectrum.”
• I was speechless. I revisited the DSM criteria for autism spectrum disorder and researched some of the characteristics that may potentially correlate with or predispose someone to a career in medicine. Here is what I found:
• 1. Attention to detail: Many individuals with ASD have an exceptional ability to focus and pay attention to detail. This can be particularly useful in medicine, where precision and meticulousness are crucial.
• 2. Strong memory skills: Some people with ASD have excellent memory skills, particularly for factual information or processes. This could be beneficial in a medical profession where remembering large amounts of information is required.
• 3. Systemizing tendency: People with ASD often have a strong interest in systems. This can translate into an interest in the human body’s systems and a passion for understanding how they work, which is a fundamental aspect of medicine.
• 4. Perseverance: Many people with ASD can be exceptionally determined and persistent, especially when they are passionate abou a particular subject. This trait can be very advantageous in the demanding field of medicine.
• 5. Honesty and directness: Individuals with ASD often have a straightforward and honest communication style. While they may need to develop soft skills for patient interactions, their honesty can be an asset in a profession where transparency and integrity are valued.
• 6. Special interests: People with ASD often have intense special interests. If their interest lies in the field of medicine, they could excel in this field due to their ability to focus intensely on their area of interest and specialization.
• Until recently, there has been little research into the experiences of autistic doctors. However, a 2023 survey of 225 physician members of the U.K.-based support group Autistic Doctors International, representing about 45% of its membership, shed light on challenges faced by neurodivergent doctors in their profession. The findings are shocking:
•  24% have attempted suicide
•  77% have contemplated suicide.
•  49% engaged in self-harm
• The average age of a formal diagnosis of autism for doctors was 36 years old, confirming that high intellect and specific apti udes – in this instance, aptitudes viewed as medical “assets” – may explain why signs can go undetected for years and mask the diagnosis in adults.
• There have always been autistic doctors, but this survey revealed that the field of medicine is extremely challenging for the eurodivergent clinician to navigate. The survey also highlighted the need for greater support and understanding of autistic doctors – and autism in general – within the medical community.
• Indeed, a 2019 study demonstrated that medical students report low knowledge of ASD, and more than 90% of students cite inadequate preparation for caring for individuals with autism. Medical students also reported a greater need for increased education and training in ASD care.
• Although a diagnosis of autism can have unfavorable consequences if individuals are met with denial or discrimination from employers, the condition is not a reason for organizations to impede the successful practice and career progression of doctors with ASD. Like the good Dr. Murphy, a successful career in medicine is possible for doctors on the autistic spectrum if the condition is recognized and supported sooner and appropriate accommodations are made.
• I don’t doubt I share some of the disorder’s features with individuals who fall on the autistic spectrum. Considering that ASD is a spectrum disorder, meaning characteristics can vary greatly from person to person, not all individuals with ASD will have these traits, and having these traits does not necessarily mean an individual with ASD will want to or be able to become a doctor.
• To be clear, I was never diagnosed with an autism spectrum disorder. Reflecting on the possibility, I feel a bit like psychologist Malcolm Crowe (played by Bruce Willis) in the movie The Sixth Sense. Dr. Crowe doesn’t recognize he is dead until the end of the movie. I’m quite alive, but the thought I might have ASD is quite unimaginable, even if it were true. Receiving the correct diagnosis – in the field of psychiatry, especially – can be a moment of sudden enlightenment and explain a lifetime of difficulties.
• (February 18, 2024)
• 19. Your Employment History Isn’t Spotless, So Learn to Master Job Interview Questions
• Anticipate difficult questions during your job interview, but control the narrative.
• I’ve known many physicians (myself included) with somewhat checkered employment histories: conflicts with colleagues, frequen job changes, burnout, medical errors, and disciplinary actions, to name a few. Assuming you fit one of these categories and decide – or have been told – to move on, whatever negative feelings you may harbor about the people in your organization should not carry over into a prospective job interview and new position. Here are some tips for navigating interviews when you have a less-than-spotless resume.
• Don’t Blame or Complain
• Blaming or complaining about your former boss or coworkers, especially in an interview, is a big mistake. You must present you self with grace and professionalism. It can be tricky.
• Here’s an example of how you might respond to a question about why you left (or are planning to leave) your job:
• “While I appreciated the opportunities I had at my previous job, I realized that I was looking for a work environment that bet er aligns with my professional values and career goals. I am excited about the opportunity at your company because it offers the kind of collaborative and supportive culture where I believe I can thrive and make significant contributions.”
• There are also short-answer options for responding to that same time-honored question, and they are applicable even if you were fired:
• Q: Why are you leaving?
• A: “There’s been a mismatch in expectations.” Or, “I’m looking for a role where I can learn and be challenged.” Or, “It wasn’t a good fit for me.” Or, “We decided to part ways.”
• It’s often best to keep it simple and avoid excessive details. Save your rants for your therapist or coach.
• Stick to (Neutral) Facts
• You’ll likely face probing questions during your new job interview. Don’t allow yourself to get tripped up by them. Stick to the facts and remain neutral. You will have the ability to control the narrative to some extent. Hook people in. Tell them your story in a way that captures their attention from the get-go. Remember, this isn’t the dust jacket bio of your book; it’s your chance to introduce yourself to the interviewer.
• For example:
• Q: Why are you leaving so soon (assume less than two years)?
• A: “I saw the job description (online, etc.), and it’s a better fit for me than my current job. Here’s what resonates with me…”
• Focus on the Positive: During the interview, try to respond to questions with a positive take.
• Mention specific skills you’ve gained: “I’m looking to deepen my interests in IT and forecasting.”
• Highlight your values: “I’m seeking a company that respects teamwork and collaboration.”
• Emphasize your strengths: “I’m a fast learner and quickly adapt to new situations.”
• Research the company and show that you’re a good cultural fit: “I’m looking forward to working with the chief medical officer and her team. They’ve demonstrated novel approaches to patient care.”
• Share what’s important to you: “I’m looking forward to celebrating our wins.”
• Tell the interviewer what you have learned: “I’ve become deeply passionate about population health and patient advocacy.”
• Take the spotlight off of a negative topic: “My colleagues swear by my character and work ethic. I’ve listed them as references.”
• Shift to your ambitions and express enthusiasm: “I’m eager to join a team that values creativity and innovation.”
• Talk about your professional development: “I’m seeking a company that invests in its’ employees’ education.”
• Show growth from adversity: “I’m sure I can make a significant contribution. I’ve become much better at solving problems.”
• Don’t Give Too Much Detail
• Don’t be afraid to show yourself and highlight what you do outside of working hours: “I volunteer once a month at a free clinic.” Or, “I play the piano (or other instrument).” Or, “I enjoy writing poetry.” However, be careful not to reveal too much of yourself or discuss highly personal matters (e.g., family, culture, religion, sexual preference, and political and ideological affiliations and positions).
• Alternatively, avoid discussing sensitive or confidential information about your previous employer. This is different than bad-mouthing them, which as I stated above you should also avoid. Maintain a professional tone, act natural, and don’t come across as stilted or defensive.
• Structure your response using the STAR method (Situation, Task, Action, Result) to provide clear and organized answers to questions that may require elaboration – the type of questions that often begin with: “Tell me about a time when….” Prepare and practice your responses to common questions about difficult situations, so you feel confident and articulate during the interview. By focusing on growth and positive outcomes, you can effectively address tricky questions and demonstrate your resilience and professionalism to potential employers.
• Leaving a job under trying circumstances may not be easy, but your experience can make you a stronger candidate. By preparing in advance and maintaining a positive, professional demeanor, you can navigate a new job interview successfully and leave a strong impression on your potential employer. Anticipate challenging questions during the interview, but control the narrative. Remember, every ending is a new beginning. Own your story and let it elevate you.
• (September 3, 2024)
• 20. Blues Power: Turning Heartache Into Healing
• This is a highly encapsulated but accurate portrayal of the emotional weight of the conversation and the tension between a physician’s personal challenges and the desire to heal, both for themselves and their patients.
• Patient/Physician (P): I’m an old blues man, and I think you understand I’ve been singing the blues ever since the world bega .
• Psychiatrist (Me): I hear you. That timeless blues spirit runs deep, carrying the weight of lived experience and heartache. I ’s like a rhythm that never fades, just keeps echoing through every generation. What’s got you singing the blues today?
• P: The medical field has become a complete mess.
• Me: I feel that frustration. Medicine has become so entangled in bureaucracy, profit-driven motives, and administrative burdens that it’s easy to lose sight of patient care. It’s a system where compassion and time are often sacrificed for metrics and margins. What aspects of it feel like the biggest failures to you right now?
• P: I don’t know where to begin. I just feel so let down by the system. It doesn’t work for the benefit of patients or providers.
• Me: It’s a betrayal, really, when the system that’s supposed to heal becomes one that harms—not only patients but those who’ve dedicated their lives to care for them. When the focus shifts to profits, efficiency, and control, the humanity of medicine fades. Providers are overworked, patients are rushed, and no one feels heard or cared for. What do you think could turn it around? Or at least soften the sharp edges?
• P: Honestly, I think it’s hopeless. Maybe put more doctors in control of the decisions. Take the administrators and politicians out of the exam room.
• Me: That would be a real step in the right direction – letting the people who actually understand patient care, the doctors, guide the system. The problem is that medicine has become too corporate, with too many non-medical folks pulling the strings, turning health care into a commodity. When business decisions overshadow clinical judgment, it’s the patients and providers who sufer. It’s easy to feel hopeless when it feels like no one’s steering the ship with compassion. Do you think there’s any way doctors can reclaim some of that control, or is it too far gone?
• P: Well, I mentioned that I’m an old blues man. I actually came of age during the era of rock and roll, and your comment that medicine may be “too far gone” reminds me of the Eagles song “Already Gone.” I suppose that’s my answer, that in my mind, I’ve already left it behind. But I don’t know what my next step will be. It frightens me, and departing my very sick patients makes me feel guilty.
• Me: That makes a lot of sense. Letting go is tough when you’ve poured so much of yourself into your work, especially when people’s lives and well-being are involved. But it sounds like you’ve given so much already, and the toll this broken system has taken on you is real. “Already Gone” fits the feeling of knowing it’s time to move on, but not without some heartache. Maybe it’s ot about abandoning your patients, but finding a different way to support them or channel your experience. The path ahead might not be clear yet, but there’s still so much you can do, even outside the system. How do you think you might continue to make a difference?
• P: Again, your choice of words is uncanny. The Eagles also sang “Heartache Tonight,” a romp about getting hurt by staying in a toxic relationship – I’m married to medicine. But to answer your question, I definitely still feel passionate about the medical field, and I would like to make a contribution, to continue to impact patient care, even if it’s through indirect means. Do you have any suggestions?
• Me: I’m glad to hear that passion for medicine is still alive in you. It can be channeled in ways that bring fulfillment without being caught up in the mess of the system. Here are a few ideas on how you could make an impact indirectly:
• 1. Teaching and mentorship: Sharing your knowledge with younger physicians or medical students could shape the next generation of compassionate, patient-centered doctors. You can pass on the values you feel the system is missing.
• 2. Writing and advocacy: Judging by your publications, you’re a capable writer. Maybe you could become a voice for change through writing or public speaking, shedding light on systemic issues while advocating for reforms that prioritize patient care.
• 3. Volunteering: There are many opportunities to use your expertise in non-profit organizations, free clinics, or community health initiatives that don’t have the same bureaucratic weight as hospitals and large systems.
• 4. Consulting: Your experience could be invaluable in advising health care organizations or startups on how to create patient-centered systems or improve current practices.
• 5. Telemedicine or specialty care: You might still be able to see patients in a more controlled, flexible environment through elemedicine or by offering second opinions or specialty consultations that don’t involve the same administrative burden.
• Do any of these resonate with where you’re at?
• P: Actually, all of these options are appealing. I just don’t know how to get started. Also, I’ve been thinking about working as a locum tenens physician. I’ve read positive stories about this type of work.
• Me: It’s great that all those options resonate with you. It shows that you’ve got a lot of potential paths forward. Locum tene s work could be a solid bridge, too, giving you the chance to continue practicing while having more control over your schedule and environment. To get started with each of these options, here’s a breakdown:
• 1. Locum tenens: There are several agencies that specialize in locum tenens placements. You could start by researching reputable agencies to find a good fit. Many of them offer flexible opportunities that might allow you to explore other interests alongside practicing medicine. Talk to other physicians who have worked locum tenens to get their perspective and advice.
• 2. Teaching/mentorship: Reach out to medical schools, residency programs, or even online platforms like Coursera or MedEd platorms where you could contribute as a lecturer or mentor. Consider joining professional organizations that have mentorship programs, or look for conferences that offer opportunities to teach workshops.
• 3. Writing/advocacy: Perhaps starting a blog or contributing op-eds to medical journals or mainstream publications could be the next step. Advocacy groups often look for people with your kind of experience to help frame important issues. Joining professional networks or organizations that focus on health care reform or patient advocacy could give you a platform to push for change.
• 4. Volunteering: Look into organizations like Doctors Without Borders, local free clinics, or national medical outreach programs. Many allow for short-term or flexible commitments that align with your skills and experience.
• 5. Consulting: You could begin by offering pro bono advice to health care startups or non-profits, then build your reputation and expand your network. Platforms like LinkedIn are great for showcasing your expertise and connecting with companies in need of medical insight.
• Locum tenens could also give you time to explore these indirect paths without fully committing to one right away.
• P: That sounds great. Thanks for your advice. Same time next week?
• Me: Why? There’s no point in crying the blues anymore!
• (September 26, 2024)
• Selected Essays: Education, Training, and Development
• 21. The First Time I Felt Like a Doctor
• I was reborn as “Lazarus” following a confrontation with a senior attending.
• The truth is, I never felt like a doctor until I was in the final year of my residency. All through residency and medical school – and even before medical school – I wasn’t sure I would ever really become one. Heck, I barely got into medical school. I was only accepted by one program, and only on my second attempt. I spent my year off selling records at Sam Goody. And even they ired me! 
• I remember reading an article about doctors with MBA degrees – yes, I’m one of them – and the author made a distinction betwee business people with an MBA and doctors with an MBA. He said no one went to business school to become a doctor. In other words, even if MDs and DOs have postgraduate degrees, they wanted to become doctors first and foremost.
• That was surely my case. I had wanted to be a doctor ever since I could remember. You could say my pediatrician made a good fi st impression (see essay 38). In kindergarten, the school’s doctor (also a pediatrician) sent me home with a note after he conducted a routine physical exam. The note read: “Quite a normal boy.” 
• “What did you say to him?” my mother wanted to know. I couldn’t recall the exact conversation, but I remember discussing being overweight and that I loved meat and mashed potatoes. Laughter erupted from the nurse and doctor when I told them. I didn’t understand why.
• In my mind, I was destined to become a doctor. My aspiration to be a physician was always top of mind, until I attended a libe al college in Boston in the early 1970s. I became part of the “turn on, tune in, drop out” counterculture. Although I never met Dr. Timothy Leary, the Harvard psychologist who coined the infamous slogan, I did meet one of his contemporaries, Dr. B.F. Ski ner, a pioneer of modern behaviorism, who wrote the book on operant conditioning and reinforcement theory. 
• In college, I became hooked on the study of behavior and switched my major from biology to psychology. I survived the cultural revolution, but I graduated college with only a 3.45 GPA and subpar MCAT scores. My premed adviser said I would never get into medical school (refer to essay 11). 
• She was almost right. After a thorough trumping by a dozen or so schools, in which I was granted only two interviews (one of them obligatory from my alma mater), I had the chutzpah to call the other physician who interviewed me and showed a genuine interest in my application. Coincidentally, he was a psychiatrist, and he liked my essay, which was heavily tinged with references o mental health. It was fortuitous that we lived in the same city.
• “Come to my house Saturday morning for coffee and we’ll talk about it,” he said over the phone. As a member of the admissions committee, any advice he could give me would obviously be welcomed. The psychiatrist told me to improve my GPA by taking a couple of science courses, as well as study hard for the MCATs and bring my science score up by 100 points. Wouldn’t you know it, that’s exactly what happened. (Thank you, Stanley Kaplan!) 
• The psychiatrist went to bat for me. “No need for a second interview,” he said. He re-presented my application to the admissio s committee. I was accepted into medical school. My dream had come true against all odds. Ironically, the psychiatrist and I would later become peers and clash over everything, from policy to treatment methods.
• But here is where the story gets interesting. I trained at the same institution where I went to medical school. In my final year of residency, I was elected chief resident, yet I still had plenty of doubts about my skills. What kind of a doctor was I? One infatuated with medicine at an early age but barely accepted into medical school? An undergraduate psychology major with a disdain for science? A resident who let a patient slip through the cracks and almost die (refer to the Prologue)? A doctor with a business degree? I questioned my abilities and career choice.
• My confidence booster finally came during my time as chief resident. I helped run the psychiatry department’s consultation-liaison service, the arm of the department that commingled with the “white coats” and “sick” patients in the hospital. I was consulted about a patient who had attempted suicide by asphyxiation; he had put a plastic bag over his head to suffocate himself. 
• His wife became alarmed, naturally, and the patient was admitted to the hospital by his doctor, a famous head-and-neck surgeon who also happened to be the father of one of my medical school classmates. Eight years earlier, the surgeon had explained to me and his daughter (my classmate) the detailed anatomy of the head and neck while helping us dissect a cadaver. I’m certain he didn’t remember me this time, late on a Friday afternoon, when I was called to his patient’s bedside. 
• After seeing the patient and his wife, I determined he was at high risk for suicide. The patient was reeling from a recent disiguring operation for oral cancer, an operation that also left him literally and figuratively speechless. I suggested that the patient be transferred to the psychiatry unit for treatment of major depression. I didn’t think he could wait to be seen as an outpatient.
• The surgeon disagreed. “He’ll be stigmatized,” the surgeon told me. Our disagreement escalated into a toe-to-toe shouting match in the hospital corridor. 
• “He’s already stigmatized by his appearance,” I exclaimed. “He’s suffered enough.” My reaction was swift and decisive. I didn’ even pause to get the OK for the transfer from the consultation-liaison attending. I did it reflexively, acting in the best interest of the patient. 
• My encounter with the surgeon turned out to be monumental. It signaled that I had arrived. For the first time in my life, I felt like a doctor.
• (December 15, 2020)
• 22. Breaking Point
• How my medical studies became the recipe for a meltdown.
• Dear Medical Student,
• Virtually all physicians have felt as though they reached their breaking point at least once during medical school, if not several times. This is especially true in the first two years, when students are tasked with learning new material at a frenetic pace. Just when you think they can’t pile it higher, they do. 
• I vividly recall the time I felt I had reached my breaking point. It was near the end of my second year, with clinical rotatio s just around the corner. But before reaching that destination, I had to get past pharmacology.
• Of all the material that needed to be mastered during the first two years of medical school, I found pharmacology the most dau ting. The amount of information, including the need to translate frequently and fluently between generic and brand name drugs, was staggering.  
• About two weeks prior to my final exam, precisely when I believed I was caught up with all the assigned reading (the basic science years are essentially a game of catch up, aren’t they?), our class was hit by a tsunami of oncology-based pharmacology. There were oh so many drugs to memorize, including where they worked in the life cycle of a cell. I felt as if I was going to blow a gasket. Mind you, this came around the time we were also supposed to be studying for Step 1 of the USMLE.  
• I didn’t think I could handle it. I left my study cubicle in the library, walked down the street to the medical research building, and popped in to see one of our admired pharmacology professors. Sensing my panic, she invited me into her office, and we chatted for well over an hour. The professor was a good listener and she was sympathetic to the onslaught of oncology reading. Just being able to vent about the travails of medical school put me at ease, albeit temporarily.
• My anxiety raged heading into the final exam, so I decided to visit my family doctor. Perhaps seeing a well-rounded doctor might help calm me down, I thought. His assessment was “situational anxiety.” And while this was true, simply hearing his recommended treatment jolted my senses and prevented my breakdown, rather than the treatment itself.
• “Take this tranquilizer,” he said, handing me a sample package of Triavil. He proclaimed it was a “new” medication.
• “Triavil?” I asked him, while exploring the package insert for its ingredients. “It says it’s a combination of amitriptyline a d perphenazine.” I was familiar with those compounds and, believe me, they were not like a typical diazepam (Valium). In no way, I told myself, is Triavil similar to the benzodiazepine class of medication commonly used to treat anxiety disorders. “It’s an antidepressant and antipsychotic combined in one pill,” I continued. “This will knock me out!” 
• The physician insisted it was a tranquilizer to help me “get by.” Though I disagreed, I thanked him and left the office. Then I discarded the medication once I got home.
• After doing so, the thought occurred to me that, as a second-year medical student, I already knew more about the pharmacology of this drug than my family doctor, whose knowledge appeared to be on par with the drug representative who dropped off the sample medication. 
• I was comforted by the fact that I possessed a fairly good understanding of pharmacology, at least enough to overrule my family physician and enter the final exam with confidence. In retrospect, I should have given myself more credit for the knowledge I already possessed.
• Now, I know what you are probably thinking. Comparing myself to a doctor whose knowledge of therapeutics was gleaned primarily from a drug “detail” is bound to instill feelings of superiority in even the lowliest of medical students. He must not be a very good doctor if he does not keep up with the medical literature to stay abreast of the latest advancements in practice and relies on marketing information instead.
• I would not argue this point with you. But consider this: There were other times in my third and fourth years when I thought I didn’t measure up. I was inclined to compare myself to my classmates – a better benchmark than my family doctor – but it was useless. Invariably, I discovered, I had areas of strength where they had weaknesses, and vice versa. Don’t let your weaknesses define who you are.
• Long before medical school, most of us achieved some degree of superstar status in our education. We were well tested on the educational battlefield and survived a very competitive pyramid system. Although we often doubt ourselves and our abilities, we should realize that past behavior is the best predictor of future behavior, and given our track record of exceptional performance, there is no reason to believe we won’t succeed in present and future times.
• One of my mentors said it best during medical school orientation: “You all belong here.” The sooner we realize that, the soone we can avoid untold worry and grief, not to mention burnout and depression, which beset many doctors today. 
• If your mood becomes persistently depressed, however, it’s a red flag that you need help. Don’t hesitate to utilize resources available at your school or elsewhere – support groups, yoga, meditation, mindfulness exercises, psychotherapy and the like – to prevent or treat a major depressive episode.
• The main message I would like to leave you with is that there is never a reason to believe you are not good enough. Otherwise, you might spiral out of control and break down, like I nearly did. Fortunately, a simple reality check got me back on track. None of us are imposters, and we must stop thinking that way. 
• If there is a denouement to this story, it is this: At graduation, I received the Upjohn Award for highest academic achievemen in pharmacology. I sometimes wonder whether I truly surpassed all my classmates in the final exam, or whether the heart-to-heart talk with my pharmacology professor endeared me to her and was the reason I received the honor. After all, she was the course director.  
• (May 10, 2021)
• 23. Coping With Rejection Requires Resilience
• What it means to be a “long-hauler,” far beyond medical school and Match Day.
• I guess you could say I showed resilience 40 years ago, long before the term was cemented into the medical lexicon. It was evident after I was rejected from medical school and was able to regroup and gain admittance on my second attempt.
• Resilience in my case was measured not by how I fared on my first try, but how I recovered from the setback and grew stronger in the process. I learned that determination and resilience go hand-in-hand. Whereas fortitude may be considered the backbone of resilience, rejection fuels our will and determination to succeed.
• I continued to deal with setbacks once I entered practice – for example, a patient’s relapse or untoward reaction to medicatio . I tended to personalize patients’ misfortunes and blame myself. I came to realize that doubting my own competencies was a form of self-rejection.
• How many times have we heard our mentors tell us, “Don’t be hard on yourself?” We nod in agreement, but self-awareness doesn’t necessarily overcome personal insecurities. A quarter of male medical students and nearly half of female students think of themselves as imposters.
• When the unexpected happens – when a patient takes a turn for the worse – it can feel overwhelming. I suggest we take a deep b eath and focus on “one brick at a time,” a phrase coined by a physician living with Parkinson’s disease. He said, “We have this saying at our house: ‘one brick at a time.’ Keep at it every day, even if it’s just one small thing a day, just one brick a day, and eventually it will turn into a path.”
• Resilience is sometimes simply a matter of continuing to show up and not give up. If it’s correct that 80% of life is showing up, well, I showed up. And there is a corollary that is equally true – “Actually, I’ve found 90% of success isn’t showing up, it’s shutting up,” which captioned a cartoon in the Wall Street Journal.
• Different types of rejection test our resilience in different ways. After medical school, the most common form of rejection is failure to match into a residency training program. This crushing blow has derailed the careers of many physicians, sometimes permanently. Approximately 10% of fourth-year medical students from U.S.-based MD and DO schools fail to match – and it requires a different approach to applying and interviewing. Successful reapplicants find resilience in their inner strength and courage to overcome adversity. They are able to unleash untapped potential when they need it most. Armed with resilience – and a suppor system – it is possible to overcome virtually any career impasse.
• Medical students who have matched on their first attempt have also been labeled “resilient,” but for totally different reasons than their unmatched counterparts. Medical school graduates in 2021 were deeply impacted by the coronavirus pandemic, not only in their experiences caring for patients, but also by changes in the residency application process, which included virtual inte views, cancellation of away rotations, and the rescheduling of board exams. Melanie S. Sulistio, MD, a cardiologist and clinical educator at the University of Texas Southwestern Medical School, remarked, “Not surprisingly, because of their unique experie ces and perspective, these students are incredibly resilient, graceful under pressure, and have risen far beyond the call to serve others.”
• Medical student and resident resilience is a trending topic among medical schools as evidenced by the ongoing research and program development. But resilience is also important after residency, as our careers progress. I have had to summon resilience to cope with many types of rejection – rejection by employers, government funding sources (for research), and even medical journal editors. JAMA has rejected my essays a half-dozen times, always for the same reason: “Criteria for determining acceptance include priority, originality, quality, and appeal for our general medical audience. Unfortunately, your manuscript was judged by the editors not to have met the criteria necessary for publication.” Undaunted, I found other homes for my viewpoints.
• Recently, I tried my hand at writing poetry. Inspired in part by my adult son, a published poet and university instructor in c eative writing, my submission was met with a quick and resounding rejection: “Knowing the frustration of many writers and poets, we strive to give a reply sooner than later. Unfortunately, given the volume of submissions we receive, even strong work such as yours has to be declined.” If my poem is truly “strong work,” why not try publishing it elsewhere? Eventually, I succeeded.
• Resilience has many definitions and meanings. It commonly refers to the capacity to recover from or adjust easily to hardship or change. Resilience is the one trait that has helped me recover from setbacks marked by rejection. Whatever ordeals our professional lives may impose, it cannot match our innate ability to cope with adversity. And speaking for a cohort of physicians who have had the privilege of treating the full spectrum of humanity and marveled at the resilience of our patients and their families, perspective should probably be added to the list of coping skills we need to be resilient for the long haul.
• (March 12, 2022)
• 24. I May Be Old School, but I’m Not Outdated
• Pejorative labels deepen divides between generations of practitioners.
• I was not content to retire at age 65 like many of my contemporaries, some who exited medicine even earlier. Still, I couldn’t resist the buy-out package my employer offered me when I turned the golden age. The problem I faced was not that I was suddenly retired; rather, it was that I hadn’t retired into anything.
• Left jobless, I thought long and hard about my next move. My only prerequisites were that whatever new work I undertook, it had to be portable so I could travel and visit my grandchildren who were scattered from the east coast to Hawaii with a stop in-between. My “encore career” had to be virtual and not involve direct patient care, not even via telehealth. I found it in the form of a collaborating physician – a physician who supervises advanced practice providers (APPs: nurse practitioners or physician assistants) because their states’ regulations require it.
• The responsibilities of collaborating physicians vary from state to state and usually involve chart review at a minimum. I suppose reviewing the charts of APPs is considered a good proxy for evaluating their quality. However, I insist that in addition to reviewing charts, I talk directly with APPs and discuss their patients – similar to conducting “curbside consultations.” They’ e quick and easy and give me a much better sense of the qualifications and expertise of the provider.
• “Oh, Dr. Lazarus, you’re so old school,” a nurse practitioner told me.
• What does it mean to be “old school?” A baby boomer? Educated before the era of computers and PowerPoint? Attended classes in person rather than virtually? Charted hand-written notes before the advent of electronic medical records? Looked at patients rather than computer screens? Listened to their stories? Probably all the above – and more.
• Suneel Dhand, MD, an internal medicine physician and health and lifestyle coach, described seven fundamental traits of old school physicians: attentive, not rushed, thoughtful, clinically astute, personally connected, independent, and technologically unchained. I believe old school values still appeal in modern medicine; patients and families seem to desire these qualities in physicians. In addition, strong physician-patient relationships promote better outcomes.
• I’m proud to be an old school physician, even if the term “old school” carries a negative connotation. Thomas Cohn, MD, is a physiatrist and pain specialist who touts the benefits of being old school on his website. He notes that in many cases, old school medicine affords him the time to do a detailed history and physical examination and correlate signs and symptoms without the eed for extensive laboratory and imaging studies.
• Dhand states, “The old school physician has the diagnosis in mind right after talking to and examining their patient.” That explains why I insist on personally supervising APPs – I’m more interested in how they treat their patients than how they treat their charts. Given that about half of the total text in the medical record is duplicated from text previously written about the patient, chart review is a waste of my time. Duplication also makes me doubt the veracity of the information in the medical record.
• The essence of my interactions with APPs is making sure they have captured the chief complaint, taken a full history (±physical exam for psych patients) including family and social history, and conducted a thorough review of systems and a mental status examination. I want to hear about the diagnosis, differential diagnosis, treatment plan, and response to therapy. You know, old school.
• Paul Simon said, “Every generation throws a hero up the pop charts.” I find it more telling that every generation seems to consider the previous one “old school.” The classic textbook The True Physician: The Modern “Doctor of the Old School” was written for young doctors by the scholarly physician Wingate M. Johnson, MD. The textbook contained “worldly wisdom,” according to a review of the book in JAMA. Here’s a revelation: the book was published in 1936, when Johnson was around 50 years old. The “young physicians” were probably half his age. Old school doctoring has been around a long time, always marked by generational gaps.
• During medical school, some of my classmates ridiculed a senior attending physician whom they considered old school. He wore a bow tie, mumbled and fumbled his way through the hospital corridors, and always seemed to be in a hurry. The attending ran a busy outpatient practice in internal medicine, made house calls, and rounded on his hospitalized patients. Medical students considered him a dinosaur.
• But the attending also taught us and conducted research, fulfilling the academic tripartite mission. “Where does he get the time and energy to do all this?” students wondered. When Dhand encountered an old school physician, he asked a more incisive question: “How have we got to the stage where a genuine and caring doctor has become the odd one out?”
• I think I know the answer.
• The attending remained steadfast to his patients. They loved him and stuck with him for decades. The attending was versatile a d efficient. Contrary to the stereotype of the old school physician who has let their knowledge lapse and lost their clinical skills, this attending was brilliant. In fact, he was the director of our continuing education department.
• It was my supposition that the medical students feared they would not measure up to the attending once they became practitione s themselves, so they felt compelled to put him down. They mocked him by joking that every one of his chart entries read the same – “as above, see below” – in reference to the attending’s heavy reliance on the house staff for the overall management of his patients. Rather than view the attending as a role model, he was vilified and marginalized for his seemingly old school ways. Yet, there was nothing about his thinking that was out of step with the times.
• The use of pejorative terms like “old school” has its origins in ageism. Labeling a physician “old school” compensates for trainees’ insecurities and feelings of inadequacy. It’s a riff from an old theme so eloquently explicated in The House of God – the desire for connection foiled by ageist (and other) assumptions that drive people apart. Sharing memes poking fun at the elderly only deepens divides.
• While visiting my daughter (the one who lives “in-between”), I related a story about someone close to us who got lost driving to the supermarket. When I tried to give this person the correct directions after the mishap, they got angry at me. “You were mansplaining,” my daughter said. To her surprise, I knew at once what the term meant, and I responded, “I may be old school, but I’m not outdated.”
• (December 10, 2022)
• 25. The Jobs You Hold Prior to Medical School are Important, but Not for the Reason You Think
• Seek out jobs that build character. Your science foundation can wait.
• Most experts recommend that premed students seek medically-related jobs to gain early proficiency and support their medical school application. There is nothing like valuable hands-on experience, they say, for students to demonstrate their passion and knowledge about the field of medicine. According to the article “25 Health Care Jobs To Get Before Medical School,” written by the Indeed Editorial Team, “students who fill their resumes with volunteer work, research projects and relevant work experience stand out as committed, stronger candidates within the medical field.”
• Patrick Connolly, MD, MBA, a neurosurgeon practicing in Philadelphia, Pennsylvania, disagrees. Before medical school, Dr. Connolly worked at a restaurant where he learned how to set tables, prioritize tasks, cater to diners’ needs, and even make béarnaise sauce. Dr. Connolly learned the importance of teamwork, considered fundamental to the practice of medicine. Working in a restaurant instilled foundational skills and enabled him to discover the pleasure of serving others. A seemingly menial job before medical school prepared Dr. Connolly for a demanding career in neurosurgery.
• While reading Dr. Connolly’s story, I had a flashback to the many mundane summer jobs I held in high school and college – stock boy at a women’s shoe store, jack-of-all-trades at a textile factory, and beer vendor at a major league baseball park. The beer vendor job, in particular, was etched in my mind. I had a captive audience on the upper deck; the fans were always thirsty fo a cold beer on a hot summer night. The profits from selling beer were second only to hawking hot dogs.
• I was able to convince the manager of the food concession that I was of legal age (21) to sell alcohol. I was only 19 years old, but I was never asked to produce identification. Did I feel guilty? Heck, yes. Did I worry about getting caught? Sometimes. But nobody paid much attention to the vendors, especially those working in the “nose-bleed” section of the stadium. We were viewed as misfits and social outcasts, arriving early at the stadium to gamble our previous nights’ wages at poker.
• Vending at night games was a second or third job for some individuals. They were struggling to get by. “I’ll never be like them,” I thought. “They would never amount to anything, and certainly, there were no doctors or potential doctors among them.” I was dead wrong. A good friend, with whom I shared rides to the ballpark and was himself a hot dog vendor, became a family medicine physician.
• My superior attitude no doubt stemmed from my own insecurity about being able to “cut it” as a premed student, as well as my fear that I would be viewed in the same light as the derelict characters collectively referred to as “vendors.” Most of all, I was embarrassed to be seen with them and indignant over the nature of the job.
• Sure enough, one night, I encountered a high school classmate attending the game with her boyfriend. I sheepishly offered an explanation that I was working my way through college, hoping to get into medical school. Meanwhile, my classmate was already beginning to taste success as a fashion designer and was merely two years removed from high school.
• I never discussed my job as a beer vendor with anyone who had anything to do with medical school. I omitted the experience from my medical school application, focusing instead on college “distinction” work at a children’s hospital. However, my ballpark experience came up during a “meet and greet” with the Dean of my medical school in my junior year. I was astonished when he included it in my “Dean’s letter” as part of my application to residency programs. I asked him to remove it, but he refused.
• “It shows you have character and adds color to your personality,” he said. I thought peddling beer in front of half-stoned bleacher bums indicated I was a character. Who would want a buffoon for a resident shouting, “Cold beer!” and “Last call for alcohol?” I was afraid of being typecast as a loser.
• The Dean did not share my perspective. “Not a loser,” he said, “a hard worker.” He believed the ability to interact peaceably with rowdy fans was a strength that would serve me well in psychiatry, dutifully noting his opinion in my letter. Still, I never shared with the Dean that I had lied about my age to get the job.
• Quality guru Donald Berwick, MD, described a similar story. He was a medical student interviewing at Peter Bent Brigham Hospital for a residency position. The day before the interview, his resident supplied him with the answer to a difficult question usually asked of prospective residents. Berwick chose to answer the question rather than confess he had been prepped for it by his resident. He aced the interview, but guilt set in shortly afterward, and Berwick dropped Brigham from his match list.
• Berwick commented, “A choice came, on little cat feet, and I did not see it at the time for what it was. This is the moral choice in its simplest, purest, most elemental form. To tell the truth, or not, when ‘not’ is perhaps in your short-term self-interest.” Lying was definitely in my short-term interest – not only to lie, but when the manager asked my age, I looked him squarely in the eye and said, “I’m 22,” inflating my age by three years and going one beyond the legal age.
• The Dean was unaware I had a hidden agenda when I asked him to delete the job from his letter. My personal shame was not that I was a beer vendor; rather, I had told a bold lie to get the job. It’s a lie that haunted me for years afterward. I vowed never to let it happen again – especially in practice – and to become more aware of those blind spots that I discussed in essay 12. Yet, from my reading, I discovered there are times when lying on behalf of patients may benefit them. And, if you believe Pamela Wible, MD, one of America’s foremost physician advisors and advocates, doctors are actually trained to lie – on billing, residency evaluations, medical records, death certificates, and in other ways.
• I emailed Dr. Connolly to congratulate him on his essay. He replied, “The stuff we do before we become other people shapes us in so many ways.” I would add that “the stuff we do” goes well beyond the job itself. Early career jobs unrelated to medicine help shape our moral fiber and set our moral compass. Ethics cannot be taken for granted.
• (December 18, 2022)
• 26. Faking Your Way Through Medical School
• What can medical schools do to ease student anxiety over uncertainty?
• Paul Simon, one of the most successful singer-songwriters in the world, feels insecure. In “Fakin’ It,” which appears on the fourth Simon & Garfunkel album Bookends, he sings: “I know I’m fakin’ it. I’m not really makin’ it...This feeling of fakin’ it, I still haven’t shaken it.” Simon leaves the listener believing he may have been a tailor in a prior lifetime. Talk about imposter syndrome!
• Although most students enter medical school with a strong sense of identity and a conviction to become a doctor, some become lost and disillusioned, uncertain of who they are, and contemplate alternative careers. Only about one quarter (27.9%) of medical students stick with their original preferred medical field or specialty throughout medical school. They begin to doubt their abilities and question their destiny. Like Simon, they resort to faking their way through medical school to please others or just to get by.
• How do I know this? Because I was one of those students. And in my 40-plus years of mentoring medical students and residents, I can assure you a significant percentage of them have high anxiety and doubts about getting through medical school and residency. In fact, about one in three medical students globally have anxiety – a prevalence rate that is substantially higher than the general population – and many doctors lack self-confidence. They pretend to have all the answers, and they have learned to become masters of disguise, lying not only to patients and other doctors, but also to themselves – for example, lying about their mental health by concealing substance use and suicidal ideation.
• In the “fake it till you make it” culture, writes Pamela Wible, MD, “[f]ake smiling happy med students and happy doctors die by suicide at alarming rates.” Yet, despite poor mental health, the overwhelming majority of students slug through school, suffer in silence, and manage to graduate on time.
• My own unhappiness as a medical student led me to question the odds that students will complete all 4 years of medical school (consecutively). The answer came 15 years after medical school graduation, when I suddenly found myself in business school. I undertook a project for a course in quantitative methods that allowed me to calculate graduation rates of medical students. One of the associate deans of my medical school remembered me when I was a medical student. He was kind enough to supply current data that I could plug into a Markov analysis, which determines probabilities. I calculated that 91% of students will graduate in years (nowadays it’s in the range of 82-84%).
• But my analysis could not possibly have captured the anguish and uncertainty endured by many medical students, the kind that forces them to fake their way through school and later in residency programs and practice. There’s actually a name for this state of mind, and it’s not imposter syndrome. Rather, it’s called uncertainty tolerance, or “UT” for short. Uncertainty tolerance is a psychological construct referring to the way an individual perceives and processes ambiguous information and situations. Uncertainty is inherent in virtually all aspects of medical practice, and the manner in which students and physicians deal with it affects their emotional well-being.
• Low UT among physicians has been linked to negative healthcare outcomes, including less favorable attitudes toward patient-cen ered care and increased risk of burnout. On the other hand, high UT appears to be protective against oneself and declining attitudes toward underserved and poor patient populations. Medical students who are more intolerant are less likely to practice in primary care or resource-limited settings. However, the clearest association is between medical student and physician UT and their psychological wellbeing, with lower UT associated with higher rates of psychological distress and mental health disorders.
• Medical students will suffer less anxiety if they can learn (or be taught) to tolerate ambiguity. Reducing students’ anxiety is important because it is tied directly to their sense of worth and purpose, and may influence their career choice. Anxiety is at the root of many situations where individuals feel as though they have to fake their way through them.
• This begs the question: what can medical schools do to ease students’ anxiety around ambivalence and uncertainty? Can they prioritize and incorporate elements of ambiguity and uncertainty into an already jam-packed curriculum?
• Several suggestions have been offered including, but not limited to: (1) acknowledging the anxiety related to uncertainty and addressing it by supporting students rather than attempting to “fix” or “solve” specific problems; (2) holding professionalism seminars and courses that include faculty-facilitated small-group discussions about ambiguity and uncertainty; (3) teaching s udents about the fundamental nature of medical practice, i.e., some degree of anxiety is natural, predictable, and to be expected; and (4) having students engage in reflective writing exercises. Indeed, there has been tremendous growth and interest among medical schools in narrative medicine writing (see the last section of this book).
• Greater control over and understanding of uncertainty in medical practice lessens anxiety in medical students. It gives them g eater comfort, suffuses them with purpose, and replaces thoughts of feeling like an imposter with feelings of genuine worth, bolstering their ego and identity. Under these conditions, the need to fake any behavior is reduced. As one medical student put i : “when it comes to mental illness, a prescription to fake it is never going to make it.”
• Nearly 20 years after Simon wrote “Fakin’ It,” and after bouncing back from his depression, he revolutionized rock music with he release of Graceland. Perhaps he was a doctor rather than a tailor in his prior existence.
• (February 17, 2023)
• 27. I Competed with My Best Friend in Medical School. It was My Worst Nightmare.
• They say competition brings out the best in people. At what price?
• In theory, entering medical school with a good friend should be a unique and enriching experience. Friends can become study pa tners, expand each other’s networks, and explore the same paths in terms of clinical rotations, research, and eventual career choices. Because medical school is a transformative period, and personal lives may undergo many changes – balancing relationships, family commitments, and career development can be challenging, and friends entering medical school together may be better prepared to adapt to these changes in each other’s lives. The level of support, collaboration, and understanding between them will play a significant role in shaping their medical school journey and the evolution of their friendship. 
• I entered medical school with my best friend and it became my worst nightmare. 
• I’ll call him Danny. Danny and I had been best friends since third grade. We had a lot in common: sports, music, and girls. He was six months older than me, and he had better luck than I did in all three categories. I was intensely jealous of him, but he never let on. My jealousy motivated me to compete scholastically, and I achieved higher grades than Danny in high school. 
• Danny stayed at home after graduation and attended a “commuter college.” I left town for a large university. Our relationship was on hiatus for several years. However, each knew of the other’s interest in medical school. We discussed it all the time sitting next to each other senior year in biology class. That’s when I first noticed the academic competition between us. However, our distant relationship during college dissipated that competition – so I thought.
• Danny and I were accepted at the same medical school. Driving together daily to school renewed our friendship. We quizzed each other every morning on the way to school, and we spoke by phone every night to see which one of us was ahead or behind in assignments. We pushed each other really hard. Discouraging statements were designed to create an impression that one of was struggling when that clearly was untrue. We aimed to throw each other off guard and pretend we were falling behind in order to gain an advantage over the other person. Our friendship turned into a fierce rivalry, each trying to outdo the other in the basic science courses. 
• Our relationship was tested toward the end of the first year. Danny called me in a panic. His fiancée had just broken their engagement. He was too upset to concentrate and study for final exams. The Dean gave him a week extension. I consoled Danny, as any good friend would do – one who understands that experiencing medical school together means they should share common challenges, triumphs, and milestones, and be there to help deal with any setbacks. 
• I took the final exams as scheduled and told Danny afterward that they were not difficult – and I truly meant it. The feedback eased his mind, and a week later he took the exams and did great. This shared experience should have strengthened our bond and created lasting memories. It didn’t.
• As our third year of medical school approached, our relationship had cooled. Danny and I did not take any clinical rotations together, and we barely saw each other until graduation. At the graduation luncheon, we both received academic awards, but we did not acknowledge each other or our achievements. Although Danny and I did our residencies in the same city at medical centers separated by less than 10 miles, we never spoke again. Our friendship was over for good. Competition killed it. The pressure to excel academically, combined with the limited number of top positions in class rankings, created most of the competition between us. Certainly, our competitiveness in high school was kindling for the raging fire. 
• Rather than foster growth, camaraderie, solidarity, and any number of positive outcomes a shared experience can create, the st ess and workload of medical school put an unbearable strain on our friendship. Our relationship could have deepened, as can happen when two good friends support each other through the rigorous demands of medical school, but instead we grew apart and chose to see each other as competitors rather than partners. We paid a steep price for competing against each other.
• Competition involves the complex interplay of various psychological factors. I used competition as a way to measure my social and personal worth, based on how I stacked up against others. I was driven to accomplish goals and improve my competency. People like me with high “achievement motivation” often engage in competition to validate their skills and abilities and overcome insecurities. I also became competitive to prove my worth and boost my self-esteem. 
• Looking back through the eyes of an older, more mature person, I see many things I would have done differently. My advice to current medical students is to set personal academic goals, but do not try to outperform your peers. Realize that your classmates are not your competitors; they are potential teammates you can learn from. There is no medical student on earth who knows it all. Seek to pair yourself with students who may complement your weaknesses. I can assure you that many of those students will look toward you the same way as they begin to recognize your strengths.
• Any competition that ensues should be healthy and for self-improvement. Leave your “cutthroat” ways at the doorstep. By all means, opt for pass/fail rather than letter grades. Pass/fail reduces stress and anxiety and, in turn, creates a less-competitive atmosphere, leading to an increase in collaboration and overall well-being. Pass/fail grading also lays the foundation for self-regulated learning so important to acquiring new skills beyond medical school. You need not worry about USMLE Step 1 and 2 scores and successful residency placement, as studies have shown no significant difference in outcome between letter grades and pass/fail grading.
• Finally, I implore you to strike a balance. Competition should motivate you to excel, but it should not compromise the importa ce of collaboration and mental health – and certainly not pre-existing relationships. The ultimate goal should be to create a learning environment that fosters personal growth, knowledge sharing, and mutual respect between you and your classmates.
• If I could tell Danny one thing today, it would be that I’m sorry for turning our friendship into a competition. I’m sure he would say the same thing.
• (January 29, 2024)
• 28. From Resident to Academic Attending: The Challenges Ahead
• With appropriate support, this can be a time of growth and learning.
• I transitioned to attending status immediately after I completed my residency. One day, I was chief resident. The next day, I was an attending physician – at the same academic center. Transitioning from a resident to an attending physician is both exciting and rewarding. After years of rigorous training, doctors are finally able to practice independently. However, this new role comes with its own set of trials. Many of them are psychological in nature.
• One of the biggest changes is the shift in responsibility. As an attending physician, you are the final decision-maker in patient care. While the autonomy can be liberating, it can also be daunting as the full weight of patient outcomes rests on your shoulders. There is no longer a safety net of a more experienced doctor to double-check decisions or to turn to for immediate advice. This can sometimes lead to “impostor syndrome,” where you may doubt your abilities and feel like a fraud, despite your qualifications and training.
• Another challenge can be managing time. Balancing the need to guide and teach a team of residents and medical students, while also ensuring high-quality patient care, can be a difficult juggling act. If you are obligated to do research to fulfill the tripartite mission of your academic medical center, time pressure will become even greater and may overwhelm you.
• Don’t be fooled into thinking that the workload will decrease because you can rely on the house staff to ease the clinical burden. Recall that the Fat Man in The House of God suggests that the best thing a medical student can do for a resident is to not do anything at all. The implication is that medical students, because of their lack of experience, may unintentionally create more work or complications for the residents, hence not saving them time. The same is sometimes true regarding the relationship between residents and attendings.
• Furthermore, any time saved by doing less direct patient care may be offset by the administrative demands of patient care that fall to attendings, including paperwork, meetings, and dealing with insurance companies. This can lead to long hours and potential burnout if not managed effectively.
• Navigating the politics and hierarchy of academia can be tricky. Building relationships with nursing staff, administrators, and other physicians is crucial for success as an attending. Ultimately, you want to be known as a “triple A” doctor, one who is Able, Affable, and Available, proud to add “AAA” after your MD or DO degree. The display of a happy façade and genial demeanor does not come naturally for some doctors.
• Because I chose to stay at the academic center where I was both a medical student and a resident, my issue was not forging new relationships as much as it was wanting to be viewed as an expert in the eyes of those who had trained me. I did not want to disappoint them or fall short of their expectations. However, after years of being a low man on the totem pole – an attending 8 years in the making – I found it difficult to work my way up.
• Nurses and other attendings still tended to relate to me in their default mode (i.e., as if I were still a trainee). I felt p essure to demonstrate my competence and dispel any prior misconceptions about my abilities. In order to be seen in a new light, I had to act with authority and assume the role of an opinion leader.
• At the same time, I had to check my ego at the door. Sure, I wanted to sound eloquent with students and residents on rounds and refer them to the latest research articles to justify my treatment recommendations. (And I did that – the residents nicknamed me “Article” Lazarus.) But I also had to demonstrate humility and not lull myself into thinking I knew more about the practice of medicine (psychiatry) than I really did. I had to remind myself I, too, was learning, and that although I was well-versed in the clinical treatment of disease, I was still figuring out how to best manage patients’ expectations and those of the people I worked with.
• As a newly minted attending, you must take on a leader’s role and orchestrate a multidisciplinary team of healthcare professio als. Leadership requires a shift in professional identity and extensive practical experience to adapt to the new role of attending. There is no way to rush the process. Yet, identity formation can take time and may involve introspection and mentorship. Most physicians do not receive regular, structured, professional mentorship or coaching. Leadership is simply expected of attendings from the beginning, like flipping a switch, which is unrealistic. The pairing of a new attending with a senior mentor who p ovides regular advice and support could be invaluable.
• New attendings often have a difficult time seeking clinical consultation. I was reluctant to ask for advice lest it make me appear less competent or knowledgeable. When a new attending asks for help it may be perceived as a weakness, whereas help-seeking behavior initiated by a senior physician, one who has already proven themselves, is often viewed as a sign of strength and camaraderie. You will have to go it alone for some time to earn your stripes before you can join the ranks of the privileged and comfortably eat with them at the faculty dining room.
• My transition to the attending role coincided with life changes that are typical at this early stage of career development, such as starting a family, paying off student loans, and studying for specialty boards. All of these events can cause stress. Many doctors take up attending positions in new cities or even new countries, and adjusting to a new location, building a new social network, and navigating a new healthcare system or hospital can be an additional source of anxiety. This is yet another reason to seek a mentor or coach, someone who can help you navigate the complexities of your career.
• Overall, the shift from resident to attending physician is a significant milestone that brings about many personal and professional changes. It is rarely seamless and, in fact, often accompanied by worries and self-doubt. Navigating these psychological challenges requires self-awareness, resilience, and support from mentors, colleagues, and loved ones. With appropriate support, his can be a time of growth and learning, both in and out of the hospital.
• While the transition from resident to attending can be challenging, with time you are bound to adapt to your new roles and responsibilities, solidifying your position while finding your own style of practicing medicine.
• (May 21, 2024)
• 29. The Ebb and Flow of Mentorship in Medicine
• Former mentors may need space to move on from their professional lives.
• Reconnecting with former mentors can be both a nostalgic and enlightening experience, often offering insights into how our pas influences have shaped our present. Recently, I decided to reach out to three physicians who played pivotal roles early in my career. Now in their 80s, these mentors each left an indelible mark on my professional journey. To rekindle our connection, I sent them an essay (#48 in this book) I had recently published about the importance of revoking reverence for unethical physicians, a topic I believed would resonate with their experiences and values.
• Given our shared history and the gravity of the subject matter, I anticipated a thoughtful and engaging dialogue. However, the responses I received were unexpectedly brief and somewhat detached.
• Doctor A, an infectious disease specialist, acknowledged the essay with a succinct, “Thanks, Arthur. This is an important issue, one that is sometimes hard to navigate. Be well.” His response, though polite, lacked the depth of engagement I had hoped for, leaving me wondering about his current perspective.
• Doctor B, a fellow psychiatrist, offered a similarly brief reply: “Thanks, Art. Well done. Hope that all is good with you and yours. [Sent from my iPhone].” The casual tone and the note about his device suggested a hurried response, perhaps indicative of a busy or distracted moment. This brevity felt particularly surprising given our shared specialty and in-depth discussions whe he was my psychotherapy supervisor.
• Doctor C, a medical ethicist, provided the most detailed response, yet it too was marked by a sense of finality: “Dear Art. Thank you for sending this article. It’s good to see your continued activism in ethics. I hope all is well with you and your family. I’m fully retired at this point. We sold our home of 50 years and are living in a 2 BR condo. With warm regards.” His note, while kind and personal, also conveyed a significant life transition and a possible retreat from professional discourse.
• This experience has highlighted the importance of adaptability in maintaining professional relationships. Our mentors, who once guided us with vigor and insight, may now be navigating different paths, where professional engagement takes a backseat to personal fulfillment and tranquility. While their terse responses initially felt like a missed opportunity for deeper connection, hey also served as a valuable lesson in respecting the natural ebb and flow of relationships and the diverse ways in which our mentors choose to engage with their past protégés.
• As a practicing psychiatrist, I have always valued the mentor-mentee relationship and the mutual enrichment it brings. My mentors were once vibrant, highly engaged professionals who dedicated their lives to the practice of medicine and the education of future physicians. Their enthusiasm and commitment were contagious, inspiring me and many others to pursue excellence in our fields.
• However, as I reconnected with them, I noticed a palpable shift in their demeanor. Their responses, while polite, lacked the warmth and depth I had once experienced. This change, I realized, is not merely a reflection of time passed but also indicative of the natural process of disengagement from the medical profession that comes with aging, retirement, and the health challenges that often accompany these stages of life.
• Retirement marks a significant transition in a physician’s life. It is a time to step back from the demands of clinical practice, to rest, and to reflect on a career well-lived. For many, it is also a period of adjustment, as they navigate the loss of a professional identity that defined them for decades. The detachment I sensed in my mentors’ replies may well be a manifestation of this transition. Having devoted their lives to the service of others, they are now in a phase where they are gradually letting go of their professional ties and embracing a new chapter, perhaps focused on themselves and their families.
• The brevity of their responses may also reflect a desire to distance themselves from the emotional and cognitive demands of their former roles. After years of intense intellectual engagement and emotional investment in their patients and students, it is natural for retired physicians to seek a simpler, more tranquil existence. This shift is a healthy and necessary part of aging, allowing them to preserve their well-being and enjoy the fruits of their labor.
• Adding to this process are the medical issues that aging brings. For example, I know that Doctor C’s wife suffered a stroke several years ago, which was a significant factor in their decision to downsize. Another mentor, not among those discussed here, responded to one of my articles not with professional insights but with concerns about his heart disease. Tragically, he passed away shortly thereafter. These personal health challenges undoubtedly impact their ability to engage as they once did.
• Understanding the disengagement that accompanies aging, retirement, and health challenges allows me to approach my interactions with former mentors with greater empathy and respect. Their concise replies are not a rejection but rather an indication of their current life stage. I am grateful for the time they have given me in the past and the lessons they have imparted, and I respect their need for space.
• In reflecting on this experience, I am reminded of the cyclical nature of mentorship. Just as my mentors once guided me, I now find myself in a position to mentor the next generation of physicians. This role comes with its own set of responsibilities and rewards, and I am committed to honoring the legacy of my mentors by providing support and guidance. The legacy of our mentors lives in the countless lives they have touched, and it is our responsibility to continue their work with the same dedication and passion they once embodied.
• (October 1, 2024)
• Selected Essays: Patient Care
• 30. Allegory Is a Powerful Tool in Medicine
• Just be sure the message isn’t lost on the patient.
• I recently came across an obscure compact disc (CD) from the equally obscure progressive rock band Caravan. The CD was titled Blind Dog at St. Dunstans. At the end of the seventh song, “Jack and Jill,” two voices can be heard amid music and barking dogs. The first voice asks, “What are those two doggies doing over there?” The second voice answers, “Well, the doggie in front is lind and his friend behind is pushing him all the way to St. Dunstans.” (St. Dunstan’s Hostel was founded in 1914 as a charity and rehabilitation center for British soldiers who were blinded during World War I.)
• My laughter yielded to somewhat serious contemplation. How often do we use allegories, parables, and fables – stories in general – to explain complicated medical concepts to patients? Probably not often enough. But as researchers in Canada observed, “collectively, physicians’ stories become ... shared awakenings to the importance of humanities in medicine.”
• One of the most pristine examples is the use of war as an allegory for medical intervention. Colleen Bell, PhD, a professor of political science, writes: “... metaphors of illness, patient, and physician – constituting a strategic allegory of medical intervention – have appeared as characters in the narrative of modern counterinsurgency.” Bell notes that physicians have a tendency to view cancer and infectious diseases as “threats” that must be evaded. Upon successful treatment, the patient has “beaten the enemy” and “won the battle.”
• Plato’s Allegory of the Cave has frequently been used as a teaching tool in medicine. The Allegory of the Cave describes a group of imprisoned individuals forced to live in a cave their entire lives. The prisoners can only see shadows of objects moving near a fire, but they cannot see the objects casting these shadows. The prisoners, Plato argues, are us: human beings trapped by the limitations of our senses.
• Plato’s cave embodies the uncertainty embedded in humans’ perception of the world and the objects it contains, contrasting reality with our interpretation of it. It is a lesson in humility to know that physicians will never have perfect or complete understanding of a patient’s disease. Living and working with uncertainty is why practicing medicine is considered both an art and a science.
• I used many allegories with my patients. I viewed storytelling as a way to bridge the divide that separates us from human frailty. Some of my favorite allegories were based on books and movies that, in themselves, were loosely based on Plato’s Cave.
• For example, I treated a patient with a severe narcissistic personality disorder. He only saw the world one way – his way. I used Ray Bradbury’s 1953 novel Fahrenheit 451 to urge him to consider other viewpoints. In this famous dystopian novel, fireman Guy Montag burns books for a living, until an eccentric young neighbor forces him to reconsider his worldview.
• I’ve treated several medical professionals for depression related to imposter syndrome. In this context, the 1998 movie The Truman Show was a useful allegory. Unbeknown to Truman Burbank (Jim Carrey), he lives a faux life used purely for television entertainment. Slowly, he begins to chip away at the facade and breaks free, discovering his true identity.
• When my patients with schizophrenia and bipolar disorder were in remission, many of them related to the classic 1966 French film King of Hearts. The inmates from the asylum literally escaped and took control over an abandoned town ravaged by war. The psychiatric patients assumed the role of shopkeepers, like “normal” people.
• My favorite allegory is the starfish story. Many of us have heard it before. In short, a little boy at the beach returns stranded starfish to the ocean. An old man asks the boy, “Do you really think you’re making any difference?” The boy holds aloft one of the starfish and replies, “It makes a difference to this one,” and hurls it back into the sea. The starfish allegory resonates most with patients who have given up on themselves and question why we work so diligently to save them.
• During my residency, I recounted to my supervisor how I planned to selectively use the starfish story. He said I had a “savior complex.” “Art,” he commented in the same vein as the older man to the child, “you can’t save them all,” reminding me that psychiatry, like other specialties, has a mortality rate – from suicide and homicide. Still, I tried.
• Understanding allegories requires abstract reasoning. Therefore, children and individuals with cognitive deficits, poor comprehension, or limited English proficiency may not be appropriate candidates, because the allegory may be misunderstood or misleading.
• Case in point: I was required to deliver bad news to a gay man I had been treating in psychotherapy. His comprehension was below average, and to make matters worse, AIDS was new on the horizon (circa 1983). He handed me a health department letter that read “HTLV III positive” (the term “HIV” had not yet been coined).
• I thought if I explained the allegory behind Nathaniel Hawthorne’s The Scarlet Letter – that “A” stood for adultery (among other possible meanings) and that shaming tactics do more to alienate than they do to heal – that it would affirm my patient’s choice of lifestyle and lessen the blow of bad news. But the message never registered. Sensing his bewilderment, I advised my patient to discuss the lab result with his primary care physician.
• I have since learned more appropriate ways to deliver bad news and how to temper my storytelling so that I can be certain to reach and join patients rather than confuse them or come across as disingenuous.
• So, if you choose to use allegories in practice, make sure they are understood and paint a complete and accurate picture of the reality of the situation. After all, the dog from behind is not really guiding the dog in front!
• (November 2, 2022)
• 31. Treatment Is a Two-Way Street
• High-functioning doctor-patient relationships can be mutually rewarding.
• I was reading about the relationship between the pioneering psychologist Erik Erikson and the iconic painter Norman Rockwell. Erikson, who gained fame for explicating eight crucial stages of psychosocial development across the lifespan, was Rockwell’s psychotherapist.
• Both men lived in the idyllic Massachusetts town of Stockbridge, where Rockwell painted one of his most recognized pieces – “S ockbridge Main Street at Christmas” – depicting picturesque Main Street during the holiday season. Stockbridge Main Street was also home to the famous Austen Riggs Center, a bastion of psychoanalytic practice and long inpatient stays. Rockwell’s wife was hospitalized at Austen Riggs for treatment of depression and alcohol use disorder. Rockwell, himself, fell into a deep depression, which led to a serendipitous encounter with Erikson and subsequent outpatient treatment with him.
• Rockwell was fussy about his paintings – a perfectionist at heart. In a depressed state, his obsessiveness was insufferable, overthinking his technique and questioning the quality of his artwork. Erikson pulled Rockwell out of depression and helped impart the social milieu of the 1950s into Rockwell’s paintings. In audio recordings, one can hear Rockwell tell his son Tom how Erikson helped him revitalize his painting, even dispensing advice to Rockwell about how he should begin the lineage of Rockwell’s celebrated “Family Tree.”
• One wonders whether the relationship between the two men held any meaning for Erikson. Erikson was born in Germany and emigrated to the U.S. at age 31. He never knew his biological father – in fact, he was initially deceived about his paternity. As Erikson wrestled with his identity, he changed his name several times, finally arriving at “Erik Erikson” and subsequently coining the term “identity crisis.” According to Jane Tillman, PhD, director of the Erikson Institute, Rockwell’s paintings helped suffuse Erikson’s identity by enabling him to reflect on art that was quintessentially American.
• Tillman’s account leads me to believe that the doctor-patient relationship is, at its best, a bidirectional affair – a two-way street. Although high-functioning doctor-patient relationships are not the same in magnitude as the one between Erikson and Rockwell, who ended up good friends, they have a special give-and-take quality. My premise is that while the physician is the oste sible healer, the patient helps heal the physician, usually through subtle means uncovered after the physician reflects on a patient’s visit or upon termination of the relationship.
• I find it much easier to give advice than receive it, which is not surprising for a physician. If I have to see a doctor for personal reasons, the conversation starts off stilted until I tell them I am also a physician. Upon informing the doctor I am a psychiatrist, there is often an enthusiastic exchange of stories about difficult or unusual patients. Bruce Springsteen would say that physicians’ collective stories are “The Ties That Bind.” I wish there would be more and better ties between doctors and their patients.
• I had an initial visit with a primary care physician (PCP) who went to medical school and trained in my hometown of Philadelphia. He told me his wife trained in emergency medicine at the same institution where I attended medical school and did my residency. We shared a good laugh when discussing the sundry characters known to visit emergency departments who are not really in crisis, and how difficult it was to decide whether to prioritize their medical needs or mental health needs.
• The conversation quickly turned serious. The PCP informed me that at least half his patients had concomitant mental health prolems that went unaddressed mainly due to time constraints (he was allotted only 15 minutes per visit). He also confessed that he didn’t feel comfortable playing the role of quasi-therapist. I told him that back in the day, I was a consultation-liaison psychiatrist, and I was routinely called to assess med-surg patients. I informed the PCP he could easily brush up on psychiatry, and I recommended a couple of primers he could read, including The Fifteen Minute Hour: Applied Psychotherapy for the Primary Care Physician, considered a classic.
• Research confirms that physicians who can emotionally engage with patients have better outcomes and higher patient satisfactio scores. When a patient perceives that their physician cares and listens to their concerns, they are more likely to comply with medical recommendations and return for follow-up visits. But there is very little research indicating that paying credence to our patients’ advice and musings makes us better doctors. Can patients stimulate our personal growth, as Rockwell did for Erikson in his search for identity?
• The short answer is that physicians can become better doctors by being patients. When doctors exchange the white coat for a hospital gown, they learn the importance of empathy and language and gain an appreciation for the trauma of illness and trauma of treatment. The well-known author and speaker Danielle Ofri, MD, PhD, echoed the same sentiment; she devoted an entire book to lessons she learned from her patients. One of the most important, she believes, is learning what it feels like to actually be a patient – in her case, the humiliation and helplessness she felt both during and after giving birth.
• In addition to assuming the patient role, listening carefully to our patients, especially the poor and others who are disadvan aged, helps physicians grow, because learning how to overcome barriers to high-quality treatment – barriers such as poverty, poor access to care, time limits on interactions, bureaucratic red tape, and general mistrust of healthcare systems – enables physicians to adopt more personalized approaches to healthcare. Clearly, if we accept our patients as teachers, they will infuse elements of humanism in our training and practice. Patients have been known to “define our work, instantiate our values, and shape our identities,” much like Rockwell aided Erikson. It is not unreasonable to expect that doctors who are exposed to diverse communities will develop strong clinical skills, become patient advocates, and contribute to a vibrant physician workforce.
• It’s been said that medicine is an art whose magic and creative ability reside in the interpersonal aspects of physician-patie t relationships. Too often, however, medical practice has become stymied by tasks that need completing and patients that need complex services. Grinding through our day, we lose sight of what a special role we can play in patients’ lives. It is only when we rediscover our passion for the practice of medicine and embrace our mission – to serve the suffering – that we realize we have the power to transform patients, and in doing so, transform ourselves.
• (December 26, 2022)
• 32. What Does It Mean When We Say Someone Has Lied After a Long Illness?
• Respecting someone’s privacy is more important than the need to know about their health.
• My personal doctor and two of my cherished mentors died within the span of several years, each “after a long illness,” accordi g to their obituaries. Rock legend David Crosby (The Byrds and Crosby, Stills, Nash & Young) died “after a long illness,” as stated by his wife, Jan Dance.
• David Crosby’s co-musicians were perplexed that his widow would attribute his death to a long illness. Crosby certainly had his share of health concerns – substance use, hepatitis C, liver transplant, cardiac catheterization, and diabetes – and he frequently joked about his death, planning his funeral in advance. However, in his final days, Crosby’s new bandmates observed him “w iting, playing [and] singing his ass off.” The day he died, Crosby “seemed practically giddy with all of it,” working on a new album and planning a tour. At 81, his vocal ability remained top-notch, even if arthritis made playing the guitar difficult. The fact is, David Crosby’s final decade of life was his most vibrant, releasing five studio albums. His sudden death was understandably puzzling.
• I have stage 3b chronic kidney disease, hypertension, gastroesophageal reflux disease, and hyperlipidemia (all treated with medication). I have Barrett esophagus without dysplasia. I have generalized anxiety disorder, including past episodes of depression. I have been overweight most of my life. I overcame skin cancer. I had lumbar spinal surgery in 2016, followed by chronic low-grade back pain. But overall, I feel good, and like Crosby was, I’m productive. If I were to die tomorrow, should my obituary attribute the cause of death to “a long illness?” Which one?
• As a psychiatrist, I am accustomed to reading that someone has died after a long illness. I know that in most cases, the illness is depressive in nature, and the individual has died by suicide. The “long illness” is a euphemism for suicide, a word we struggle to say out loud. I can certainly understand why families would want to keep suicide a secret, given the stigma attached to it and the stigma that continues to surround mental illness in general. But unless we confront the epidemic of suicide, the problem will continue to fester, and we’ll never be able to break through the cloud of silence.
• Perhaps we are more at ease discussing death due to medical illnesses than death due to mental illnesses, Crosby’s death notwi hstanding. Even conditions once dreaded and believed to be horrifying and incurable, such as cancer and HIV/AIDS, are discussed openly – advertising their treatment on television to millions with catchy, upbeat melodies in the background. So, why do family members still prefer the term “after a long illness” as a code for conditions that result in death? Crosby’s guitar player commented: “He was a weakened guy from many different preexisting conditions, and everyone knew it …” Why not say what those conditions are?
• The answer is: respect and privacy trump the need to know. However well-intentioned I may think it is to disseminate information about someone’s cause of death, the family’s interests in the matter override mine. Crosby’s fans were curious to know more about his death, but his wife had the final say, as it should be. (Ironically, her refusal to go into detail led people to question her background.)
• I was reminded of the sanctity of death in an account by Ashley Judd to the New York Times about her mother, Naomi. You may recall that the iconic country singer Naomi Judd died by suicide in April 2022. Several months later, her daughter Ashley penned a guest essay in the New York Times about her family’s efforts to keep police reports related to the suicide private, including photographs and body cam footage. Judd wrote: “Though I acknowledge the need for law enforcement to investigate a sudden violent death by suicide, there is absolutely no compelling public interest in the case of my mother to justify releasing the videos, images, and family interviews that were done in the course of that investigation.”
• At the urging of the Judd family, Tennessee Senator Jack Johnson introduced legislation to make death investigation records private when the death is not the result of a crime. Judd remarked: “The raw details [of death] are used only to feed a craven gossip economy, and as we cannot count on basic human decency, we need laws that will compel that restraint.” A catch-22 is that public disclosure of the nature of the death may be required to determine whether it is or is not the result of a crime, but such instances are rare.
• Judd pointed out that a big problem for law enforcement personnel is that they are not adequately trained to respond to and investigate trauma-related cases. They employ outdated interview procedures and methods of interacting with family members who are in shock and grieving. Not only are families at their most vulnerable following the acute death of a loved one, but in Judd’s case, she felt “cornered and powerless” when interrogated by the police, “stripped of any sensitive boundary,” as though she were a suspect in her mother’s death. Ashley Judd had to re-enter trauma-focused psychotherapy to deal with the events.
• In addition, Judd wrote that her family felt “deep compassion” for Vanessa Bryant, the wife of NBA star Kobe Bryant who was killed along with his daughter and other passengers in a 2020 helicopter crash. Like the Judd family (and other families), Bryant had to endure the release of details surrounding the deaths. Families and their memories of deceased relatives deserve respect. To say that someone has died after a long illness, regardless of the specific cause of death, gives them that respect.
• Regrettably, attempts to describe cryptic deaths are frequently inaccurate or maligned. My personal doctor did indeed die “after a long illness.” He was my neurosurgeon, and he died tragically by suicide. When I clicked on his “link” to an affiliated hospital’s website a week later, I received an error message: “Page not found.” Worse yet, Queen Elizabeth’s death was attributed o “old age,” as meager, and some would say ageist, as describing an elderly person’s death as “natural causes” or “failure to thrive.” The latter term originated in the pediatric world and has now migrated to geriatrics and might best be avoided.
• I’ve kidded my family about what to write in my obituary and on my gravestone and how to divide my possessions when my time comes (refer to essays 3 and 4). In the final analysis, however, people should be remembered for how they lived, not for how they died, and certainly not for the private details of how they may have suffered. As Paul McCartney said, “Let it be.”
• (February 27, 2023)
• 33. Medicine Has Become the New McDonald’s of Health Care
• Sorry, you can’t have it your way, not even at Burger King.
• I was having a conversation with a colleague about a state-funded Medicaid managed care organization (MCO). She told me that he mental health performance measures used by the state to evaluate the MCO were all “placement and provider issues,” such as the amount of time children spent sleeping on the floors of social services offices or languishing in emergency departments (ED) before they were transferred for treatment or placed into foster homes.
• The performance measures used by state officials also included the number of adults waiting in hospital psych units to be transferred to state hospitals and the number of children and adults waiting at home to receive outpatient services or enhancements to current services.
• “This is not how MCOs should be measured,” my colleague said. “There are no metrics that reflect the actual quality of services.” She was referring to measurements that typically reflect quality and used by stewards such as CMS and NCQA: follow-up after hospitalization or emergency department visits, 30-day hospital readmission rates, 6-month response to antidepressants, metabolic monitoring for children and adolescents on antipsychotic medication, and other core measures intended for use in value-based payment programs.
• “This is terrible,” I replied. “Medicine has become the McDonald’s of health care – drive-through services – where the only thing that matters is throughput and not quality.”
• “To make matters worse,” I continued, “politicians and lawmakers created the resource shortage in the first place by failing to recognize the mental health crisis and plan for it by allocating more dollars toward essential services. Now they blame MCOs and everyone else for the service bottleneck. If that’s not a case of the pot calling the kettle black, I don’t know what is. Pe haps we should all take out construction loans and build more hospitals and residential and assisted living facilities?”
• I admit, this is not an original idea. Health insurers have been dabbling in the brick-and-mortar business for years and, vice versa, provider-based organizations have ventured into the world of health insurance. It’s just that there is such an intense push for health care to be more accessible to patients, especially psychiatric patients. After all, the lack of access to evidence-based mental health care is the root cause for the mental health crisis in America. We must act urgently to overcome common yet difficult barriers to treatment – geographic, financial, cultural, structural, and social (poverty, education, support networks, etc.) – and do a better job of integrating psychiatry and primary care medicine.
• Perhaps we should follow McDonald’s lead. McDonald’s pioneered the fast-food industry and is known for its efficiency and accessibility, being available worldwide. McDonald’s is also vertically integrated, meaning that the fast-food chain processes the meat themselves, grows its potatoes, and transports its own materials. With the rise of telemedicine and retail clinics in locations like pharmacies and supermarkets, the future of medicine is already beginning to resemble the fast-food industry with “fast medicine.”
• The comparison of modern medicine to McDonald’s illustrates many trends and issues in health care apart from accessibility and integration, such as the drive (no pun intended) for standardization and consumerism and the over-reliance on technology. Here are some ways in which medicine has become the “new McDonald’s” of health care:
• 1. Standardization. Just as McDonald’s has standardized menus and processes across its outlets, health care has seen a significant rise in standardized treatment protocols and guidelines. This is meant to ensure consistency and quality of care. However, critics argue that it might lead to impersonal care and overlook individual patient needs. It’s no wonder rival Burger King came up with the slogan “Have it Your Way” (abandoned in 2014 and now “You Rule”).
• 2. Drive-through approach. The pressure to see more patients in less time can lead to a fast drive-through approach in health care, where the focus is on quick, high-volume service rather than personalized care. This can result in rushed appointments and a lack of comprehensive care. It’s not uncommon for office staff to instruct patients to wait “curbside,” in the hallway, at the end of a visit for their paperwork, lab slips, and other business.
• 3. Consumerism. Like McDonald’s, health care has also seen a shift toward consumerism. Patients are increasingly viewed as consumers or “clients” who are told they have choices in health care providers and decisions. But instead of delivering care that is person-centered, the emphasis on consumerism has aided marketing by rebranding health care. Interstate billboards advertise hospital ED wait times, but how good is their quality?
• 4. Cost efficiency. Both McDonald’s and modern medicine strive for cost efficiency. In health care, this often means a focus o reducing hospital stays, increasing use of technology, and streamlining processes. However, this drive for efficiency can sometimes compromise patient care and outcomes by neglecting education and prevention and increasing medical errors and staff burnout.
• 5. Dependence on technology. Just as McDonald’s uses technology for order taking and processing, health care has become increasingly dependent on technology for patient records, diagnostics, and treatment. Soon we’ll be selecting treatment options from kiosks, like keying in our choice for a Big Mac over a double cheeseburger – sorry, “super-size” is no longer available.
• 6. Fragmented care. Similar to how a McDonald’s meal is often made up of different components prepared at different stations, health care can often be fragmented with different specialists treating different conditions. This can lead to issues with coordination and continuity of care. Incorrect medications due to multiple prescribers are the McDonald’s equivalent of receiving a hamburger with mustard and relish when you asked for ketchup and pickles.
• While fast-paced medicine has some advantages, it also poses many challenges, as above. The psychiatric sequelae of assembly line practice are most concerning, because 15-minute “medication checks” are generally insufficient unless coupled with psychotherapy, and even then, treatment that is “split” between a psychiatrist and non-medical therapist is less than optimal. If we can order through a McDonald’s kiosk, why not simply outsource therapy to a chatbot? (Actually, we’re already there; see essay 44.)
• In addition, the mental health system is on the brink of collapse after decades of defunding and financial diversion, causing community services to dry up. Deinstitutionalization was a noble experiment, but it neglected the serious and persistently mentally ill who now fill our prisons and seek warmth on sidewalk steam grates during the winter.
• It’s critical for policymakers to consider both the medical and mental health needs of vulnerable children and older adults and balance these with personalized, quality care. I worry about our health care system and the politicians tasked with deciding how to fund it when they have no direct experience working in these systems and do not appreciate the gaps in service, let alone the effects of workplace distress and violence.
• To make any sense of our health care system, lawmakers need to experience a “Big Mac Attack.” They need to have their access revoked to the drive-through lanes at McDonald’s lest they continue to equate fast food with fast medicine.
• (November 2, 2023)
• 34. Spread “Aloha” in Health Care
• Let’s work toward a more idyllic vision of our system.
• I spent most of January 2024 in Honolulu – writing, working, and vacationing. With its high cost of living, scarce affordable housing, and homelessness problem, Hawaii is far from perfect, but the vibe is mostly better in this island state than on the mainland.
• While ordering shaved-ice (a local favorite) at Uncle Clay’s House of Pure Aloha (HOPA), I came across the following “oath.” It was written by Clayton “Uncle Clay” Chang and his nephew Bronson Chang in 2008.
• “I solemnly promise To live every heartbeat of my life From this day forward With pure Aloha. Every single word that comes out of my mouth And every single action, be it large or small Must first come from my compassionate heart And be supported by my thoughtful mind. With an open heart and an open mind I will unconditionally love Every person who crosses my path in life As a fellow member of our one world ‘ohana. If I truly do my best to do all these things I will become the person I was born to be Filled with inner peace and complete happiness. Living every heartbeat with Pure Aloha I can bring love into the hearts o others And make our world a better place.”
• The spirit of Aloha is all encompassing, including the core values or virtues of unconditional caring, personal inner peace, passionate self-discovery, courageous belief, humble collaboration, and the pursuit of excellence.
• If we could live Aloha by conforming to the HOPA oath while also honoring the tenets of the Hippocratic Oath, just imagine wha healthcare might look like today. The following changes could be observed:
• 1. Patient-Centered Care: Every patient would receive personalized, patient-centered care. The focus would be on understanding the patient’s needs, preferences, and values, and involving them in decision-making processes.
• 2. Preventive Medicine: There would be a significant emphasis on preventive care rather than just treating diseases. Regular screenings, healthy lifestyle promotion, vaccinations, and early detection of potential health issues would be prioritized.
• 3. Universal Access: Everyone would have equal access to healthcare services, regardless of their socioeconomic status, race, or geographical location. Patients and doctors would be better matched. There would be no disparities in the quality of care received.
• 4. Holistic Approach: Care would not focus just on treating the physical symptoms but also would consider mental, emotional, a d social factors affecting health. Integrated care involving psychologists, social workers, and other professionals would be standard.
• 5. Technological Advancements: Advanced technologies would be fully integrated into healthcare. This includes telemedicine, ar ificial intelligence, electronic health records, genetic therapies, advanced imaging techniques, and personalized medicine.
• 6. Efficient Administration: There would be streamlined administrative processes that would reduce paperwork and allow physicians to spend more time with patients. Billing would be transparent and straightforward. AI-powered medical scribes would be commonplace.
• 7. Continuous Learning and Improvement: Medical professionals would be engaged in continuous learning, keeping up with the latest research and innovations. Healthcare professionals would stay abreast of the latest scientific developments and incorporate evidence-based treatments into their practice, yet still embrace the ‘art’ of medicine. There would be a culture of feedback and improvement, with reduced medical mistakes and, in the event of error, sincere apologies to families without legal ramifications.
• 8. Interdisciplinary Collaboration: There would be effective collaboration and communication among healthcare professionals ac oss different specialties for comprehensive patient care. Internecine wars between various disciplines and practitioner types would not exist.
• 9. Global Collaboration: Healthcare providers and researchers would collaborate globally to share knowledge, resources, and best practices. This would accelerate medical advancements and ensure that breakthroughs benefit people around the world.
• 10. Emphasis on Mental Health: Psychiatry would not be a stepchild to medicine. Stigma associated with mental health disorders would be eliminated, and mental health services would be routinely integrated into practice. Adequate mental health and substance use resources, funding, and services would be available for all.
• 11. Ethical and Transparent Practices: Medical professionals would adhere to the highest ethical standards, with transparent communication about treatment options, risks, and costs. Open and honest informed consent would be a cornerstone of medical practice.
• 12. Patient Empowerment: Patients would be empowered with information and involved in decisions about their care. This would i volve effective communication between healthcare providers and patients, ensuring that individuals have a clear understanding of their health status and treatment options.
• 13. End-of-Life Care: There would be compassionate, respectful end-of-life care ensuring that patients can spend their last days in comfort and dignity. Treatment spending in the last 6 months of life would significantly decrease.
• While achieving such an idealized vision may be difficult, ongoing efforts in healthcare aim to move closer to these principles through research, policy changes, and advancements in medical technology and practice.
• What’s missing is Aloha. An infusion of Aloha is desperately needed to overcome challenges such as financial constraints, workorce shortages, and systemic inequities that often make it difficult to fully realize an ideal health system.
• It’s important to note that many healthcare systems around the world strive to achieve these goals and have done a much better job than the U.S. without incorporating Aloha into their strategies. Can you imagine how differently medicine would be practiced today if the U.S. were to incorporate the power of Aloha?
• In 1962, Aunty Pilahi Pakī (1910–1985), a beloved native Hawaiian poet and spiritual guide, shared a bold prophecy that in the 21st century, “The world will turn to Hawaiʻi as they search for peace because Hawaiʻi has the key; and that key is ALOHA.”
• Aunty Pilahi’s life’s work and desire was to spread the true meaning of Aloha to Hawaiians and non-Hawaiians alike.
• Emulate people like Aunty Pilahi and Uncle Clay, and help spread the meaning and spirit of Aloha. The future of the U.S. healthcare system depends on it.
• (February 12, 2024)
• 35. Appreciate the People in Your Life
• How simple words can make a big difference.
• One of my all-time favorite quotes from the original Star Trek episodes (“Balance of Terror”) is spoken by Dr. McCoy to Captain Kirk: “In this galaxy, there’s a mathematical probability of three million Earth-type planets. And in all of the universe, three million million galaxies like this. And in all of that, and perhaps more, only one of each of us… [pause]… Don’t destroy the one named Kirk.”
• McCoy is waxing philosophic. He’s saying that despite the enormous vastness of the universe, there is only one of you. You are unique and quite irreplaceable. So don’t destroy yourself. (Kirk was about to wage battle with the Romulans.) And while three million million must have seemed like a large number in 1966, it turns out he may have been off by about three orders of magnitude.
• Nevertheless, the message hits home: everyone is special, more specifically, that Kirk was special to McCoy. I ask, who is special in your life – and have you told them recently how much you appreciate them?
• Nowadays, it is common to hear people say, “I appreciate you.” I’ve gotten used to it, but quite frankly, it unnerves me a bit. I just smile and nod dumbly, not knowing if I should thank them for their special appreciation of me as they stare into my soul.
• This expression has been popularized by the television show Ted Lasso, an Apple TV comedy/drama of an American football coach hired to manage a British soccer team. Ted doesn’t know the sport, the rules, or much about the culture, but what he lacks in hard facts, he more than makes up for in soft skills.
• Ted often asks for input from others, both for new ideas and to get them on board with his way of thinking. When he gets an answer that’s not correct or not what he’s looking for, he’ll say something like, “That’s a great idea, just not the one I’m looking for,” or “I appreciate you weighing in,” or “Love you jumping in, but nope, that’s not it.” All said with eye contact, softness in his face, and a light tone.
• People used to say “I appreciate it” when you did something for them. I have thought that the phrase “I appreciate you” is wro g or strange, hovering somewhere between “thanks” and “I love you,” but some people apparently believe that it is not only OK to use it but important to let others know that you appreciate their good deeds. If you’re undecided about whether to use the ph ase or aren’t sure what to say, “I (really) appreciate it” may sound more normal when somebody does a favor for you.
• There are plenty of situations where “I appreciate you” is appropriate to use. A person may say it to a spouse, partner, or close friend as a way of expressing thankfulness for that person’s presence in their life. In such a situation, “I appreciate you” is not necessarily said in response to any preceding comment or act but often just as a spontaneous and non-specific expressio of emotional connection and gratefulness for the relationship.
• I heard the phrase when some college students expressed their gratitude to their favorite security guard for his long service. The security guard was in charge of a college dorm, and the students lived in the dorm. They seemed to have an emotional connection with him.
• I can imagine being one of those students and saying, “I appreciate you.” By this, I mean that I feel respect and some affection for the security guard – not just for his thankless and possibly dangerous job he’s been doing for years but also for the way he treats the students he sees every day. I picture him interacting with students in such a way that they recognize (maybe unconsciously) that he has their safety at heart and takes pride in protecting them.
• I’ve been supervising a nurse practitioner for several years. She routinely says, “I appreciate you,” every time I give her advice on managing one of her patients. I “appreciate” her acknowledgment of my skills and abilities, but hey, I’m just doing my job. Yet, I like the way she intones, “I appreciate you, Dr. Lazarus,” in a slight show of affection. Maybe I’m reading too much into it. I should only interpret her acknowledgment as, “I want you to know that I notice your efforts, and I’m grateful.”
• I’ve observed that in many professional contexts, especially in medicine, the phrase “I appreciate you” can provide us with a powerful alternative when “thanks” may not pack enough punch. My version of the phrase usually takes into account my southern exposure: “I appreciate y’all for helping me out.” When I’m back north, especially in my hometown of Philadelphia, it usually comes out as: “I appreciate youz.”
• Here are some examples where “I appreciate you” might be especially impactful in a medical setting:
•  When acknowledging team effort: “I appreciate you for your hard work and dedication during the night shift. Your efforts made a significant difference for our patients.”
•  In recognizing patient care: “I appreciate you for the compassionate care you provided to Mrs. Smith. Your kindness and professionalism are truly commendable.”
•  When expressing gratitude to support staff: “I appreciate you for always keeping the clinic running smoothly. Your organizational skills are indispensable to our team.”
•  To thank colleagues for their support: “I appreciate you for covering my shift last week. Your willingness to help out is greatly valued.”
•  For encouraging team morale: “I appreciate you all for your continuous dedication and hard work. Together, we make a great team.”
•  In patient communication: “I appreciate you for trusting us with your care. Your cooperation and positivity help us provide he best possible treatment.”
• Using “I appreciate you” in these contexts helps foster a positive and supportive environment. It highlights the importance of each individual’s contributions and promotes a culture of mutual respect and gratitude. Adopting this phrase can help strengthen relationships, boost morale, and create more enjoyable moments.
• Go on, then, sprinkle the sparkle of gratitude on your coworkers and the special people in your life. Make their day shine brighter with your words: “I appreciate you.”
• And don’t forget to tell your patients.
• (June 15, 2024)
• 36. How the Time-Honored Tradition of a Baseball Catch Became a “Test” for a Brain Injury
• Pay close attention to the effects of aging and contextual discrepancies in displays of strong emotion.
• I find myself becoming more passionate with age, swept into a sea of emotions during certain movie scenes, and even crying during my favorite rock songs as the lyrics and melody crescendo and become one.
• The brain’s ability to adapt and change over time, known as neuroplasticity, means that our emotional responses can evolve based on the kinds of experiences and stimuli we are exposed to over the years. It is not uncommon for people to experience heightened emotions as they age, and several factors have been shown to contribute to this phenomenon.
• Life experiences play a significant role, as accumulating a wealth of experiences can make us more empathetic and attuned to the emotional content in movies, music, and other forms of art. These experiences can make certain scenes or songs resonate more deeply with us, especially when listening to artists performing during their “farewell” tours.
• Hormonal changes that come with aging can also affect emotional regulation. For instance, changes in levels of hormones like estrogen and testosterone can influence mood and emotional responses. I even asked my primary care physician to check my testosterone level (it was normal).
• Psychological growth often accompanies aging, leading to a greater understanding of oneself and one’s emotions. This growth ca result in a deeper appreciation for the emotional subtleties in art and life.
• Cognitive changes that occur with aging can affect how we process and respond to emotional stimuli. Older adults might prioritize positive emotional experiences and be more affected by emotionally charged content.
• Shifts in social roles and relationships, such as becoming a grandparent, retiring, or experiencing the loss of loved ones, ca also impact emotional responses, contributing to a heightened emotional state.
• My emotional outbursts are few and far between, and they usually occur when I am alone. They do not cause me distress or interere with my daily life. I am not concerned by them, but occasionally my children become alarmed by my unexpected display of affect when I am in their presence – for example, watching a movie. I reassure them that these are “happy” tears, a normal part of my heightened emotional status acquired with age, like a good bottle of wine that becomes richer and more complex over time, revealing unexpected and nuanced flavors that were not there in its youth.
• I don’t intend to make my children feel uncomfortable or think that their dad is “off his rocker.” Still, several of them are healthcare professionals, and they are aware of a condition called “pseudobulbar affect.”
• Pseudobulbar affect (PBA) is a neurological condition that presents with sudden, uncontrollable episodes of crying or laughing, which at first blush might explain my emotional reactions. The difference is that individuals with PBA experience involuntary episodes of crying, laughing, or other emotional displays that don’t match the context. These episodes can occur spontaneously and may not reflect the person’s actual feelings.
• For example, imagine a person attending a funeral or a serious meeting where the atmosphere is somber and respectful. Suddenly, they burst into uncontrollable laughter. Despite understanding the gravity of the situation and feeling the appropriate emotions of sadness or solemnity, they are unable to control their laughter. This reaction is not aligned with the expected emotional response to the context.
• Consider a scenario where someone is at a celebratory event, such as a wedding or a birthday party, where everyone is happy and enjoying themselves. In the midst of the celebration, the person begins to cry uncontrollably. Even though they are not feeling sad or distressed, the tears flow without their control. This incongruous emotional display can be confusing and distressing or both the individual and those around them.
• PBA is often linked to conditions or injuries that impact the brain. It can be associated with stroke, multiple sclerosis, amyotrophic lateral sclerosis, traumatic brain injury, Parkinson’s disease, and Alzheimer’s disease, among others. A thorough neurological examination is important to assess any of these underlying conditions and to rule out depression as a possible cause of symptoms.
• While there is no cure for PBA, treatment focuses on managing the symptoms. Medications can help reduce the frequency and seve ity of episodes. These may include certain antidepressants and a combination of dextromethorphan and quinidine. Behavioral strategies, such as distraction methods or breathing exercises, can also be helpful in managing episodes.
• For those with PBA, open communication with family members and caregivers is crucial. Educating loved ones about the condition can help them understand and respond appropriately to the episodes. Caregivers play an important role in their loved one’s care team and are in a special position to help make an impact.
• Every spring, I try to gather our family to watch The Field of Dreams, one of the greatest father-and-son bonding movies (see essay 53). Without fail, I wail at the end when Ray Kinsella (Kevin Costner) asks his dad if he wants to have a catch. At first, my wife and daughters were astonished by my reaction; now, after a half-dozen or so family viewings, they are accustomed to it. I can see them nudging each other on the sofa as if to say: “Wait for it. Here it comes. Dad’s going to ball again!”
• If you are concerned that your emotional responses might be related to PBA, it would be wise to consult with a healthcare professional. They can provide a thorough evaluation and determine if further investigation or treatment is needed. This approach can help ensure that your emotional expressions are indeed a normal part of aging and not indicative of PBA or another neurological condition.
• Also, if you are a father and happen to watch The Field of Dreams with your adult son, notice his reaction to the final scene as he, too, unabashedly wipes away his tears.
• (June 23, 2024)
• 37. The Power of “Enough-ness” in Medicine
• How the principles of “Dayenu” apply in everyday practice.
• Prior to hurricane Helene, my son, his wife, and their young son made the long flight from their home in Honolulu to our “summer” home in Asheville, North Carolina. Normally, my wife and I make the trek to Honolulu twice a year to visit them. However, this time, we were spared a visit (expense), and in doing so, we were able to have a large family and friends gathering.
• After their visit, as I dropped off my son at the airport, I looked at him intently and said, “You know, your mother and I would have met you half-way. It would have been enough for you to fly to the west coast and meet us there rather than schlep to Asheville.”
• My son immediately invoked the Hebrew term “Dayenu” (pronounced “die-yay-new”). “Dayenu” translates to “it would have been enough.” “Dayenu” is both an expression and a song. The latter consists of 15 stanzas referencing different historical contexts the Israelites experienced during slavery in Egypt. It is traditionally sung on Passover to express gratitude for each of the many gifts that God bestowed to the Jewish people during their exodus from Egypt, stating that each act in itself would have been enough.
• While “Dayenu” originates from a religious context, its underlying principles can offer valuable secular lessons, even in heal hcare. Applying the concept of “Dayenu” to the practice of medicine may seem unconventional, but it can manifest in various ways. One instance is in patient care, where physicians can encourage patients to adopt an attitude of gratitude for any progress hey make in their health journey, regardless of the size. This can contribute to patient satisfaction and overall mental well-being, which can also positively affect their physical health.
• The concept of “Dayenu” can help physicians appreciate their achievements and the progress they’ve made in their career or in reating a patient, even if they haven’t reached the end goal. Healthcare providers can find solace in each small improvement in a patient’s condition. Celebrating small victories can boost the morale of physicians, helping to mitigate burnout, which is a guably the most plaguing problem in the medical profession today.
• As “Dayenu” (the song) builds, it calls out miracles, punctuating each one with Dayenu! The song’s structure, which highlights a series of incremental steps, parallels the step-by-step approach often needed in medical treatment and recovery. Understanding that each small improvement is significant can help manage expectations and maintain motivation in long-term care or complex medical situations.
• “Dayenu” teaches the importance of seeing the broader picture while recognizing the value of individual components. In medicine, this can translate to a holistic approach to patient care, where addressing physical, emotional, and psychological aspects of health are all deemed important.
• The principles of sufficiency and contentment inherent in “Dayenu” can prompt healthcare providers to reflect on ethical issues such as the limits of intervention, resource allocation, and the balance between aggressive treatment and quality of life. Specifically, the principle of “Dayenu” aligns with the idea of avoiding overtreatment in medical interventions. This approach recognizes when enough has been done for a patient’s health, understanding that further intervention may not improve, and could potentially harm, the patient’s quality of life.
• The historical context of “Dayenu” is one of overcoming adversity and oppression. In medicine, maintaining resilience and hope is crucial for both patients facing difficult diagnoses and for healthcare workers managing the demands of their profession. The song’s message can be a source of inspiration and strength.
• In essence, the values represented by “Dayenu” – gratitude, contentment, and moderation – originating from a specific religious tradition can be universally applied, including within the field of medicine. By drawing lessons from this ancient song, healthcare professionals can enhance their practice, ensuring they not only treat illnesses but also nurture the overall well-being of their patients.
• (June 27, 2024)
• 38. First Impressions Count in Health Care
• By modifying our habits, we can improve the care experience for all.
• My son was enjoying his morning latte at his favorite coffee shop in Honolulu and he texted me: “The guy at the register rememered you from last year. He says you are ‘super memorable!’”
• “Funny,” I replied, “I don’t remember him!”
• However, the man’s remark that I am “super memorable” resonates with me. I’ve found that the cliché “first impressions count” holds true in most instances, especially in health care.
• A pharmacist declined to offer me a part-time job when I was in high school. The job was to deliver prescriptions to patients’ homes. The pharmacist said my appearance – long hair, worn jeans, and hippy accoutrements of the time (1970) – would be a “turn off” to his customers.
• Initial interactions can indeed influence how patients perceive their care (and how healthcare providers remember their patients). First impressions in health care can set the tone for future interactions and relationships. They can affect a patient’s comfort level, trust, and overall experience. It’s a reminder of the lasting impact that even brief encounters can have on both patients and providers, as first impressions can be made within milliseconds in some instances.
• It doesn’t take a lot of effort to make a positive first impression: introduce yourself; smile and make eye contact; acknowledge concerns and provide reassurance (when possible); ask the patient whether they are comfortable; respect their time and apologize for long waits. Of course, there is more you can do to put patients at ease, but the point is that a positive first impression can foster trust, reduce anxiety, and enhance patient satisfaction.
• When patients are greeted, respected, and understood from the outset, they are more likely to engage openly with their healthcare providers, adhere to medical advice, and follow through with treatment plans. This can lead to better health outcomes and a more efficient healthcare process.
• In contrast, a negative first impression can create barriers to effective communication and trust. Patients who feel dismissed or undervalued may withhold important information, question the competence of their caregivers, or even avoid seeking necessary medical attention in the future. This underscores the importance of healthcare providers being empathetic, attentive, and professional from the very first encounter. Simple gestures like a warm greeting, attentive look, and clear communication can make a significant difference in how patients perceive their care.
• First impressions also affect professional dynamics and relationships among healthcare workers. A positive initial interaction with colleagues can pave the way for effective teamwork, collaboration, and a supportive work environment. In healthcare settings, where multidisciplinary teams are common, the ability to quickly establish rapport and mutual respect is essential. When coworkers view each other as competent, approachable, and reliable from the start, it enhances communication, reduces misunderstandings, and promotes a cohesive team dynamic.
• Conversely, a poor first impression among colleagues can lead to tension, miscommunication, and a lack of cooperation, which can ultimately affect patient care. Healthcare professionals must often make quick decisions and rely on each other’s expertise, so trust and respect are paramount. By making a good first impression, healthcare workers can build strong professional relatio ships that contribute to a more positive, efficient, and effective workplace.
• A long time ago, I read an article that asked, “How kind can a psychiatrist be?” The gist of the article was that of all the medical specialists, psychiatrists probably face the most unique challenge of making a good first impression because they must balance hospitality with professional neutrality. Maintaining neutrality is crucial for fostering an open and non-judgmental therapeutic environment, yet psychiatrists can still make a positive first impression by focusing on several key aspects of their initial interactions with patients. For example, we can demonstrate empathy and warmth, practice active listening, present ourselves as competent and professional, and create a safe and non-judgmental space for patients to “open up.” Putting too much distance between ourselves and our patients is not a good idea, regardless of one’s specialty.
• Physicians in all specialties should pay attention to the physical environment as well as the quality of their interactions to affirm positive first impressions. Patients often look for signs, even subtle ones, that indicate a caregiver’s reliability and attention to detail. A tidy, well-maintained office and exam room convey professionalism and care.
• Doctors, nurses, and office personnel may feel that using verbal and non-verbal cues to ensure good first impressions will add time to an already busy workplace environment, or that their own personality doesn’t lend itself to facilitating initial positive encounters. It is surprising how little time these communication efforts take since they focus on better, quality experiences and do not necessarily add more time. In fact, they may save time by dodging grievances that would have otherwise manifested in patient complaints.
• In summary, making a good first impression in health care is vital not only for patient satisfaction and outcomes but also for fostering a collaborative and harmonious work environment. Whether interacting with patients or colleagues, healthcare providers should endeavor to demonstrate empathy, respect, and professionalism from the outset.
• It’s no coincidence that my 1980 medical school yearbook was dedicated to a doctor (a psychiatrist) who made the best first impression at our freshman orientation in 1976 – an encounter described as “especially propitious” by our yearbook editor. Countless students sought this physician’s advice and guidance. I was one of them.
• (July 20, 2024)
• 39. Hidden Heroes Who Fought for Women’s Reproductive Rights in the 1950s
• The story of the “Dainty Maids.”
• The term “Dainty Maids” could refer to various subjects depending on the context – ranging from historical groups to fictional characters.
• Historically, women in service roles, such as maids or attendants, were referred to as Dainty Maids. They were noted for their refined manners and appearance, women who embodied ideals of delicacy and decorum. In literary works, poetry, and plays from various periods, particularly in the Victorian era, Dainty Maids were often described with particular attention to their elegance and grace. These characters might be depicted as young women of high social standing or those serving in noble households.
• “Dainty Maid” has also been used as a brand name for various products over the years. For example, in the mid-20th century, Dainty Maid was a brand of baking products, including cake mixes and other dessert items. These products were marketed to homemakers with an emphasis on creating delicate and delicious treats.
• Around this time (1950s), women known as “Dainty Maids” surfaced, selling door-to-door feminine hygiene products while covertly distributing contraceptives. This was a significant and somewhat clandestine effort during a time when birth control was a controversial and legally restricted topic: birth control was illegal in the U.S. until 1965 (for married couples) and 1972 (for single people).
• In the 1950s, women had limited options for family planning and faced significant challenges if they wanted to control their reproductive health. The “Dainty Maids” played a crucial role in providing access to contraceptives. They worked under the guise of selling feminine hygiene products, which were socially acceptable and did not raise suspicion. This allowed them to enter homes and offer information and products related to birth control (often spermicides) in a discreet manner. The Dainty Maids’ work was, therefore, not just socially risky but also legally perilous.
• The legacy of the Dainty Maids is significant. Their efforts led to more widespread acceptance and eventual legalization of co traceptives. Their bravery and commitment to women’s health and rights laid the groundwork for future advancements in reproductive health. These women were pioneers, and their actions contributed to the gradual change in societal attitudes towards contraception and women’s health, culminating in the groundbreaking 1973 Roe v Wade decision of the U.S. Supreme Court to legalize abortion.
• We are now witnessing a concerning reversal in the progress made toward women’s reproductive rights, spurred by recent legal a d ideological shifts. The 2022 Supreme Court decision in Dobbs v. Jackson Women’s Health Organization overturned Roe v. Wade and Planned Parenthood v. Casey (1992), concluding that the Constitution does not protect the right to an abortion. “Dobbs” has played a significant role in setting back nearly five decades of precedent and undermining the Constitution’s promise of freedom and equality for women, catalyzing the rise of laws and attitudes that restrict access to reproductive health services.
• This regression is reminiscent of earlier times when women’s autonomy over their reproductive health was severely limited. The “Dobbs” decision has emboldened efforts to enact more restrictive laws, making it increasingly difficult for women to access contraception and abortion services. The legal landscape is shifting, with numerous states implementing stringent regulations tha curtail reproductive freedoms.
• The impact of these changes is notable, affecting not only women’s health – teenagers in particular – but also their social and economic well-being. Restricted access to reproductive health services can lead to higher rates of unintended pregnancies, which in turn can perpetuate cycles of poverty and limit women’s opportunities for education and employment. The ideological underpinnings of this movement often stem from deeply held beliefs about gender roles and the sanctity of life, which are being translated into policies that prioritize fetal rights over women’s rights. As a result, an increasingly robust body of evidence is emerging that clearly illustrates “Dobbs” is harming reproductive health and freedom.
• As we observe this reversal, it is crucial to recognize the historical context and the struggles that led to the advancements in reproductive rights. The efforts of past advocates, like the Dainty Maids, highlight the importance of continued advocacy and education to protect and advance women’s health and autonomy. The current climate calls for renewed vigilance and activism to safeguard the hard-won gains in reproductive rights and to ensure that future generations do not face the same barriers.
• (August 18, 2024)
• Selected Essays: Practice and Career Concerns
• 40. I Retired After Speaking Out. Now I Can Speak My Mind.
• Be prepared to have difficult conversations with people in charge; otherwise, seek another job.
• I worked 40 years as an employed clinician, but I always feared losing my job. There were many reasons to be scared: mergers, acquisitions, downsizing, and potential conflicts with new bosses, to name a few. However, the primary reason I feared for my job was for speaking my mind. Existing in a constant state of anxiety due to job insecurity is a terrible way to live. But, as the sole earner for a family of four children and a spouse, I felt I could not afford to take any chances, and the greatest risk I perceived was voicing my opinion about something negative at work. Let’s face it: nobody likes a whiner or a whistleblower. The problem is, the less you say, the more you enable others to define your voice and your identity. 
• Had I owned my practice rather than worked for health care organizations all my life, things might have been different. Nowadays, however, about 80% of physicians are employed, so my experience is quite relevant. I worked at academic medical centers and pharmaceutical and health insurance companies. Clinicians working in the industry are considerably outnumbered by the “suits” a d must conform to business values that may clash with patient care values. Sometimes, for example, business dictates that the truth be hidden, like refraining from publishing the outcomes of negative clinical trials. Clinicians working in-house for large corporations also walk a fine line when organizational demands intrude on obligations to individual employees. Companies may try to downplay clinicians’ opinions that employees’ illnesses are work-related.
• When I was 41, I was approached by the CEO of a psychiatric hospital where I was CMO. They told me they were about to default on a substantial loan that could bankrupt the hospital and allowed me to listen in on a telephone conversation between himself, the chief financial officer (CFO) and the bank loan officer. The CEO fabricated an excuse why the hospital was in default, and he promised to satisfy the payment if the loan officer granted him a two-week extension. The loan officer agreed. The CEO and CFO smiled smugly and chuckled after the call, leaving me tangled in their web of lies. Somehow, they made the payment, but soon after, the hospital was again on the brink of bankruptcy. It was acquired by another healthcare system, proving the adage that you can call yourself an “acquired health care company” and be correct half of the time. I saw the handwriting on the wall afte that call, and I changed jobs before the acquisition.
• I’ve felt muzzled throughout my career due to the fear that my opinions might not sit well with individuals who rank above me in the organization.
• Many well-intentioned bloggers have shared their tips for speaking your mind at work. They tend to frame the issue in terms of courage rather than fear. They ask, “What’s the most courageous act you ever did at work?” 
• Employees’ responses are remarkably consistent, such as, “I stood up to my boss,” “I shared truthful information no one wanted to hear,” and “I argued an unpopular point of view.”
• However, none of their answers speak to the nuanced practice of a physician.
• In the world of medicine, opinions can be dangerous and politicized. Holding a controversial opinion can damage your reputatio ; stating a belief that contradicts the medical establishment can leave you vulnerable; voicing your opinion at the wrong time can make you appear foolish. The axiom attributed to Abraham Lincoln goes: “Better to remain silent and be thought a fool than o speak and to remove all doubt.” One can easily see how this mantra may inhibit physicians in their practice of medicine.
• My first week into a job with a renowned pharmaceutical company, I challenged the senior vice president (a clinician) regardi g the feasibility of conducting a clinical trial in depression – I was in favor of the trial, but the senior vice president was not inclined to fund it. I argued my rationale to them, and the next thing I knew that my boss was calling me advising me to back off. He said he had just saved my hide, as the senior vice president was disposed to firing me – simply for speaking my mind in opposition.
• Another time, while working in the health insurance industry, I outlined a comprehensive plan to manage mental health benefits for the company’s insureds. I suggested that the company carve in mental health benefits rather than carve them out, as was the prevalent arrangement at that time and still is today. A couple of weeks later, the CMO told me he was eliminating mental heal h benefits, a euphemism for eliminating my job rather than the benefits per se. The back-to-back blows I suffered while working in the industry further silenced me and curtailed any aspiration for a position in the C-suite. I figured I was still capable of leading by example. Why should I risk putting my neck on the chopping block by gunning for an executive position of authority? To quote Jimmy Cliff: “The harder they come, the harder they fall.”
• I retired when I reached full retirement age, as defined by the Social Security Administration, and when my return on lifetime investments provided sufficient income. To help pass the time, I began consulting from home for a few companies. My consulting business has now grown to 30 hours per week, so you could say I came out of retirement. But the important thing is I feel I have nothing to lose by speaking my mind because if a client were to drop me today, I would still be financially independent. My clients seem to like me and appreciate my openness, directness, and honesty. My retirement, or at least my vision of being “retired,” has allowed me to speak my voice – ironically, at a time when I was not expecting to work anymore. If your workplace would support firing you because you voiced an unpopular opinion, you shouldn’t be working there.
• (August 7, 2021)
• 41. Whatever Happened to Professional Courtesy?
• A good argument can be made for preserving professional courtesy for health workers in need.
• Acts 20:35 of the Bible says, “It is more blessed to give than to receive.” If pressed, many physicians generally believe it – or we think we do. But how many physicians actually offer professional courtesy – taking care of colleagues and the families of other physicians without charge? It seems to be a dying practice.
• I gave free psychiatric consultations and discounted psychotherapy rates to many colleagues over the years. And when I was a resident, I received psychotherapy at a discount. Professional courtesy used to be offered by most specialists – not only psychiatrists – in the normal course of practice. A study from nearly 30 years ago showed that physicians were likely to offer professional courtesy, ranging from 91% to 99%, although lower for psychiatrists (80%), a specialty where money and psychodynamics are highly confounded.
• In time, as my family grew, I found that professional courtesy was less important in terms of money and more important in terms of my colleagues’ availability. “Fever and ear pain? Sure, bring your child in to see me now,” our pediatrician once told us at 1 a.m. in order to quell the anxiety of two very worried parents. Doctors always seemed to be able to accommodate other docto s and their family members on a dime. 
• That’s not necessarily the case today, however. I have played the “doctor card” many times to get an expedited appointment for myself or someone in my family – to no avail. In a recent example, a relative was in treatment for depression, yet not improving, so I reached out to a young psychiatrist who came highly recommended. Like me, the psychiatrist was on the academic faculty of a medical school. I emailed the psychiatrist requesting the favor of an appointment ASAP, and I gave her a brief synopsis of the situation. I did not hear from the psychiatrist for several days, so I wrote again and asked the psychiatrist to reach out directly to the individual whose contact information I had previously supplied. 
• One week later, the psychiatrist wrote to me on her cellphone: “Hello, Dr. Lazarus. I understand your urgency and concern. However, I do not have the availability to accommodate your relative at this time due to very limited clinic hours due to research and administrative duties.” The reply went on to say that I should call the “intake line” for help, and that her colleagues are “fantastic.” I was also given the phone number of a facility to contact 90 miles away. I was dismayed by the psychiatrist’s impersonal and untimely response. I felt compelled to inform the chairperson of the psychiatry department. When I did, he wrote that he appreciated my feedback and that I should feel free to connect with him directly in the future, but he exerted no apparent pressure on the psychiatrist. Anyway, if he had given her an order to see my relative, would I still want to have the appointment under coercive conditions? 
• Subsequently, I had a conversation with a psychiatric colleague – a former department chairperson – about the incident. He lamented the good old days, a time when professional courtesy was a byword and psychiatrists were “complete” because they provided both psychotherapy and pharmacotherapy. Nowadays, psychiatric treatment is usually split between a psychiatrist and a nonmedical therapist – not an ideal arrangement. My psychiatrist friend muttered “millennials” as an excuse to explain the psychiatrist’s inaction. It seems self-preservation has taken root in many physicians these days, and although I understand the need for work-life balance, academicians have a tripartite mission: clinical care, teaching, and research.
• I also understand there are pros and cons of offering professional courtesy, and doctors must be mindful of certain laws and regulations that could imperil their practice should they treat patients preferentially or give the appearance of impropriety. From my perspective, I was simply asking for quick service – a request from one professional to another. Perhaps even this component of professional courtesy is becoming obsolete. I remember discussing professional courtesy with a co-resident many years ago. The resident’s take on professional courtesy surprised me. She said she never identified herself as a doctor to an examining physician lest the physician deviate from his or her practice standards. Quite a commendable position, I thought, but not always feasible when there is a pressing medical concern for a family member or relative.
• The original purpose of professional courtesy was to discourage physicians from treating themselves and their immediate and ex ended family members. The custom dates back to Hippocrates. In addition, recent studies have shown there is a benefit to volunteering one’s time: It helps overcome anxiety and depression. But with the increasing regulation of medical practice, there has een a shift away from professional courtesy to business as usual delivered impartially and impersonally. Still, it stings when you’re on the receiving end. My relative found appropriate help, albeit 90 miles from home.
• (September 3, 2021)
• 42. Have You Lost Your Desire to Practice?
• Medical practice became a stepping stone to a nonclinical career.
• I was intrigued by medicine from an early age: the smells emanating from my pediatrician’s office, his assured ways, and his p onouncement that I was “anemic” all fascinated me. My personalized, confirmatory finger-prick test made me feel unique. There was also a cultural supposition that young boys of my religious faith (Jewish) would become professionals – doctors, lawyers, o accountants. I didn’t foresee law or accounting in my future.
• The problem was, I lacked confidence in myself, and I felt awkward around my peers. I was overweight and I was always one of the youngest students in my class, a result of skipping second grade upon transitioning mid-school year from an inner-city elementary school to a suburban school. The new school suggested I drop back to second grade, but my third-grade teacher said she saw “potential” and persuaded my mother to keep me in third grade with kids a year older than me. Still, I doubted my own ability and lacked maturity, especially compared to the opposite sex. My childhood inadequacies became a permanent stain on my ego.
• I entered junior high school in poor academic standing, in the lower third of the student body, based on the school district’s standardized testing in sixth grade. By the time I reached twelfth grade, I had worked my way up to “academically talented.” Yet, my standardized testing results were barely improved, achieving only average SAT scores. Although I graduated high school in the top 20% of my class, my overall record was undistinguished. I certainly was not the sharpest tool in the shed.
• However, with unwavering determination to get into medical school, I applied to a combined 6-year baccalaureate-MD program. The interviewer, a physician, politely but firmly suggested that I modify my application and apply only to the baccalaureate program and revisit medical school after 4 years of college. Her put-down was another blow to my ego, but I never gave up on my dream of entering the medical profession (refer to essay 21).
• I suppose I learned at an early age to keep medicine at the forefront of my ambitions in order to compensate for my perceived deficiencies and to prove others were wrong about me (refer to essay 11). I figured if I could win at the game – get accepted into medical school – whatever came afterward was immaterial and icing on the cake. In other words, the means became the end; once I had an MD degree, I would decide my next move. My outlook amounted to blind faith in the medical profession. “There has to be something I can sink my teeth into,” I thought.
• Fortunately, medical school was able to hold my interest, especially psychiatry, which was a natural extension of my undergraduate major in psychology. But the reality is that although I found medical school intellectually rewarding, and I performed well enough to be selected for the Alpha Omega Alpha Honor Medical Society in my senior year, practicing medicine was not a good fi for me. I realize I had made that determination a priori; practicing now confirmed it. After 4 years of residency and 15 years of practice, half of that time transitioning into management, I called it quits. I had lost my desire to see patients, and I assumed a nonclinical career.
• I am not alone in my career path. I also know that readers’ reactions will vary. Some will consider me a traitor to the profession – especially with an MBA degree and for working in managed care organizations – and others will criticize me for taking a slot away from students allegedly more dedicated to medicine than me. A minority of readers, however, will identify with me and see the value of training physicians for nonclinical careers. In fact, they will fault medical schools for not teaching business concepts, leading to the demise of private practice.
• The truth is, medical school applicants are very bright. They know how to answer essay questions and approach interview interrogations regardless of their ultimate persuasion. Physicians have learned early on how to game the system and even lie to get what they want (refer to essays 25 and 26). I’m not advocating dishonesty, but if it means using medical school as a stepping stone to an alternative or non-traditional medical career, so be it.
• While I don’t practice any more, I’m just as passionate as the next person about fixing our broken healthcare system. And I’m just as concerned (perhaps more so) about the plight of patients in this dysfunctional system, which has seen declines in average life expectancy and other important outcomes despite spending far more of our GDP on health care compared with other high-income countries.
• Of approximately 1 million active physicians in the U.S., less than 2% are fully administrative. Yet, the need for physicians o plug critical leadership gaps and assume positions in industry and government is greater than ever. These critical roles will remain unfulfilled unless students who have an inclination to enter the profession of medicine without necessarily aspiring to be clinicians are welcomed by medical school admission committees and are not judged harshly by their teachers and peers.
• In my case, my third-grade teacher was right. She knew I had potential. It was up to me to figure out how best to channel my i terest in medicine even if it meant being a “doctor” would lead me down a path less traveled.
• (January 9, 2023)
• 43. When an MBA Degree Meets Medicine: An “Eye-Opening” Experience
• The unusual path of doctors with MBA degrees leads us to question their intentions.
• I recently saw an ophthalmologist for my worsening eyesight. The doctor came highly recommended and was credentialed as an MD and MBA. He founded his practice, which has grown to over a dozen practitioners. His website boasts how he works with the pharmaceutical industry to help develop and market new medications “that improve the standard of care.”
• According to Open Payments data, the doctor has relationships with ten drug companies and received nearly $20,000 total compensation in 2021 – 60% for consulting fees and the remainder for honoraria, travel, lodging, food, and beverage. His industry payments since 2015 have been well above the U.S. mean and the mean for his specialty.
• I googled the physician before my appointment. The feedback was generally positive, with occasional references to patients feeling rushed or being pushed into surgery. My exam lasted approximately 3 minutes. The doctor told me I had “dry eyes” and gave me sample medications marketed by companies with whom he had relationships. Then came the bombshell: the doctor told me I needed cataract surgery. I decided to seek a second opinion. It pains me to admit it, but I wished the doctor did not have an MBA degree or industry ties.
• My pain stems from the fact that I’m guilty on both accounts. I have an MBA degree (1996) and worked in the pharmaceutical industry (2001-2014). While working in big pharma, I gave many promotional talks to physicians and visited “key opinion leaders” – that is, physicians of influence – keeping them abreast of products in the pipeline and current scientific research so they could pass the knowledge on to other physicians.
• Should I apologize for my activities? Should I think less of the ophthalmologist? I don’t think so. Both of us have conflicts. Conflicts are universal in medicine. It’s not the declaration of conflicts that’s important – it’s how you manage them. Rule number one for managing conflicts of interest is to be aware of them. They’re like the blind spots (no pun intended) I discussed in essay 12: our conflicts diminish as we develop greater insight about ourselves and begin to behave ethically. Personal integrity cannot be taught in medical or business school.
• It’s often assumed that doctors with MBA degrees have sold out to big business or are at least mired in conflict. I’m not convinced that’s true. I used to laugh and tell people I have conflicts and that’s why I became a psychiatrist. The fact is, I sought a second ophthalmological opinion for my own peace of mind – to ensure the initial recommendation for surgery was based on the ophthalmologist’s obligation to me as his patient and not on his role as a practice owner or pharmaceutical consultant.
• The reality is that an MBA degree creates value and opens doors to new opportunities. More than ever, job descriptions will state an MBA degree is a “plus.” There is no doubt that healthcare organizations are in search of business-minded physicians capable of leading the “medical industrial complex.” A salary premium comes with a dual degree. Perhaps most important, MBA-trained physicians understand the language of business, just as medical students are taught the language of medicine. Fears that an MBA degree will draw physicians away from practice are unfounded.
• Soon after I obtained my MBA, I wrote a book about dual-degree physicians – MDs and DOs with MBA degrees. A good friend and colleague, Kenneth Veit, DO, MBA, was an “early adaptor” and turned me on to the idea of business school. I asked him to contribute a chapter to the book, specifically addressing the value of an MBA degree to someone in his position: Dean of the Philadelphia College of Osteopathic Medicine (now emeritus).
• Veit said his decision to go to business school came about with a slowly developing interest in administration. He wrote: “[An] MBA education can be applied to [operational] interactions … The MBA skills constantly function in the background. When the occasion calls, this database of knowledge moves to the foreground … [An MBA degree] provides a set of skills that is rarely directly applicable but that at the same time is constantly being used indirectly in various formats.”
• A survey of 66 dual-degree orthopedic surgeons provided additional insight. They were asked about their motivations for obtaining an MBA degree and its perceived value. Most respondents (89.4%) viewed the MBA degree as either extremely valuable or valuable. Their time spent in administrative activities significantly increased – consistent with their goals – and business school allowed them to focus on learning important management theory considered a prerequisite for leading healthcare systems undergoing change.
• I utilized my MBA degree in a somewhat different capacity while working in the pharmaceutical industry. I had an opportunity to dive deeply into marketing while in business school, and I decided to put that knowledge to good use in big pharma. I trained sales teams and reviewed all types of promotional material – for physicians and consumers – for medical accuracy, completeness, and realism.
• Working as an “insider,” I guarded against potential FDA violations and was able to boost the credibility of advertising claims in areas where pharmaceutical companies struggle mightily – that is, incurring fines for false or misleading prescription drug promotion. I was asked, “Why do you stoop to popularizing medicine?” The answer rolled off my tongue: “Because advances made i the lab cannot benefit people without actions taken outside the lab.”
• Butting heads with the “suits,” however, was another matter. I understood profit and loss as well as them. I was adept at reading financial statements. I understood forecasting models – heck, I formulated models in business school. One of my professors told the class he loves to make models for fun. We thought he was talking about replica cars!
• Pharma politics eventually wore me down. But that’s not why I left my first job in pharma. I was asked by a salesperson to speak at a “lunch ‘n learn” at an academic medical center to promote a new drug for depression. I met the salesperson in the parking lot. He had a half-dozen large pizza boxes to bring to the conference room. I offered to carry some boxes. We entered the room together. The faculty mistook me for the salesperson.
• I realized I was too deep in the big pharma marketing machinery, so I left the company for a more respectable position in R&D. Still, I lent my skills to marketing teams throughout my pharmaceutical career, including generating ideas for television commercials. My MBA degree put me on a level playing field. And who other than a physician could advise a director and actor on port aying a patient with schizophrenia or bipolar disorder?
• (March 25, 2023)
• 44. Medicine Is a Joke, Except No One is Laughing
• A tale of a near-apocalyptical ending to the medical profession.
• My brother and I, now in our 70s, like to swap stories from past times. I suppose it’s only natural. Like a heat-seeking missile searching for a target, story treasures from our shared experiences seem to find their way into our conversations, illuminating moments that have shaped our lives and highlighting the bonds that have grown stronger over the years.
• Occasionally, our father becomes a topic of conversation. He loved to read to us. “Casey at the Bat” was recited so many times that the binding of the book of poems that housed it became frayed. “Casey at the Bat” is a narrative poem written by Ernest Lawrence Thayer in 1888. It tells the story of a fictional baseball game in the town of Mudville. The home team is trailing in the final inning, but there is hope as the star player, Casey, comes up to bat.
• Thayer writes: “There was ease in Casey’s manner as he stepped into his place … No stranger in the crowd could doubt ’twas Casey at the bat.” The crowd is ecstatic, confident in his ability to turn the game around with two men on base and two outs. However, despite the anticipation and excitement, Casey strikes out, taking three straight called strikes. The crowd – the “stricken multitude” – leave the ballpark completely demoralized.
• “It’s a shit show,” my brother tells me from his home on Martha’s Vineyard.
• “What! Casey, I ask in disbelief?”
• “No,” he replies, non-sequitur. “I’m talking about the health scene here on the Vineyard. No one’s left. The doctors have stopped seeing new patients or have incredibly long waiting lists.” My brother is forced to go to medical centers in Boston to see doctors.
• It’s not the shortage of physicians that irks him, however. It’s the impersonal way health care is delivered plus the fact tha telemedicine isn’t the panacea it’s cranked up to be, certainly not when physical and neurological exams are required to evaluate his fused lumbar spine and peripheral neuropathy.
• “Now it’s my turn to complain,” I tell him. I relate that I logged on to my patient portal to send my PCP a message, but before the message could be delivered, I received a pop-up screen:
•  Call 911 if you have an emergency.
•  Allow up to two business days for a medical question response.
•  For new problems, including skin conditions, use Symptom Checker or schedule an appointment before sending a message (both “Symptom checker” and “Schedule an appointment” were hyperlinked).
•  Messages to your provider are part of your medical record.
• I was curious to learn about Symptom Checker, so I clicked on the hyperlink, which first directed me to the “Terms and Use.” I pretended to understand “legalise” and then I was introduced to Symptom Checker.
• Here is what the bot offered:
• “Welcome to Symptom Checker!” Tell us how you’re feeling, and we’ll help you get the right care, including:
• If your symptoms are minor, you might be able to complete an eVisit right away. You’ll just have to answer a few questions about your symptoms, and a health care provider will send a diagnosis and treatment plan to your inbox.
• Some minor conditions don’t require in-person care, but do require a face-to-face conversation with a provider. In those cases, we’ll help you start a video visit and get the care you need from the comfort of home.
• If your condition is minor but requires in-person care, we’ll help you find an urgent care near you or schedule a visit with your doctor.
• “If your symptoms are life-threatening, call 911 or seek emergency care right away.”
• A few things strike me as both funny and tragic about the messaging. First, the health care system doesn’t want me to see my PCP. It prefers instead to shield him with a chatbot acting like a downfield line blocker.
• Second, the health system puts the onus squarely on me, aided by minimal advice, to figure out if my condition requires an in-person visit. The proverbial cart is before the horse insofar as triage is suggested before a diagnosis is made.
• Third, a dummy understands to call 911 if they are experiencing a life-threatening emergency. I am not a dummy.
• Lastly, all I needed from my PCP was a refill of medication.
• Nevertheless, I clicked on the Symptom Checker to explore the application. I was asked to pick the symptom or condition that most closely matched what I had been experiencing. The artificially unintelligent program actually generated over two dozen conditions to self-treat or self-medicate with OTC drugs. The conditions ranged from sunburn to rash to athlete’s foot to jock itch o constipation and even COVID. Once again, the goal was to spare the health system an unnecessary PCP visit.
• I clicked on “mental health” because at this point, I thought I might need a psychiatrist. I was advised to call the Suicide & Crisis Lifeline (988) if I am in crisis.
• Next, I was asked to enter my phone number and questioned whether I was thinking about hurting myself or someone else. Responding in the negative, I was asked if I am either sad, anxious or worried, or unusually happy, excited, or hyper. Choosing none of these options, I was offered an urgent video call. However, endorsing manic-like symptoms (happy, excited, hyper) ordered me instead to make an appointment with my PCP.
• Now I felt like hurting someone. The algorithm was clinically flawed. It didn’t recognize hypomania or mania as a psychiatric emergency. Furthermore, when I endorsed “sad” or “anxious and worried,” I was required to take the PHQ-9 and GAD-7 screening instruments for depression and anxiety, respectively. Although commonly used in primary care settings, these screens are far from perfect. Interpreting their results at face value without the benefit of a clinical evaluation can have detrimental consequences for patients.
• I played along and endorsed severe depressive symptoms on the PHQ-9. I was advised to contact my PCP. Ironically, Dr. Symptom Checker further burdens PCPs by designating them to be on point for patients’ mental health problems. This is especially egregious considering that the health system where my PCP practices has a separate department of psychiatry. Mental health care should be integrated with primary care whenever possible.
• The over-reliance on and uncertainty of artificial intelligence is one of myriad problems plaguing health delivery systems. Add to those problems the depersonalization and dehumanization of the medical experience, and you have a recipe for … well, as my brother put it: “a shit show.” And let’s not forget about the increasingly intolerable conditions under which physicians must p actice: toxic workplaces, EHR calamities, and incessant hounding by third parties, to name a few.
• Medical practice has become a joke, staffed by threadbare providers, possibly not even human. Physicians who remain loyal to the cause – to heal the sick – are not laughing, however. They are burning out at record rates and dealing with moral injury inflicted by deceptive health systems, especially those that dangled lucrative employment contracts promising to honor physicians’ eliefs and values, only to find they were sold a false bill of goods. Although physicians clearly feel a moral imperative to spend time forming important human connections, inherent transactional demands of health systems undermine these ideals.
• There is no joy in practicing medicine in Mudville. Mighty Casey has struck out, and happiness may never prevail again.
• (May 4, 2023)
• 45. Never Ask Me to Be a Medical Expert Witness (Again)
• “Medicine is a science of uncertainty and an art of probability.” —Sir William Osler
• Once, in 2011, I agreed to be an expert witness. Never again! Not because I was grilled on the witness stand for several hours. Not because my qualifications were questioned. And certainly not because I was compensated poorly for my time. Rather, I don’t ever want to have to defend our profession’s great tradition steeped in the “art” of medicine.
• I was hired by an attorney who was suing a health insurance company for “bad faith” decision-making, i.e., for denying his client (the patient) what I and other physicians believed was medically necessary treatment. The lawyer representing the insurance company – counsel for the defense – confronted me on the stand.
• “Dr. Lazarus,” he belted out, “are you familiar with this textbook?” The lawyer practically heaved Harrison’s Principles of In ernal Medicine at me, further questioning whether I was familiar with the tenets of evidenced-based medicine. I have lived by those principles my entire career, I told him, but I remained silent about the real truth: the fact that “textbooks tell lies.”
• “Textbooks tell lies” is a phrase I’ve never forgotten after reading Viktor Frankl’s Man’s Search For Meaning (see essay 54). Frankl and other physicians at Auschwitz concentration camp quickly learned that the information contained in medical textbooks was irrelevant to their plight, i.e., the brutal conditions their bodies and minds were required to endure. Who could have predicted the need for treatments for the myriad illnesses resulting from the unimaginable inhumanity prisoners were subjected to? And conversely, no medical textbooks of that era anticipated the surprising resiliency of some prisoners in the face of famine, torture, and disease. “Resiliency” wasn’t even a concept in the early to mid-1940s.
• As someone who embraced and practiced evidenced-based medicine long before the term was coined, testifying about the sanctity of the art of medicine was an interesting turn of events because I had to find it within myself to tell the lawyer how compassion and caring should have factored into the insurance company’s decision. I had to channel Viktor Frankl.
• My opening pitch involved telling the insurance company’s lawyer that there’s much more to practice than what textbooks and journal articles teach us. However, the attorney tried to shut me down, implying I was not familiar with the concept of evidenced-based medicine. He actually asked the judge to excuse me, claiming that I did not qualify as an “expert” in managed care.
• The judge had the good sense to let me testify, and testify I did! I explained that the art of medicine entails understanding patients’ histories – where they’ve been and how they got here – and listening to their stories, in many instances stories of grief and destitution. To practice the art of medicine means that you know your patients inside-out, including social and psychological issues impacting their health. You know their occupation, who they are close to, and what their living situation is like. When you’re a psychiatrist, you know them even more deeply. Who do they love? Who do they argue with? Who do they hold a grudge against and regret not making amends? Textbooks and journal articles do not steer you in that direction, I said to the attorney.
• The lawyer objected to my testimony as being “non-responsive,” but I was on a roll, and the judge held up his hand like a stop sign to the attorney and let me proceed. The art of medicine goes beyond mere knowledge obtained from double-blinded placebo-controlled studies, I continued. It requires treating the patient as a whole person, not just their illness. This includes taking into consideration their mental and emotional health, lifestyle, and personal circumstances. It demands treating patients with empathy and concern. Understanding and acknowledging a patient’s feelings can greatly improve their healthcare experience and can positively influence their health outcomes. Doctors have to discover the essence of their patients’ existence on their own and not through some textbook, I concluded.
• The insurance company doctors who denied care to this patient knew nothing about him other than that he had condition “X” and his physician was requesting treatment “Y,” which the insurance doctors deemed was “not medically necessary.” They did not even weigh the fact that, despite the patient’s current therapy, he was not responding to it and was becoming progressively blind (from Lyme disease).
• Such callous decision making and patient neglect, I argued, was tantamount to practicing medicine in bad faith. My argument was a stretch because legally “bad faith” generally refers to intentional dishonest behavior or misleading actions that result in harm or potential harm, and that was not entirely evident here since the insurance company physicians were simply relying on a set of guidelines, misguided though they were. Nevertheless, the judge was sympathetic and he essentially forced the insurance company into a settlement, not least because he became aware that the insurance company’s chief medical officer called my employer’s legal department and tried to intimidate me from testifying.
• The art of medicine and the science of medicine are two fundamental aspects of healthcare. They represent different but complementary approaches to patient care. The science of medicine aims to provide objective, evidence-based solutions to health problems. It provides the tools and knowledge necessary to diagnose and treat diseases. The art of medicine, on the other hand, refers to the more subjective and personal aspect of healthcare. It involves understanding the patient as an individual, empathizing with their experiences, and building a therapeutic relationship. The art of medicine ensures that broad knowledge of the patien is applied in a compassionate and culturally competent manner. Both the art and science of medicine are necessary for effective medical practice.
• I don’t have anything against lawyers, I just wish more of them would read Man’s Search for Meaning.
• (October 7, 2023)
• 46. Euthanizing Our Pets Teaches Us About Progressive End-Of-Life Care
• While euthanizing a pet is a deeply painful experience, it also offers valuable lessons about death and dying.
• Over the years, our family has been a home to more than a dozen pets – cats and dogs – cherished and loved beyond description. None of them died in their sleep due to natural causes. All were euthanized when it became clear their quality of life was rapidly deteriorating and they were failing to thrive. Sometimes there was an obvious underlying condition such as cancer, but mostly the cause was unknown.
• “Sully” was our beloved 14-year-old Bernese Mountain dog mix, small for the breed and lacking the characteristic white stripe unning up his snout plunging deep into his forehead. Sully’s namesake was the Monsters, Inc. character known for his gentle and compassionate nature. My daughter named him “Sully” unaware that Chesley “Sully” Sullenberger was the pilot who landed his disabled airliner on the Hudson River, although our “Sully” was also deemed a miracle, rescued from a puppy mill.
• When Sully began to deteriorate – his personality vacated by dementia and subsequently losing control of his hind legs and bowels – we decided not to let nature take its course. When it became time to euthanize him, I remarked to the veterinarian, “I just wish he would die in his sleep.”
• “Hardly,” she replied. “They rarely go that way.” She explained that most dogs and cats will have many days of challenging stages of deterioration and pain before they finally pass. “Natural death is neither peaceful nor gentle,” she added.
• “The same is true for humans,” I murmured.
• Losing such a big part of your family is never easy. The decision to euthanize a pet is dreaded and difficult, especially if family members are not all in agreement. My wife, for example, has witnessed her mother and grandmother battle prolonged Alzheimer’s disease. She makes life and death decisions quicker than me. We are different because my medical education taught me to prolong life. There was much less emphasis on quality of life when I trained in the 1970s and 1980s than there is today.
• Regardless, our discussions about euthanasia always involved our children. We continue to include them now as grown adults. They, in turn, include us with their own families when facing the same agonizing decisions. A typical conversation about euthanizing our pets invariably branches into several areas as we strive to reach a unified decision. The process is somewhat analogous o a jury deliberation.
• Comparing Euthanasia in Pets Versus Humans
• First, we compare and contrast euthanasia in pets and humans. We recognize that the emotional and ethical aspects of euthanasia are complex, regardless of whether the subject is a pet or a human. Both situations involve making difficult decisions about ending a life to alleviate suffering or progressive mental or physical deterioration. However, there are significant differences in how society and the medical field approach these situations.
• In many parts of the world, euthanasia or assisted suicide for humans is illegal, whereas euthanasia for pets is not only legal but often seen as a humane choice when the pet is suffering. The ethical considerations surrounding human euthanasia are more complex due to the higher consciousness of humans, their ability to express their wishes, and societal and religious views abou the sanctity of human life.
• The emotional burden in both cases is immense. However, the grief experienced by a pet owner may be different from the grief experienced by a family member or loved one of a human patient. In both cases, the individual must grapple with feelings of loss, guilt, and bereavement. However, the decision-making process for human euthanasia can be further complicated by the patient’s wishes, family dynamics, and legal considerations.
• In veterinary medicine, the decision to euthanize is usually made by the pet owner, often guided by the advice of the veterina ian. In contrast, the decision to end a human life involves the patient (where possible), family members, physicians, ethicists, and sometimes legal professionals. The patient’s wishes, as expressed in living wills or through healthcare proxies, play a significant role in human euthanasia.
• In both human and veterinary medicine, the decision for euthanasia is often considered when the patient’s quality of life is poor, and there is little to no hope for improvement. However, the assessment of “quality of life” can be more complex in humans due to their cognitive abilities, emotional states, and personal beliefs.
• Euthanasia as a Taboo Subject
• Second, our family feels comfortable freely discussing the topic of euthanasia whereas recognizing that for many the practice of intentionally ending a life to relieve pain and suffering is often considered taboo, particularly when it comes to humans.
• In many cultures and religions, life is considered sacred, and ending it, even to alleviate suffering, is seen as morally wrong. These beliefs often stem from the idea that only a higher power has the right to determine when a life should end. Although is generally accepted that humans have a right to a dignified death, the question of who gets to decide when a life is no longer worth living is a contentious one.
• For many, the ethical dilemma lies in the potential for misuse or abuse of euthanasia. There are concerns that legalizing euthanasia could lead to situations where it is used inappropriately, such as in cases of severe disability, old age, or even economic burden. Clear guidelines and strict regulations are necessary to ensure that the process is not misused or exploited, particularly in cases involving vulnerable populations like the elderly.
• The topic of euthanasia is less taboo when it comes to pets, primarily because animals are not considered to have the same rights or consciousness as humans. The decision to euthanize a pet is often seen as a compassionate act to end an animal’s suffering. However, it is important to note that this decision can still be emotionally devastating for pet owners and veterinary professionals.
• Although the taboo surrounding euthanasia is gradually easing – some estimates indicate 50% of all Americans will live where medical aid in dying is authorized and accessible by 2028 – euthanasia remains a sensitive subject that requires careful handling and open, respectful dialogue, which is what our family has always valued during these stressful and emotional times.
• The Outcomes of Euthanasia
• Third, our family discussions consider the potential outcomes of approaching euthanasia in humans as we do in pets. Applying the same principles of pet euthanasia to humans could potentially ease suffering for those with terminal or debilitating illnesses. It might address inequities in end-of-life healthcare, expand end-of-life healthcare options, and transform the emergency room experience for dying patients. Euthanasia might also provide a sense of control to individuals over their life and death, respecting their autonomy and right to a dignified death.
• For loved ones and medical professionals, this approach could alleviate the emotional distress associated with watching a person suffer without the ability to provide relief. However, it might also bring about feelings of guilt or conflict, similar to what pet owners experience when deciding to euthanize their pets. Therefore, emotional support at this time is a prerequisite.
• A shift in approach would integrate the option of medical aid in dying into standard practice for patient-directed end-of-life care by expanding outreach, education and technical support for clinicians, medical societies, and residency training programs. This would require significant legal changes, including the legalization and regulation of euthanasia or assisted suicide. Societal changes in how we view life, death, and the right to die would be necessary to advocate for a more progressive agenda.
• Conclusion
• Given that euthanasia is illegal in the majority of the United States, our family discussions have been mostly academic. However, we firmly believe that if we approach human euthanasia as we do with pets, it could potentially change perspectives on end-of-life decisions. The scales are gradually tipping in favor of death with dignity, and I have become less of a holdout over time.
• (May 17, 2024)
• /
• “Sully” (R.I.P.)
• 47. The Artificially Intelligent Physician
• Envisioning the role of an AI doctor from sci-fi accounts is intriguing, if not alarming.
• WarGames is a 1983 American Cold War science fiction film directed by the legendary John Badham. The film’s premise revolves a ound a young computer whiz kid named David Lightman (Matthew Broderick) who accidentally connects to a top-secret supercomputer which has complete control over the U.S. nuclear arsenal. The supercomputer, named WOPR (War Operation Plan Response), is designed to predict possible outcomes of nuclear war. Mistaking the computer’s simulation for a real-life game, David starts playing a nuclear war scenario, causing a national nuclear missile scare and almost starting World War III.
• While the movie itself does not directly relate to the field of medicine, the themes of technology, ethics, and responsibility are highly relevant. In medicine, the increasing use of artificial intelligence (AI) and machine learning brings up concerns similar to those in WarGames and other sci-fi movies like Star Trek. For instance, the potential for miscommunication or misinte pretation of data, the ethical implications of machine decision-making, and the importance of human oversight and understanding of complex systems are all pertinent issues in today’s medical field. Sci-fi movies can often serve as metaphors for the poten ial risks and unintended consequences of relying heavily on advanced technology in sensitive areas such as healthcare.
• The integration of AI in healthcare is rapidly advancing. AI has the potential to revolutionize many aspects of patient care, as well as administrative tasks within the healthcare system. This includes, but is not limited to, AI algorithms for diagnosing diseases, predictive analytics for patient outcomes, automation of routine tasks, and personalized medicine based on individual genetic makeup.
• AI can also help physicians with decision-making, provide predictive insights, and improve accuracy in diagnosis and treatment. It can aid in treatment planning, patient monitoring, and even in surgical procedures. AI can process vast amounts of data faster and more accurately than humans, potentially leading to earlier detection of diseases and more precise treatment plans.
• It is important to remember that AI should be seen as a tool to aid healthcare professionals, not replace them. But deep down, many of us fear the latter possibility. Perhaps one day we will create an artificially intelligent doctor who, like Professor Moriarty in Star Trek: The Next Generation episode “Ship in a Bottle,” will clamor to leave the holodeck (a virtual reality room able to reproduce any place and person[s] one imagines).
• An AI doctor practicing medicine at the patient’s bedside is an interesting vision for the future of healthcare.
• The concept of an AI doctor is not entirely far-fetched. We are already seeing the beginnings of this with AI systems like IBM’s Watson, which can analyze a patient’s medical history and suggest potential diagnoses and treatments. Additionally, there are AI-powered virtual health assistants that can interact with patients, answer their queries, and even monitor their health conditions.
• In one study, the use of a microphone on a secure smartphone allowed an ambient AI scribe to transcribe – but not record – patient encounters and then use machine learning and natural-language processing to summarize the conversation’s clinical content and produce a note documenting the visit. Study participants were reportedly “blown away” by the ability of the technology to appropriately filter the conversation from a transcript into a clinical note. The AI scribe saved doctors an hour at the keyboard every day.
• However, while AI can analyze data and provide clinical summaries and recommendations, it is important to remember that the practice of medicine involves more than just data analysis. It requires empathy, understanding, and human connection. These factors are currently beyond the capabilities of AI. Therefore, while an AI doctor might be able to assist with clinical decisions or administrative tasks, the need for human healthcare professionals who can provide compassionate care and understand the nuances of human health and disease will always remain.
• This is where the concept of creating an AI doctor from a holodeck becomes intriguing. If we could create an AI doctor that no only processes data and makes clinical decisions but also interacts with patients in a human-like manner, the potential benefits could be amazing. It could allow for 24/7 availability of medical care, decrease the burden on human doctors, and provide a consistent quality of care. The AI physician could be programmed with the most up-to-date medical knowledge and guidelines, ensuring patients receive the best possible treatment.
• However, even with this advanced technology, some challenges would remain. Ethical considerations, such as who is responsible when an AI doctor makes a mistake, would still need to be addressed. Furthermore, while a holodeck AI doctor might be able to mimic human interactions, it may still lack genuine empathy and understanding -- and be no better than an android.
• In one episode of Star Trek (“Requiem for Methuselah”), attempts to instill emotions in an android (“Rayna,” played by Louise Sorel) overwhelmed her and caused her death. Future iterations of Star Trek, most notably Star Trek: Voyager, employed holographic representations of a doctor, to be used primarily in medical emergencies. The doctor is programmed to become more like people, but its attempts to build human experiences, attributes, senses, and feelings into the doctor’s subroutines are often disastrous.
• So, although the potential benefits of an AI doctor could be enormous, the concept should still emphasize that AI complements human healthcare professionals rather than replaces them. It is also essential to remember that the use of such technology should always be guided by the principles of medical ethics and the ultimate goal of improving patient care.
• Why is it important to mention that AI should be deployed for the betterment of healthcare? Because science fiction accounts tend to portray the nefarious side of AI (think: the medical thriller The Algorithm Will See You Now, by Jennifer Lycette, MD). And let’s not forget that Professor Moriarty actually seized control of The Enterprise and endangered the crew, demanding that Captain Picard find a way to transfer him into the real world.
• Until the benefits of AI are fully realized and portrayed in a less sinister or dystopian light – which can contribute to public fear and misunderstanding – we should probably close the holodeck.
• (June 18, 2024)
• 48. How Should Unethical Legacies in Medical History Be Handled?
• Reexamining legacy and revoking reverence help restore medical integrity.
• In 2021, Congress ordered the Defense Department to look into renaming military bases, ships, and anything else that was named in honor of Confederate figures. The Naming Commission recommended changing the names of nine Army bases and Navy ships.
• Even more recently, my college dormitory at Boston University, Myles Standish Hall, was renamed “610 Beacon Street” – its physical address. Standish provided military muscle for the Pilgrims and notoriously ambushed and slaughtered Native Americans at a supposedly peaceful summit.
• In recent years, there has been a growing movement to reevaluate and often rename medical programs, buildings, statues, and other honors that bear the names of physicians and professionals whose past actions or beliefs are now considered unethical or harmful. This mirrors the broader societal shift towards acknowledging and rectifying practices considered racist, sexist, discriminatory, and dehumanizing.
• But is this trend justified? It can be difficult to draw the line between condemning unethical behavior and recognizing valuable contributions when looking back in time. Additionally, such actions could lead to a slippery slope where historical figures are judged solely by contemporary standards, potentially leading to the erasure of important aspects of history. Thus, some institutions have instead chosen to keep the names of certain individuals in question but add plaques or exhibits that provide a fuller context, acknowledging both their achievements and ethical failings.
• Let’s look at a few instances where a naming overhaul felt warranted to those in charge.
• One prominent example is the legacy of J. Marion Sims, MD, often referred to as the “Father of Modern Gynecology.” Sims developed pioneering surgical techniques in the 19th century, but his methods included performing experimental surgeries on enslaved African American women without anesthesia and without their consent. Such practices, viewed through the lens of contemporary ethical standards, are deeply troubling. As a result, a statue of Sims was removed from Central Park in New York City in 2018.
• Similarly, the name of Thomas Parran Jr., MD, a former Surgeon General, has come under scrutiny. Parran played a significant role in public health advancements, but he was the intellectual inspiration of the infamous Tuskegee Syphilis Study. Due to his involvement, the University of Pittsburgh renamed Parran Hall, which previously housed the Graduate School of Public Health. The American Sexually Transmitted Diseases Association (ASTDA) renamed the Thomas Parran Award as “The ASTDA Distinguished Career Award.”
• The legacy of Hans Asperger, MD, an Austrian pediatrician after whom Asperger syndrome was named, has also been reexamined. Recent historical research has uncovered Asperger’s complicity with Nazi eugenics policies, including his involvement in the euthanasia of disabled children. This has led to a reconsideration of the use of his name in medical diagnoses. The Diagnostic and S atistical Manual of Mental Disorders (DSM-5-TR) eliminated Asperger’s disorder, which is now subsumed under the general heading of autism spectrum disorder (refer to essay 18).
• Many other Nazi and Nazi-sympathizing physicians have been discredited and had their names removed from the medical lexicon and disorders that once bore their names:
• • Julius Hallervorden, Hallervorden-Spatz disease, neurodegeneration;
• • Hans Eppinger, Cauchois-Eppinger-Frugoni syndrome, portal vein thrombosis;
• • Hans-Joachim Scherer, van Bogaert-Scherer-Epstein disease;
• • Hans Seitelberger, Seitelberger disease, infantile neuroaxonal dystrophy;
• • Hans Scherer, van Bogaert-Scherer-Epstein syndrome, cerebrotendinous xanthomatosis;
• • Eduard Pernkopf, seven-volume anatomical atlas;
• • Friedrich Wegener, Wegener syndrome;
• • Hans Reiter, Reiter syndrome, reactive arthritis
• Some esteemed physicians have had their names removed from a plaque or edifice. Joseph DeJarnette, MD, had his name taken off a Virginia mental health facility in 2001 after it was discovered he had championed Nazi eugenics policies and supported increased sterilization efforts in the U.S.
• More recently, the “Father of Space Medicine” fell to earth when allegations of the involvement of Hubertus Strughold, MD, in Nazi concentration camp medical experiments earned greater credibility. The controversy caused the Space Medicine Association to end the annual presentation of an award given in Strughold’s honor. His name was dropped from a plaque on a building façade, a d his portrait was removed from a gallery at Ohio State University.
• These efforts are part of a broader movement within the medical community and society at large to critically assess the legacies of historical figures whose contributions to science and medicine are overshadowed by their unethical actions or beliefs. Renaming programs, buildings, and statues is seen not only as a way to rectify past wrongs, but also as a means to ensure that the names honored in public spaces reflect values of equity, justice, and respect for all individuals.
• Promoting moral standards is the key outcome of this process. Reexamining legacy helps identify practices and individuals whose actions may not meet today’s ethical standards, encouraging a shift towards honoring those who have made positive contributions without ethical compromises. By revoking reverence for those whose actions are deemed unethical by modern standards, the medical community reinforces the importance of integrity and ethical behavior within the profession.
• Fostering diversity, equity, and inclusion is also achieved through this critical reassessment. Reexamining legacy allows for he recognition of previously overlooked contributions from diverse and marginalized groups, promoting a more inclusive and accurate historical narrative. Addressing and correcting past biases through revoking reverence helps create a more equitable environment that respects the contributions of all individuals, regardless of their background.
• The educational impact of this process is significant. Reexamining legacy – and providing context for various acts of renaming – provides an opportunity to educate current and future medical professionals about the complexities of medical history, including both its achievements and ethical failings. Revoking reverence works to incorporate ethics in medical school curricula.
• Restoring public trust is another vital benefit of reexamining legacy and revoking reverence. Transparent reassessment of historical figures and practices builds public confidence in the medical profession’s commitment to ethical standards. By taking a stand against unethical behavior, the medical community can demonstrate that the profession holds itself accountable to the highest standards.
• While prominent figures may have made significant contributions to the medical field, their actions and beliefs must be scruti ized in light of their impacts on vulnerable populations. By reexamining legacy, revoking reverence, and instituting corrective measures, the medical community can uphold its commitments to equity and ethical inquiry.
• (August 24, 2024)
• 49. I Was Quietly Fired Even Though I Complied
• Don’t expect to work much longer after you are shunned by your employer.
• Less than a year into a new job as medical director at a health insurance company, it surfaced that I had retained a small percentage of ownership in my former group practice. I never disclosed it to the company, and quite frankly, I didn’t think it was necessary. However, in order to remain employed, I was required to sell my stake in the practice. The CEO informed me that he was being “kind” by letting me stay with the organization, and that undeclared conflicts of interest such as mine were grounds for immediate termination, as I might preferentially steer patients to that practice over others, and I stood to profit from that arrangement.
• I divested my portion of the practice, but due to my initial lack of compliance (failure to report the conflict), I was quietly fired – allowed to stay with the company but demoted in position and moved to a basement office in a satellite location. Essentially, I was managed out, and I left the organization not long afterward.
• “Quiet firing” refers to a situation where an employer subtly pushes an employee to resign rather than directly terminating their employment. This can be achieved through various means, such as gradually stripping away significant duties and responsibilities, excluding the employee from important meetings, projects, or decision-making processes, providing consistently negative feedback without basis or constructive criticism, denying promotions, raises, or professional development opportunities, assigning tasks that are excessively difficult or impossible to complete within given deadlines, and creating a work environment that is uncomfortable or hostile, making the employee feel unwelcome.
• Physicians might be quietly fired due to failure to meet evolving productivity targets, disagreements with administrative decisions, or persistent clashes with colleagues or superiors. Furthermore, changes in hospital policies, restructuring, or a shift toward more profitable specialties can result in decreased support, undesirable shifts, or reduced responsibilities, making the work environment untenable for the physician. This approach allows institutions to avoid potential legal disputes and public backlash while gradually encouraging the physician to leave voluntarily.
• A quiet firing can have significant professional and personal implications. Physicians may find it challenging to secure new positions if they leave their current role under such circumstances. Negative performance reviews and lack of recent achievements can impact their professional reputation. A physician experiencing quiet firing might be distracted or demoralized, which could negatively affect their ability to provide high-quality patient care. 
• The stress and uncertainty associated with quiet firing can lead to burnout, anxiety, and other mental health issues. Additionally, physicians need to ensure they are complying with medical and ethical standards despite the difficult work environment. Quiet firing tactics could indirectly pressure them to compromise on these standards. Being quietly fired can strain relationships with colleagues and patients, which are crucial for successful medical practice.
• One physician described his quiet firing this way: “…often subtle but firm pressure, manipulative changes, and general discomfort designed to make you want to leave. It is a cold, calculating, passive-aggressive business approach to help guide a person away from continued employment. At first, you may think it is a small event that you simply overlooked, but those events quickly add up and escalate. Your work is never good enough, your approach is overlooked, you might even be ignored, and over time you wonder how you could even improve. Could this truly be your problem, or is something else at play here? Eventually, time, examples, and intuition tell you something is not right.”
• Physicians who feel they are being quietly fired can take several steps to address the situation. They should keep detailed records of changes in responsibilities, performance reviews, and any communication that might indicate quiet firing. Attempting to have open and honest conversations with supervisors or HR about their concerns and seeking feedback is important. Engaging with professional organizations, mentors, or legal counsel can help them understand their rights and options. 
• I never sought legal advice on the matter, but my research has led me to believe that there is no definitive answer to whether a physician employed by a health insurance company can retain partial ownership of an in-network group practice. I imagine I should have consulted a legal expert before starting the job to ensure I was in full compliance with all relevant laws and company policies. Better yet, I should have declared the conflict upfront whether or not I believed it was relevant. This is what virtually all corporate compliance officers will advise new or potential hires, and it would be prudent to seek out legal advice of your own if you suspect quiet firing.
• If you try to hang in there as you are being quietly fired, be prepared to be treated poorly while seeking affirmation and answers from colleagues. You must prioritize your mental and physical health, take a step back, and view the situation objectively. Would you advise a family member to keep enduring, taking punishment, and asking for more? Understanding the dynamics of quiet firing and its implications can help you navigate the situation more effectively by knowing when to leave and protecting your career and well-being.
• I knew it was time to leave within a few short months as my responsibilities gradually shifted and became mundane. My role was diminished and no longer aligned with my skills and interests. The isolation excluded me from important meetings and decisions. My efforts were being deliberately overlooked. I realized my professional development would be limited and there would be no opportunity for career advancement. 
• I looked for new employment, and I timed my exit with a new job, protecting my career by telling my new employer that my old job was no longer a good fit (refer to essay 19). I was careful about my language regarding my former company on the way out. I wasn’t worried about a relatively short stint appearing on my CV and what that might signal. The average medical director stays at their job for a few years, and physicians in full-time corporate practice also seem to change jobs quickly. In my experience – and I believe HR personnel would attest to this – the gold watch is a relic of the past.
• (October 14, 2024)
• Selected Essays: Writing and Reflection
• 50. Narrative Medicine Writing Saved My Sanity
• Take your writing to the next level in graduate school.
• Storytelling and writing saved my sanity during the coronavirus pandemic. The lockdown afforded me time to write and share sto ies about my life and career. I wasn’t writing my memoir as much as I was engaged in the practice of narrative medicine writing – penning stories about the meaning of illness and reflecting on memorable patients and their incredible experiences, as well as my own!
• As I began writing my stories, I discovered that the field of narrative medicine has been around for a long time. Rita Charon, MD, PhD, is widely credited as the originator, in an official sense. She inaugurated and teaches in the Master of Science in Narrative Medicine graduate program at Columbia University, where she received her PhD degree in English following her medical degree from Harvard. Charon is also co-author of Principles and Practice of Narrative Medicine and other scholarly works. In her seminal article on narrative medicine, published in JAMA in 2001, Charon wrote: “The effective practice of medicine requires nar ative competence, that is, the ability to acknowledge, absorb, interpret, and act on the stories and plights of others.”
• Storytelling and writing competencies are taken for granted. But the fact is that few narrative medicine writing programs actually incorporate writing skills as a program goal, including medical schools that have integrated medical humanities into their curricula, which now number well over 100 in the U.S. In one of the most comprehensive reviews of narrative medicine writing programs, the authors recommend expanding program objectives “to include the development of enhanced writing skills and self-efficacy related to the writing process as measurable learning outcomes.”
• Laura Roberts, MD, MA, chair of psychiatry at Stanford University and editor-in-chief of Academic Medicine, observed that many gifted physicians “...struggle when it comes to writing. They fret. They delay. They feel inadequate – even inauthentic. While these colleagues may view teaching and healing as natural capacities, they view writing as anything but.”
• Perhaps some physicians need tools to write creatively – tools that can only be obtained through formal education. In my own case, despite my penchant for writing, I realized I had virtually no formal education in writing and English literature. That’s why I decided to take a couple of a graduate-level courses in a narrative medicine writing program at a university (Lenoir-Rhyne, in North Carolina). Here are just a few of the courses that the university offered:
• “A study of readings by narratively trained practitioners as well as writing assignments that move practitioners beyond clinical knowledge into narrative knowledge. Through engagement with literature and writing, students develop comfort with the less-defined areas of care – the open spaces of provider-patient relationships where ethics, empathy, and the unknown hold more power han heart-rate and x-ray.”
• “A study of illness narratives in poetry, short fiction, creative nonfiction, and novels. Emphasis on close reading and developing narrative competency and empathy.”
• “A study of narratives by doctors and other care providers. Emphasis on reflective writing skills as students develop their ow narratives, addressing presence, complexity, paradox, fatigue, shame, love, listening, and other human facets of care.”
• One of the features of this program is that classes can be taken in any order. Each class is 3 credit hours given for 2 hours one evening per week. Courses are conducted remotely via zoom and can be spaced out over semesters. Individuals choosing a more formal course of study leading to a Master of Fine Arts (MFA) in creative writing need to accumulate 45 credit hours (a total of 15 three-credit courses), which usually takes several years to complete.
• There are many enticing “supportive” workshops conducted at this university and courses designed to identify and apply rhetorical theory to various writing genres including poetry and fiction. However, at a cost of $690 per credit hour (in 2024) – or a minimum of $2,070 per course – one has to choose wisely should they decide to pursue training beyond a few courses.
• I was impressed that at least one physician, a cardiothoracic surgeon, decided to take the plunge and shell out over $30,000 for an MFA degree. He was asked: “Why did you decide to pursue a master’s degree in writing?” The physician responded, “Writing has helped me in more ways than I can count. I host a monthly Narrative Healthcare Seminar at our hospital, which is very gratifying. I also think writing is an excellent way for physicians like myself to prevent burnout and to focus on the deeper meaning of what we do and how we can enhance care for our patients.” This physician has subsequently retired from practice and now markets himself as an author (six novels) and freelance writer on his LinkedIn profile.
• Indeed, the benefits touted by narrative medicine programs include enhancing narrative competence, communication, and empathy; detecting and mitigating burnout; fostering reflection with regard to professional identity formation; promoting team-building; and facilitating teaching competencies. Interacting with highly engaged students in the health professions and energetic teachers – most of whom are accomplished authors and writers in their own right – creates an esprit de corps, a passion for a life of impact. The learning environment becomes a stimulus for the narrative.
• My son is a writer and teaches creative writing at the college level. When he was in graduate school, one of his professors said, “The best advice I can give you is to write every day whether you feel like it or not.” The great science fiction writer Isaac Asimov was a compulsive writer. He said his idea of a good time was to go up to his attic and sit at his electric typewriter and bang away. Asimov reasoned: “If my doctor told me I only had 6 months to live, I wouldn’t brood. I’d type a little faster.”⤀
• (May 4, 2023)
• 51. On Juneteenth I Learned the Ugly Truth of My New Hometown. It Restored My Faith in Humanity.
• We can’t change history, but we can certainly learn from it.
• Most of the racially debated issues these days can be summed up by the terms “critical race theory” and “wokeism” – terms that have become the defining issues of our time even though half the people can’t explain them and the other half use them for political gain to dictate how history is taught, stripping it of any mention of slavery, racism, and LGBTQ+ people. So, I’d like to reframe the debate and ask whether there is a middle ground where we can reject racist hatred while attempting to understand it and teach the truth about past social injustices to present and future generations – to keep our children from hating our coun ry and each other.
• I thought this was a noble proposition given that my wife and I moved to a southern town and attended its celebration of Juneteenth, which brought the community together with arts, dance, music, spoken word and an educational panel discussion. I learned that our town, officially known as Indian Trail, takes its name from the city’s history as a trade route that connected Petersburg, Virginia, to the Waxhaw Indian settlement and nearby gold mining areas in North Carolina.
• There is also some debate whether Indian Trail is situated along the path referred to as the “Trail of Tears,” a network of routes used for the forced displacement of approximately 60,000 Native Americans from the southeast U.S. to present-day Oklahoma between 1830 and 1850. It didn’t strike me as a coincidence that my hometown would be named “Indian Trail” unless it was somehow part of the actual “Trail of Tears.”
• One of the likely routes comprising the “Trail of Tears” bisects Indian Trail and is now a major thoroughfare named “Independe ce Boulevard” – an incredible slight to the Cherokee Nation – over 5,000 of whom perished during their westward journey across the Mississippi River, many originating from North Carolina and buried in unmarked graves along the way. Even worse, Independence Boulevard is officially named Andrew Jackson Highway in homage to the seventh president of the U.S. who signed the Indian Removal Act into law and was a prominent slave trader considered by many to be an “ideal slave-owner.”
• Driving west on the “Highway” takes me to uptown Charlotte in about 20 minutes. In the same amount of time, heading east, I ca reach historic Monroe, North Carolina, a city marked by violence against the minority Black community during the civil rights movement years of the 1960s and where people still defend the display of the Confederate flag and monuments.
• As I learned about the dark history surrounding my newly adopted hometown I thought, “Who will make reparations for the Native Americans and African Americans so unfairly treated here over the past two centuries?” Although I have long known about injustices embedded in the fabric of our society, it was Juneteenth that crystalized the connection between racism and the medical proession – by heightening my awareness of the case for reparations in general, and the case for health reparations, in particular⤀
• While Juneteenth is widely observed as a celebration of Black American history and heritage, commemorating the emancipation of the last of enslaved African Americans on June 19, 1865, the holiday also highlights health impacts of structural racism – namely, the disparity in health care and health literacy access that continues to contribute to chronic disease, hospitalization and mortality among Black Americans. The toll that health inequity has taken on the African American community is extensive, as reflected in data compiled by the Centers for Disease Control and Prevention.
• Additional data presented by The Commonwealth Fund showed a surge in preventable deaths in every state in 2021, fueled mainly y COVID-19, with Black, Hispanic, and American Indian/Alaska Native people experiencing the highest mortality rates in many places. Researchers also noted that many Americans with mental health needs face barriers to obtaining care, and millions of people – particularly in the South – are wallowing in medical debt.
• I was saddened to learn that North Carolina does not have the best track record when it comes to healthy living: the state ranks 39th in the country for access to mental health treatment, and it ranks in the lower half of all states in overall health outcomes and healthy behaviors.
• Our town’s celebration of Juneteenth reminded me that health inequalities also extend to the LGBTQ+ community. Many LGBTQ+ individuals continue to face stigma and discrimination based on their sexual orientation, gender identity, or gender expression. As a result, research shows that the LGBTQ+ population struggles disproportionately with mental illness, substance use, and suicide.
• Medical bias and social stigma particularly towards transgender and gender diverse (TGD) people is widely prevalent in the U.S. The TGD community is faced with health disparities, discrimination, harassment, and lack of access to quality health care. Gender-affirming care should be regarded as health care that can reduce health disparities and save lives. This cannot be understated in light of the increasing violence against the LGBTQ+ community and LGBTQ+ people of color – particularly transgender people – who are disproportionately affected by hate crimes.
• Individuals and organizations that attempt to limit access to treatment or ban therapy intended to maintain the health and welare of marginalized groups – African Americans, Native Americans, Latinx, Native Hawaiians, Native Alaskans, LGBTQ+ and TGD – restrict their lives and freedoms. These groups must be stopped, along with their hate-fueled ideologies, until they learn to emrace the incredible diversity and heterogeneity of the U.S. population. To me, that is the essence of Juneteenth: a time to reflect on past racial injustices and rectify ongoing health inequities in wide swaths of the populace – and maybe, just maybe, help restore our faith in humanity.
• (July 14, 2023)
• 52. Discovering Self Through Creative Writing and Medicine
• On the road to explore all that the narrative has to offer.
• “The balance to fact and analysis is feeling,” our narrative medicine writing instructor informs us. “You’ll find that each poem and essay and story that you write reflects a new aspect of yourself. Be curious about what’s going on. Allow new poems onto the page. Allow free writing in prose and poetry. You have worlds inside you.”
• And then, predictably, the homework assignment for next week: “Create and post your ‘800 words.’ The word count is purely there to make writing into the void less intimidation. When we write, we open a portal to our inner life. Joseph Campbell calls it ‘following the echoes of the eloquence within.’ I love that. The challenge lies in trusting those echoes. It is related to trusting intuition. Allow. Allow. Allow. Trust. Trust. Trust. No matter how many classes I’ve taught, no matter how many poems I’ve written, no matter how many books I’ve read: Every single new thing is just that. A new field to move into within myself. I neve have any clue what I am doing.”
• Clueless. That’s me, too. I’m not good at this stream-of-consciousness thing. But I should be. After all, I am a psychiatrist. I’ve been at this for more than 40 years – listening to patients’ free associations and reflecting on my own in therapy. And trust. What’s that? Post-pandemic moral injury has all but obliterated trust.
• Nevertheless, I am eager to learn more about this free-form process of creative writing and narrative medicine and how to follow my “echoes.” So, I do what comes naturally to me: I research (Google) it. Except I’m told: “No results found for Joseph Campbell ‘following the echoes of the eloquence within.’” But Google tells me that Joseph Campbell encourages the audience to discover what excites them, and to make that the basis for their personal journeys. That sounds exactly like what our instructor was trying to tell us.
• I then stumble upon similar words of wisdom from Paul Simon. No one writes poems as creatively lyrical as Rhymin’ Simon. “I’m more interested in what I discover than what I invent,” Simon tells American Songwriter, discussing how he crafted “You Can Call Me Al.” Asked what the distinction is between discovery and invention, he explains, “You just have no idea that that’s a thought that you had; it surprises you; it can make me laugh or make me emotional. When it happens and I’m the audience and I react, I have faith in that because I’m already reacting. I don’t have to question it. I’ve already been the audience. But if I make i up, knowing where it’s going, it’s not as much fun. It may be just as good, but it’s more fun to discover it.”
• So that’s the key to creative writing! Follow the yellow brick road, the one paved with dreams and aspirations, hopes and failures, love and kindness, betrayal and refuge, levity as well as gravitas. It’s a long and winding road to be sure, maybe one with no terminus, or maybe one that, as our instructor imagines, “lies beyond, within and woven through the anatomy and physiology of life,” adding: “In the words of Dr. Chris Adrian of the Columbia University Narrative Medicine Program, ‘Narrative Medicine begins where medicine ends.’”
• Now I am really curious. I follow this thread further in my research. I become immersed in discovery much like Paul Simon. Hell. I am Paul Simon. I am on a father and son journey to Graceland. Simon tells American Songwriter: “The song [Graceland] started to write itself. It became a narrative … and Graceland became more like a metaphor than an actual destination.”
• I begin to travel along this metaphorical path. It is a path familiar to purists in the field of literary medicine, those who distinguish between “narrative medicine” and “narrative practice.” Following Simon, I, too, begin to see “angels in the architecture.” They’re “spinning in infinity.” Hallelujah!
• There’s one stop remaining on my journey. I am at the doorstep of Cat “Yusuf” Stevens, who, like Simon, has set out on a voyage of self-discovery, to clear his mind and see what he can uncover “On the Road to Find Out.” Stevens was not writing about traveling in a literal sense but instead bent on finding out who he was and the purpose, if any, of his existence. The last couplet of the song is revelatory:
• “The answer lies within, so why not take a look now?Kick out the Devil’s sin, pick up, pick up a good book now.”
• Narrative medicine does indeed involve close reading. It is the discipline of inspection, introspection, and telling stories aout illness – “honoring” the sick and suffering – from multiple perspectives: literary studies, film theory, philosophy, anthropology, and social sciences. Narrative practice, on the other hand, encompasses various forms of training that aim to apply nar ative ideas and skills to clinical conversations. Putting words on paper is an extension of narrative practice, one that aims to develop narrative practitioners rather than practitioners who have undertaken narrative studies.
• I clearly aim to be both – a student of the narrative as well as a practitioner – as I travel on the road to discovery. It’s a road that leads to the creation of meaning and understanding. It’s a road to rejoicing and redeeming. It’s a road that represents the coming together of cultures and genres in a place where everyone is welcome. Or, as my instructor tells our class, “You are all welcome here, and all of you is welcome.”
• This is my pilgrimage. Welcome me. Join me.
• (September 3, 2023)
• 53. A Season of Emotions: Spring, Trauma and Healing
• Reconciling conflicting emotions is a complex, deeply personal process.
• Spring is an interesting time of the year for me. April 15 may actually be my favorite day, but certainly not because income taxes are due. My dad was born on April 15, but that’s not the reason either.
• Let me set the scene. I lived in a beautiful home in a wooded area outside Philadelphia for 10 years. The area is known as the Brandywine Valley. It’s the site of the Battle of Brandywine (September 11, 1777), the bloodiest and deadliest of skirmishes during the Revolutionary War. The Brandywine Valley is also home to individuals with impeccable lineage: the famous DuPont (chemicals) and Wyeth (painting) families. (Allow me the vicarious pleasure of sharing the splendid tapestry and cultural heritage of this historical region.)
• Our modest one-acre home had a koi pond out front. A small bridge spanned the pond and served as a walkway connecting the fron yard to the front door. The koi hibernated at the bottom of the pond during the cold months of December through March. An expert told me not to feed the fish during wintertime, because their metabolism was so slow that they would “implode” if they ate.
• Come April 15, however, after several months of hibernation, with spring on the horizon and nature beginning to bloom, the koi were ready to surface and eat. I would stand at the apex of the bridge and dangle food pellets in their line of view. Conditioning would bring them to the pond’s surface. The fish opened their mouths, waiting – no, begging – for me to drop the pellets in the water. They devoured the food. Once again it was possible to begin my ritual of daily feedings from the bridge.
• Life seems to start anew each spring. It holds tremendous symbolism for renewal and regrowth. I’m reminded of the classic 1949 movie It Happens Every Spring. The movie is about a chemist-turned-baseball pitcher who invents a compound that, when applied to the baseball, repels wood, so bats can’t hit it. Thus, the pitcher is able to strike out every batter. However, he is unable o manufacture the secret sauce just when he needs it the most: during the World Series. The pitcher must rely on his own skills to win the game. And of course, he does win!
• My favorite baseball movie is The Field of Dreams. I used to watch it every spring with my son. We are geographically distanced now, but we reenact some of our favorite scenes on the phone at the beginning of spring training. The Field of Dreams is the ultimate father and son bonding movie, in my opinion. Neither of us refrains from crying at the end, when the son (Kevin Costner) asks his dad if he wants to have a catch (refer to essay 36). Such is a time-honored tradition between a father and a son, and Lord knows, my son and I have had many catches
• Springtime isn’t all roses. The psychological trauma I related in the Prologue happened in the month of April (in 1981): a ma nearly jumped to his death. I have carried this burden throughout my career. When I decided to “come out” and write about the incident in 2014, my article was warmly received. Several doctors wrote to me describing similar fates and circumstances related to medical errors falsely attributed to them.
• An obstetrician-gynecologist wrote: “I, too, have a memorable patient I never saw when I was in training, and I continue to feel waves of shame and sadness over the outcome which might have been prevented if I had not gone back to sleep when the resident assured me that it was not necessary for me to see the patient.”
• A colleague confided that when he was a resident and moonlighting at a mental health crisis center, he evaluated and discharged a man who went home and killed his partner. The homicide was covered by the local newspaper and television stations. My colleague escaped mention, but he was crushed by the ordeal, plagued by intrusive memories and disturbed sleep for months afterward – signs and symptoms typical of PTSD.
• One physician who wrote to me recalled how he was traumatized by a malpractice lawsuit and further traumatized when his attorney pressured him to settle it. Failing to “get his day in court,” where he was certain he would be vindicated, significantly contributed to his PTSD and “emotional inability to stay in practice.”
• The groundbreaking 1999 Institute of Medicine (IOM) report said To Err is Human. The report stressed that systems are more of en at fault than individuals when it comes to medical error. I felt somewhat vindicated. But the IOM report also estimated that nearly 100,000 Americans die each year due to medical errors, which certainly grabbed the attention of the media. A more contemporary analysis by the noted physician Danielle Ofri, author of When We Do Harm: A Doctor Confronts Medical Error, indicated that the IOM account was grossly exaggerated, although she conceded that much work needs to be done to prevent medical errors. Scapegoating doctors and torturing them with malpractice suits is not in anyone’s best interest.
• For obvious reasons, then, spring engenders a range of emotions in me, often extreme. In one moment, I am recalling with delight the annual spring feeding of the koi. For no rhyme or reason, dark clouds roll in and cast shadows on my trauma, reminding me of the “jumper” and leaving me unsettled by the memories of the season. Then my thoughts turn to my father – mostly positive, ut some negative. Thank goodness for the uplifting Field of Dreams.
• John Fox, in Poetic Medicine, affirms the therapeutic benefits of writing about difficult personal problems and struggles. He states: “Whatever form of therapy fits your particular temperament, externalizing your experience by creatively expressing it on paper, and if possible sharing it with someone special who listens well, is a way to state how things are, release old hurts, set healthy directions and develop potentials that make destructive past behavior or experience more a thing of the past.”
• The second chapter of Poetic Medicine is titled “The Same River Twice.” It’s a reference to Heraclitus, a Greek philosopher bo n in 544 BC, who said: “No man ever steps in the same river twice, for it’s not the same river and he’s not the same man.” Every day, people change because they have new experiences that shape them. They encounter new people who influence them. People (myself included) read books, take courses, and travel to new places – all of which change them and encourage them to open up and be more comfortable in their own skin. You cannot step into the same river twice, because both the individual and the river are constantly changing and interfacing in different ways.
• They say spring showers bring May flowers. I’m thankful when fall and football season arrive.
• (September 9, 2023)
• 54. Man’s Search for Meaning is Spiritual, and Relevant to Medicine
• Viktor Frankl epitomizes the spiritual and psychological dimensions of healing.
• Viktor Frankl’s Holocaust memoir Man’s Search for Meaning is an extraordinary essay on resilience and spirituality, a reminder that human life, under any circumstances, never ceases to have meaning. At the risk of mentioning Bob Dylan in the same sentence as Viktor Frankl, it was Dylan who said: “When you ain’t got nothing, you got nothing to lose.” I suppose Bob Dylan read Frankl’s book too, ranked by the Library of Congress as “one of the ten most influential books in America.”
• Man’s Search for Meaning is as much about hope as it is about loss. “Whoever was still alive had reason for hope,” Frankl told his comrades in the concentration camp. They could hope for health, family, happiness, fortune, and a return to their occupation and position in society. “After all, we still had our bones intact,” Frankl reasoned. Clearly, he set the bar low.
• Anyone searching for a meaning to their life will be disappointed if they think they will have it after reading Frankl’s book. Frankl specifically writes that the meaning of life cannot be defined in a general way, because it “differ[s] from man to man, and from moment to moment.” Nor can the meaning of life be answered by “sweeping statements.” A person’s unique opportunity – the reason for their existence – lies in the way in which they bear their burden. Indeed, the words over the entrance gate to Auschwitz concentration camp – Arbeit Macht Frei – meant: “Work Sets You Free.” Even under the most difficult circumstances such as forced labor, Frankl would have seen a deeper meaning to it.
• Frankl was of the persuasion that “it did not matter what we expected from life, but rather what life expected of us.” Individuals content with the life they lead and forgiving of their own flaws may not be able to learn much from Man’s Search for Meaning, for Frankl would have us believe that it is important to overcome adversity and hardship to derive meaning in life. Frankl speaks not only of hard labor and the day-to-day unknowing of whether one would be executed or gassed, but also the ability to withstand the brutal pain of disease and famine. Common among the prisoners were malnutrition, severe vitamin deficiencies, lice infestations, frostbite and typhus outbreaks.
• Epidemic typhus is caused by a bacterium (Rickettsia prowazekii) spread to people through contact with infected body lice. Though epidemic typhus was responsible for millions of deaths in previous centuries, it is now considered a rare disease. Occasionally, cases continue to occur, in areas where extreme overcrowding is common and body lice can travel from one person to anothe .
• The concentration camps were a different story; they were fertile ground for the spread of typhus. The exact number of prisone s who contracted typhus cannot be determined, but the number has been estimated at well over 100,000. Frankl became infected with typhus and almost died. The first symptoms, visible several days after infection, were high fever and a rash. Next came damage to the central nervous and circulatory systems, including delirium and myocarditis.
• Effective treatment with antibiotics was not available during World War II, and a lack of nutrition made it harder for a priso er’s immune system to fight off disease. Mass selection of infected prisoners for the gas chambers was a common method of “prevention.” Recovery without treatment occurred after about four weeks for the lucky few, although to be sure, many did not consider themselves lucky to survive the ordeal, believing they would be better off dead.
• One has to wonder how those who were not killed straight on arrival at the camps and were instead condemned to unimaginable to ment – both physical and psychological – as well as to a sense of constant insecurity about their future, starvation, labor beyond their capacity, and to life in utterly unsanitary conditions that fostered the spread of numerous infectious diseases (not only typhus), managed to survive. On this point, Frankl quotes Nietzsche – “He who has a why to live for can bear with any how” – and concludes that “only the men who allowed their hold on their moral and spiritual selves to subside eventually fell victim to the camp’s degenerating influences.” However, not many were capable of reaching great spiritual heights, which Frankl conceded was man’s meaning in life even if spirituality was experienced differently by each person.
• There is a parallel between Frankl’s world and the medical arena, where patients have survived grave medical illnesses associa ed with grim prognoses. Research has shown that spirituality often provides a coping mechanism for individuals facing severe illnesses. Conversely, a decline in spirituality seems to be associated with potentially negative health effects.
• For example, a spiritual life can offer comfort, improve resilience, and provide a sense of purpose, which may enhance the ove all quality of life and even positively influence survival rates. Spirituality can influence health behaviors like adherence to medication, diet, and exercise regimens, which can significantly affect the outcomes of patients with grave illnesses.
• Patients who engage in spiritual practices may experience less anxiety, depression, and stress, which can positively affect their overall health status and potentially their prognosis. Some studies suggest a potential link between spirituality and the immune system. Patients with strong spiritual beliefs may experience less inflammation and improved immune response, which could potentially impact their ability to combat serious illnesses.
• As a physician and psychiatrist, Frankl was keenly aware of the impact of the prisoners’ physical and mental states on their survival: they were highly correlated. In other words, prisoners who were better able to withstand the mental and physical torture were more likely to survive partly due to a healthier immune system and fewer depressive and suicidal thoughts. In this context, it is worth noting that spirituality can also play a crucial role in end-of-life care, influencing decisions about treatments and interventions (refer to essay 46). It can lead to better patient satisfaction and potentially improved survival rates.
• It is also important to note that while these correlations exist, the relationship between spirituality and health is complex and influenced by a variety of factors. More research is needed to fully understand the mechanisms behind these associations, including the roles of individual belief systems, cultural contexts, social support networks, and psychological resilience, all o which can contribute to the diverse ways spirituality impacts health outcomes.
• Meanwhile, why not make Man’s Search for Meaning required reading for all healthcare practitioners?
• (September 14, 2023)
• 55. Transitioning From Academic Writing to The Narrative
• An alternative writing style can give a voice to our patients’ stories.
• “How should I write?” I asked a mentor when I was a medical resident. He replied, “Art, just write what you want to say.” Indeed, a fellow student in my narrative medicine writing class reminded me that the definition of a writer is “someone who writes.”⤀
• Still, there has been a slight hitch: I wasn’t trained in the narrative. My mentor was a well-published physician researcher t ained in the scientific method, and that’s how I learned to write – scientifically and technically, without jargon, adhering to the no nonsense “instructions for authors” in the likes of JAMA and its sister specialty journals. (To their credit, JAMA and other major medical journals now consider narratives and poetry for publication.)
• Academic writing primarily focuses on the objective presentation of facts and data in a structured, formal manner. Its emphasis on empirical evidence, research, and statistical data is often used to advance medical science and share new knowledge. It involves a clear, concise, and formal style of writing that adheres strictly to specific formats and standards. The language is technical, the tone is impersonal, the expectation is precision and accuracy, and the primary goal is to inform, educate, and persuade based on facts and figures.
• In contrast, narrative medicine writing is a form of reflective writing that centers on the experiences of patients and clinicians. It utilizes storytelling to explore the emotional, psychological, and social aspects of healthcare. The language is more personal, descriptive, and emotive, focusing on the human experience rather than just the clinical facts. The goal is to foster empathy, compassion, and a deeper understanding of the patient’s perspective, thereby enhancing patient care and the overall healthcare experience.
• Doctors often find their inspiration in narrative medicine because the discipline guides them in the art of empathic listening and allows them to be more responsive to their patients’ needs. Medical training has the opposite effect. Openness and beneficence are suppressed by conditioning, forcing students to sacrifice compassion in the name of intellectual clarity. Declaring tha physicians must remain dispassionate and detached from their emotions to ensure patient care is anathema to narrative practice.
• I have had to unlearn the academic way of thinking and writing to write narratively. How am I finding my writer’s voice? Or, to paraphrase John Fox, the author of Poetic Medicine, am I finding yeast in my words so that my prose will become like “fresh bread on the table,” leavened with experience, resilience, and intuitive understanding? I’ll answer in a moment, but first let me tell you about Fox, whom I mentioned in essay 53.
• Fox is an educator and a certified poetry therapist who believes he has been “called” to poetry as a form of healing. He claims that poetry is a “natural medicine.” Fox likes the feelings-oriented, non-linear logic of poetry because it allows for paradox and even celebrates it. After all, isn’t the presence of paradox ubiquitous in medicine: joy and woe; pain and comfort; sadness and exaltation?
• Unfortunately, the poetry of my youth has left a sour taste that I cannot cleanse. In the preface to Fox’s book, the New York Times best-selling physician author Rachel Naomi Remen, MD, observes: “Much of the old poetry was pretentious and erudite, full of references to mythology or the ancient Greeks, poetry whose words I could not easily understand.” My sentiment exactly!
• I understand that modern poetry is different. Nevertheless, I have turned to other sources and forms of writing to help me unleash my inner self on paper, specifically to break free from an academic climate that is increasingly insular, and often reflects the narrow-minded vision of clinical investigators, grant-writers, and pseudo-scientific scholars. I am breaking free of those literary gatekeepers by reading essays written by physicians and non-physician authors from multicultural perspectives and backgrounds: Black, Latinx, Indigenous, Asian, Middle Eastern, LGBTQIA+ – or a combination of those identities – and by participating in writing exercises.
• The multicultural writers have reminded me that institutions, particularly academic centers with their strict rules, formats, and expectations, can feel stifling and limit individual expression, in essence impeding learning by teaching exclusively to scientific analyses and objective understandings, neglecting the creative, spiritual, and cognitive dimensions underlying practice.
• Stated differently by Kandace Creel Falcón, PhD, while pursuing her doctorate degree as a Xicana femme feminist: “The PhD track is supposed to discipline you. During my time as a graduate student the process tried to beat me out of my writing...Soon I could no longer recognize myself in my pages. I had been disciplined.” Falcón’s personal battle was to push against the forces of the academy that sought to minimize and invalidate her perspective. Her triumph over academic tyranny prevented her from becoming lost in her own stories.
• I, too, believe that breaking free of the academic gatekeepers is the first – and most important – step in bridging the gap be ween academic writing and narrative medicine writing. Once unchained, other steps considered prerequisite for narrative writing seem to quickly follow:
•  Adopting a mindset that values the patient’s story as much as the clinical data
•  Listening deeply and empathically to capture the nuances of the patient’s experiences
•  Weaving the patients’ experiences – hope, fears, emotions, and aspirations – into a coherent, engaging narrative that captures the reader’s attention and evokes empathy
•  Employing narrative techniques such as scene-setting, character development, and plot construction
•  Using language that is accessible and relatable to a broad audience
• The transition from academic writing to narrative medicine writing is a challenging but rewarding journey that requires a fundamental change in mindset, approach, and style. Making the transition requires a commitment to use writing as a tool to enhance health care by finding a voice and giving voice to our patients’ stories.
• (September 19, 2023)
• 56. Why Aren’t You Writing?
• Expressive writing is an alchemical process, turning the lead of personal experience into the gold of insight and understanding.
• Sir Isaac Newton dedicated as much, if not more, of his time to the study of alchemy than he did to the natural order of the u iverse, but most of his work as an alchemist remained unpublished until long after his death when a metal chest full of his belongings was auctioned in 1936. The great man of science, the first of the Age of Reason, was simultaneously the last of the magicians.
• To think that Newton may have thought more about levity than gravity seems absurd. It also explains why he couldn’t or didn’t publish much of his research; he would have needed a different physics and a different calculus to explain his findings. His peers would have thought him crazy, as if the apple that befell him did some brain damage.
• Perhaps it is best that we keep some things to ourselves as personal secrets never to be shared, lest we are considered extremists, completely out of step with the times, or simply misunderstood. However, I suspect that the great majority of physicians have within them relevant literary contributions that they’ve been holding back, maybe written yet fearfully tucked away in a drawer.
• Most physicians keep their thoughts and stories to themselves. Doctors feel they may be judged or criticized for their writing. Some believe they lack sufficient talent to be writers, while others insist they don’t have the time to write. These are all excuses used by physicians who aspire to be narrative writers – excuses not to write. My advice to them is please do not let you great-great-great-grandchildren discover your unpublished ideas or manuscripts and sell them at auction. The time to write and publish is now. The question is: Why aren’t you writing?
• Sara Coffey, DO, is the author of Unpacked: A Psychiatrist Explores and Unpacks Our Collective Experience of the COVID-19 Pandemic. Writing, in particular, became a powerful tool for Coffey to process her thoughts and experiences during the pandemic, a way to heal and rejuvenate afterwards. “Despite the passage of time,” she writes, “the impact of those events lingers, urging us to confront them with curiosity, empathy, and a shared commitment.” How fitting that she was gifted a Smith-Corona typewriter as a birthday present and has spent countless hours crafting narrative.
• Writing is not rocket science. All of us have had to write narratives of some sort since grade school. Believe me, if I can do it, so can you. The reason I say this is because my fourth-grade writing assignment was to compose and illustrate a short fiction piece about Halloween. I remember writing about monsters and ghosts and clumsily outlining them and coloring them with crayo s. I wanted the piece to be scary, so I chose a cemetery as the backdrop (no surprise considering my essays in Section 1). The creatures were eyeing the candy of the trick-or-treaters in the cemetery – literally eying the candy. I drew them with big eyes, long before I became fascinated by psychiatry (schizophrenic patients will often draw eyes because they can constantly feel like they are being watched). My fatal flaw was not that the plot was ill-conceived – why should people be trick-or-treating in a cemetery? – or that my artistic ability was nil. Rather, in the story, I spelled the word “human being” incorrectly, writing “bean” instead of “being.”
• Now that word processing programs have spell check, spelling should not be a problem for anyone, although you still have to proofread your work because even in my example, “bean” may not have been detected as an improper spelling. Otherwise, the mechanics I aimed for in my fourth-grade story still apply: write to foster empathy and active listening and engage the audience in you narrative.
• Here are some other basic principles you should consider when incorporating narrative medicine writing into your daily practice.
• Pay attention to the patient’s story, not just their symptoms. This includes their emotional state, their living conditions and lived experiences, their fears, and their hopes.
• When taking patient histories, don’t begin with, “What brings you here today?” Instead, ask, “What do you think I should know about your condition (or situation)?” Delve deeper than just the medical facts. Ask about their personal lives, their experiences with their illness, and how it affects their daily routines.
• Keep a journal close by to write about your experiences (see essay 59) and those of your patients or give yourself prompts and reminders to reflect upon later. Ponder patient interactions, your decisions, and your emotions. This can help you process your experiences and gain insights.
• Read narratives and memoirs by other health care professionals. This can provide you with new perspectives and help you unders and the value of narrative medicine. Practice close reading, i.e., looking at both what the text says (its content) and how the text says what it says – through imagery, figurative language, motif, and so on.
• Consider participating in workshops or courses on narrative medicine (refer to essay 50). This can provide you with certain skills and knowledge to incorporate narrative medicine into your practice.
• Encourage your team to share their experiences and reflections. This can foster empathy, improve communication, and promote a etter understanding of patients.
• Encourage your patients to share their stories. This can be in the form of verbal narratives, written stories, or even art and music. This can help you understand their experience better and provide more personalized care.
• Narrative medicine is not just about storytelling. It’s about using narratives to improve health care delivery and promote healing. It requires practice and patience, but the rewards can be significant.
• One of the greatest compliments paid to me was by a prominent psychiatrist, and his remarks were about my writing. I had asked the psychiatrist to write the lead chapter for a book I was editing, and it was already under contract with a publisher. The psychiatrist was late in submitting his chapter, and on top of that, his manuscript was poorly written. I did a major revision of his chapter, staying true to his points but improving the flow, grammar, and syntax, and inserting scientific references to bolster its credibility.
• I mailed the new and improved manuscript to the psychiatrist for his approval. Several days later, he called me.
• “Art,” he said, “You’re an alchemist.”
• “How do you mean,” I asked.
• “You know how to turn shit into gold!”
• Newton may have been onto something after all.
• (October 16, 2023)
• 57. Kick Start Your Writing with a Surprise
• Our life’s journey is not always apparent, and neither is our written destination.
• One of the most memorable scenes in Goodfellas occurs early on, when the audience is introduced to most of the crew at the Bamoo Lounge. Henry Hill (the late Ray Liotta) and Tommy DeVito (Joe Pesci) get into a tense exchange. Tommy seems to get offended after Henry calls him funny. “I’m funny how,” Tommy wants to know? “I mean, funny like a clown? I amuse you? I make you laugh?”
• Unknown to the other actors, the scene was being improvised, although it was based on a true incident: A young Pesci in real life was a waiter at a restaurant and told a mobster that he was funny. Needless to say, the wise guy didn’t take this compliment too well. Director Martin Scorsese wanted the dialogue between Pesci and Liotta to be improvised because he wanted to capture he unrehearsed reactions of the supporting actors.
• Clearly, that is one way to make a story impactful: through improvisation and authentic dialogue, i.e., dialogue used to reveal character traits and advance the story. The fun in writing, many people say, is surprising yourself as you write. You begin with an idea, and simply start typing, not knowing exactly where you are going. You pause to reflect or daydream, and suddenly a memory or old lesson pops into your head. This moment of surprising yourself with your own thoughts can translate into words on a blank canvas, and it is at the heart of good writing and even songwriting.
• Paul Simon’s take on the element of surprise is covered in essay 52. The title of Simon’s eleventh studio solo album is, in fact, Surprise, and it features a baby’s face on the cover to illustrate the sense of wonder and new discovery found within songwriting and writing in general. Children surprise us all the time with their imagination and insight, challenging our own fixed assumptions and perceptions.
• In Poetic Medicine, John Fox observes: “The statement ‘I had no idea my child thought that way’ is exactly what many adults wa ted to hear from their own parents but didn’t.” If you’re someone who “didn’t hear it” from your parents, it’s not too late to unearth your creativity and incorporate the element of surprise in your writing, especially in health narratives, as you discover your true voice.
• We often think of “surprise” as a powerful tool to engage readers, keeping them interested, and making the narrative more memo able. But writing health narratives can be a surprising process for the writers themselves due to several reasons:
• 1. Unforeseen insights. While writing, physicians may discover new insights about a situation, condition, or patient that they hadn’t realized before. This could be a different perspective, a deeper understanding of a medical condition, or a newfound appreciation for a particular treatment approach.
• 2. Emotional discoveries. Health narratives often involve delving into deep emotional territories. As physicians explore these areas, they might surprise themselves with the depth of their own emotional responses, empathy, or resilience. Writing health narratives has been shown to help clinicians better appreciate the importance of the emotion and intersubjective relation borne of the telling of and listening to patients’ stories.
• 3. Unplanned directions. Sometimes, a narrative can take an unexpected turn as it develops. A physician might start with an idea or a plan, but as they delve deeper into the narrative, they find it evolving in ways they didn’t initially anticipate. My creative writing instructor told our class that narrative medicine writing “opens the conversation to magic,” meaning the creative direction and nature of the narrative can be limitless. Lewis Mehl-Madrona, MD, PhD, a name synonymous with the narrative medicine movement, observed that physicians may see themselves “as coauthors in the creation of new stories that have uncertain endings, at least while they are being written.”
• 4. Self-reflection. Writing health narratives can lead to significant self-reflection (refer to essay 52). Physicians may surprise themselves by uncovering personal biases, strengths, weaknesses, or beliefs that they weren’t previously aware of. Narrative medicine reflective writing has been used to help promote incorporation of diversity, equity, and inclusion training into medical school curricula.
• 5. New connections. As clinicians delve into the intricacies of health narratives, they might discover surprising connections etween disparate ideas, events, or facts. These connections can add depth and complexity to the narrative.
• 6. Therapeutic impact. Many physicians find the process of writing health narratives to be therapeutic. The act of writing can help them process their experiences, emotions, and thoughts, leading to surprising personal revelations or growth. Some physicians’ careers have been totally revitalized by writing real-life stories about the joys and challenges of practicing medicine in the modern era.
• 7. Enhanced skills. Through the process of writing and revising, physicians often surprise themselves with the improvement in heir writing skills, ability to articulate complex ideas, and capacity to engage readers in a meaningful way. Adopting narrative medicine as an intervention in medical education has played an important role in the professional identity development of medical students.
• 8. Patient outcomes. Writing about patients’ stories might lead to surprising revelations about patients’ resilience, their responses to treatment, or their coping mechanisms, which can add a new layer of understanding to the narrative.
• The element of surprise certainly factored into this essay. I had originally planned to write about rules for writing health narratives, such as “show, don’t tell,” first do background research, etc. I sat down with that blank canvas, began typing, and my 3-year-old grandson barged into the office and exclaimed, “Bops, how ‘ya doin’ man?” (“Bops” is a neologism for “Pops” and “Be-Bop”-style music.) His surprise attack, coupled with my thinking about the beauty and innocence of children, steered me in a different direction.
• “Kids do say the darndest things,” Art Linkletter used to say. Whenever I get stuck at writing, I begin to think like a child again to spur myself on. “It takes a long time to become young,” noted Pablo Picasso.
• (October 23, 2023)
• 58. The Real Story Behind Woodstock is Not the Brown Acid
• If you can remember the ‘60s, you weren’t there!
• In my search for ever-obscure rock music from my generation – not the greatest generation but the flower generation – I came across a CD collection of rare songs titled Brown Acid: The Seventeenth Trip, appropriately subtitled: “Heavy Rock from the Underground Comedown.” A review of the CD began as follows: “Lucky number 17? You better believe it. We here at Brown Acid have been scouring the highways and byways of America for even more hidden stashes of psych/garage/proto-punk madness from the so-called Aquarian Age. There’s no flower power here though – just acid casualties, rock stompers and major freakouts.”
• Psychedelia seems to be everywhere these days, especially in my field of psychiatry, where hallucinogens are front and center in psychiatric R&D, and there are now FDA-approved agents for depressive disorders (although they are quite expensive). Psychiatrists and other “helpers” (not necessarily healers) began dabbling with hallucinogenic drugs in the 1960s, lending their name in part to the “turn on, tune in, drop out” counterculture popularized by LSD guru Timothy Leary, a Harvard psychologist. Hallucinogens have been used for centuries for spiritual purposes, shamanism, and healing. We are now seeing a resurgence of interes in their therapeutic potential.
• Several studies have shown that hallucinogens, particularly psilocybin and LSD, may be effective in treating mental health disorders such as depression, anxiety, post-traumatic stress disorder (PTSD), and addiction. They appear to work by disrupting patterns of thought and allowing patients to have transformative experiences. Some hallucinogens may promote neuroplasticity, or the brain’s ability to form new connections and change its structure and function. This could potentially be harnessed for therapeutic benefits. For example, psilocybin, found in “magic mushrooms,” has been used in clinical trials to treat existential anxiety related to terminal illness. Patients have reported significant reductions in anxiety and depression, often after just one or two sessions.
• Other hallucinogens, like ketamine and its “sinister” enantiomer, S-ketamine, have shown promise in treating postpartum depression, treatment-resistant depression, and depression with suicidal ideation, sometimes providing relief from symptoms within hours of use. Ketamine exerts its activity on the brain primarily through its actions on the N-methyl-D-aspartate (NMDA) glutamate receptor (glutamate is the major excitatory neurotransmitter in the brain). NMDA receptor antagonism causes complex “downstream” effects and is believed to be the mechanism of action underlying the antidepressant effects of ketamine. However, multiple other NMDA receptor antagonists have failed to demonstrate antidepressant efficacy, suggesting additional neural pathways are involved.
• The future of psychedelic research was dealt its biggest setback in years in 2024 after the FDA declined to approve midomafetamine (MDMA, ecstasy)) for PTSD. The Psychopharmacologic Drugs Advisory Committee voted 9-2 that the available data failed to show MDMA was effective in treating patients with PTSD and 10-1 that its risks outweigh the benefits, even with a proposed risk evaluation and mitigation strategy (REMS). Also, there are few long-term studies on the safety and effectiveness of hallucinoge s. Many hallucinogens are classified as Schedule I drugs, meaning they are illegal and considered to have no medical value. This makes it difficult to conduct research and limits access to potential treatments. Although hallucinogens are generally not co sidered addictive, they can be misused. They can also potentially lead to dangerous behavior, particularly if used without medical supervision.
• Some people may have negative reactions to hallucinogens, including panic, paranoia, and psychosis. There is also the risk of riggering latent mental health problems. Due to their illegal status, there is no standardization or quality control for hallucinogens. This means that users can’t be certain of the strength or purity of what they’re taking.
• So, while hallucinogenic drugs may show promising therapeutic benefits, their limitations and potential risks should not be overlooked. More research is needed to fully understand their potential and to develop safe and effective treatment protocols.
• That’s the scientific overview. Here’s the mythical one.
• Those of us belonging to the “Woodstock Generation,” or those who were aware of this incredible hippie festival held for “three days of peace and music” in August 1969 on Max Yasgur’s dairy farm in upstate (Bethel) New York, may recall announcer Chip Monck’s cautionary words about the “brown acid”:
• “To get back to the warning that I’ve received, you might take it with however many grains of salt you wish, that the brown acid that is circulating around us is not specifically too good. It’s suggested that you do stay away from that. Of course, it’s your own trip, so be my guest. But be advised that there is a warning on that, OK?”
• This has to rank among the most magnificent public service announcements of all time. I’m not sure how accurate Monck’s warnings were, or what effect they had, but that is beside the point. Because, fast forward six decades, and it’s pretty clear that the acid is still floating around – in whatever form and color – and it’s finding a legitimate place in the armamentarium of psychiatric treatment.
• I did not attend Woodstock. I was entering my junior year in high school at the time, and too young to appreciate the significance of events that were about to unfold. (Could anyone really anticipate the magnitude of the event?) However, I have seen the full-length feature film a number of times, and I suppose that this counts me as an expert of sorts.
• Mike Greenblatt, author of Woodstock: Back to Yasgur’s Farm, wrote that when he returned home from the festival, his mother clutched him to her bosom and cried. “Since then,” he says, “I’ve done nothing my entire life but listen to music and tell people about it [Woodstock].”
• There were at least 400,000 other stories from those who made it to Woodstock, and millions more from people who wished they were there but never made it. Maya Angelou said: “There is no greater agony than bearing an untold story inside you.”
• The reason I wrote this piece was to let you know that the brown acid at Woodstock and the newfound popularity of psychedelic drugs in psychiatry are not the headlines. No, the reason I wrote this essay was to remind you that the real story behind Woodstock is the untold stories that never saw the light of day. Let’s not forget to pay tribute our patients by telling their stories and sharing ours with them.
• (November 5, 2023)
• 59. My Journey of Missed Journaling Opportunities in the World of Medicine
• Write about your experiences in real time; don’t reconstruct them from memory.
• Many writers – songwriters in particular – rarely go anywhere without a notebook. The jot down ideas and fragments of lyrics that later become songs, poems, and narratives. Bob Dylan, Bruce Springsteen, and the late Jim Morrison are prime examples. Morrison said, “I kept a lot of notebooks through high school and college, and then when I left school, for some dumb reason –maybe it was wise – I threw them all away. There’s nothing I can think of that I’d rather have in my possession right now than those two or three lost notebooks.”
• I regret not keeping a diary or journal to write about patient encounters and interactions with peers, residents and attendings, not to mention the sundry characters connected to the academic health center where I trained and practiced. Had I done that, I would have had a lot more material to write about, and my depictions of events probably would have been more accurate.
• With a world of rich clinical material in front of you, regardless where you practice, you will regret relying solely on your memory to write about patients and players you will meet along the way. The vignettes will seem fresher and will be more reliable when there is a permanent record of them, and your stories will be less affected by cognitive distortion wrought by time.
• But even without the benefit of prompts or a written record, my career memories are very good, and my reconstruction of events is probably not affected by the vagaries of memory that can plague some writers.
• I find myself gravitating toward short personal essays incorporating events that have special meaning to me and, I hope, to readers (hence, the reason for this book). I want these essays to have a moral or educational component to them, or at least a strong take-home message. My narratives could be considered memoir in that they often integrate material from an important time i my life. As I am typing this essay, for example, a memory from medical school erupts. Here is how the scene unfolds.
• I am a fourth-year medical student on a family medicine elective in a community hospital located in a predominantly Black neighborhood. I am seriously dating a girl – she becomes my wife – and I am beginning to wear men’s cologne. I am feeling good about life, making my mark (so I think), a survivor of my junior year of med school and cruising midway through my final year. I wa t people to notice me. I want to announce myself. I want to make a statement that I have “arrived.” I want people to know I will soon be a doctor. I want to wear cologne.
• It is lunchtime in the clinic. My attending has disappeared. I am finishing my charting. The only other person is an elderly Black woman from housekeeping doing some light dusting.
• Earlier in the morning, I open the exam room door to examine a young Black male. I do not remember his chief complaint, but I do remember that when I take out my pen flashlight to see if his pupils are equal and reactive, he grabs the pen and flips it around, to shine a light on me. He also reaches for my stethoscope, which is dangling around my neck. He wants to examine me.
• His affect is weird, and he brushes aside my questions. He isn’t acting right. Putting it all together, I suspect he is in the midst of a psychotic episode. I excuse myself and inform my attending what is happening. He trusts my judgment – after all, I have completed two psych rotations, and my attending knows that I am going into psychiatry. The young man is sent to the emergency department for further evaluation.
• Why do I tell this story? Why does the memory of the event suddenly occur in the fourth paragraph? I have told many stories about my medical training, but never this one. Perhaps the most important question is: is the story accurate?
• In Patricia Hampl’s book I Could Tell You Stories, one of her vignettes (“Memory and Imagination”) describes a scene from early childhood in which her father drops her off at her first piano lesson. After providing intricate details of the scene, Hampl reflects, “No memoirist writes for long without experiencing an unsettling disbelief about the reliability of memory, a hunch that memory is not, after all, just memory.” Upon reexamining her own account of the piano lesson, Hampl realizes that, although she tried to give a truthful version of the lesson, not all aspects of her story were accurate or even true. She would have wri ten it differently if she had to do it over.
• In narrative medicine, as with life, the truth of the events lies waiting in the details. I wonder how accurate are the details of my story, indeed all my stories? Was the stethoscope loose around my neck, or did I pull it from the pocket of my short white coat? Was it only the patients’ affect that was bizarre, or did I do a full mental status examination and there were other anormalities I have forgotten? Did my attending really trust my judgment (I would like to believe so), or did he do a cursory evaluation of the patient himself? I simply do not recall. And why, when I have retold some of my stories, have I repeated or written them slightly differently than before? Why does it matter?
• The answer is: the truth.
• There are very few rules when it comes to writing medical narratives. But one rule that cannot be broken is that narrative medicine writing must be truthful. It may not always be accurate, but any inaccuracies cannot alter the truth. Lee Gutkind, author of Keep it Real: Everything You Need to Know About Researching and Writing Creative Nonfiction, stands firm on this point: “The writer cannot embellish, condense, or otherwise manipulate characters or events in order to make a more compelling story…The writer of creative nonfiction is bound, by an implicit and sometimes explicit contract with the reader, to make sure that the architecture of his story is based on authentic and reasonably verifiable experience.”
• Hampl writes, “I did not choose to remember the piano lesson. The experience was simply there.” The same is true of my encounter with the patient: the memory merely trapsed forward, colored by my residual impression of it. But that’s the risk of writing personal narratives without the benefit of transcription or source material: they are prone to inaccuracies. And that’s why I wish I had kept a journal throughout my career – to rely less on my memory and more on a solid footing of events as they actually occurred.
• According to Hampl, minor inventions to preserve the story do not necessarily make one a liar; rather, the need to reconstruct pieces of history forces us to admit that “memory is not a warehouse of finished stories, not a gallery of framed pictures.”
• However, there is one thing I’ll say that I will always remember about that patient encounter, one undeniable, unshakable truth. The cleaning woman caught my gaze as I moved close to her. She smiled and said, “There’s nothing I like better than a sweet-smelling man.”
• (January 17, 2024)
• 60. The Power of Story
• Story is a key element of narrative medicine and patient-centered care.
• People love to hear a good story, and there’s no question that the fertile clinical life of a doctor can furnish an endless supply of them. But doctors tend to withhold telling stories to patients about themselves, especially about their childhood and upbringing. Such stories can help humanize physicians, making them more relatable and approachable. When we share personal anecdo es with our patients, it can build trust and strengthen the relationship by showing them we have relatable experiences and emotions – and that we are as fallible as anyone else. I’ve related a few of those kinds of stories in this book, but here’s one I’ve seldom told.
• I was around 5 years old. I was feeling a tender moment towards my mother. In Freudian theory, a tender moment between a young boy and his mother could be related to what Sigmund Freud described as the “Oedipus complex.” This concept suggests that during the phallic stage of psychosexual development (typically around ages 3 to 6), a child may experience feelings of attachment a d affection toward the opposite-sex parent and view the same-sex parent as a rival.
• In contemporary understanding, a tender moment between a child and their mother is generally seen as a natural expression of afection and attachment, reflecting a healthy parent-child relationship. Such moments are part of the normal developmental process where children form secure emotional bonds with their parents (or caregivers).
• In any case, with the intention to express love towards my mother, I walked a short distance to the neighborhood pharmacy. I skimmed through the array of greeting cards and chose the one with the most attractive cover – adorned with a floral arrangement. I handed it over the owner/pharmacist. He knew me and my family. He seemed startled.
• “Is everything alright,” he asked?
• I explained that the card was in appreciation for my mother, that I loved her. He seemed even more concerned. I handed over all the change in my pocket, unable to count money yet and not knowing that I was a few cents short. He accepted the change, and I walked home.
• I handed the card over to my mother. She was deeply touched. Tears welled in her eyes.
• “Are you okay, mom” I wanted to know.
• “Everything is fine, honey,” she replied.
• Years later, I came to realize that I had unintentionally bought a sympathy card. The pharmacist, concerned about the situatio , promptly called my mother after I left the store to ensure her well-being and inform her about the incident.
• Here’s a literary analysis of this charming story:
• 1. Symbolism of the Greeting Card: The choice of a sympathy card to express affection for my mother carries symbolic weight. I highlights the innocence and purity of my intention, despite the mismatch between the card’s intended purpose and my sentiment.
• 2. Character Development: My actions demonstrate their earnest desire to show love and appreciation for my mother, despite my young age and limited understanding of societal conventions. This highlights the innocence and sincerity of childhood gestures.
• 3. Irony and Humor: The irony of the situation, where I unknowingly select a sympathy card instead of a traditional greeting card, adds a layer of humor to the anecdote. It showcases the innocence and naivety of childhood, as well as the unpredictability of human interactions.
• 4. Themes of Love and Family: The anecdote explores themes of love, family bonds, and the innocence of childhood. It emphasizes the profound impact of simple gestures of affection, even when they may seem unconventional or unexpected.
• 5. Narrative Structure: The narrative structure, with my perspective as the focal point, allows readers to empathize with the innocence and sincerity of my actions. The gradual reveal of the misunderstanding adds suspense and emotional depth to the story.
• Overall, this nostalgic story beautifully captures the innocence, love, and humor inherent in childhood experiences, while also offering insights into the wonder of human emotions and interactions. Wouldn’t you consider sharing such a poignant and touching anecdote with a patient, perhaps to help them reflect on their own experiences with family relationships, feelings, or misunderstandings? The power of the story moves me to tears recollecting it (refer to essay 36).
• While stories are sometimes remembered and often forgotten, I’m quite convinced that their power lives on in our unconscious. I don’t think it’s coincidental that the first major piece of art I purchased for my wife was a lithograph of Marc Chagall’s “Lovers with Bouquet of Flowers.” The painting portrays two lovers entwined, floating in a dreamlike, colorful space. The vibrant colors and whimsical style give the painting an emotional intensity that can be interpreted as a passionate celebration of love. The bouquet of flowers held by the lovers could symbolize life, beauty, and the ephemeral nature of human emotions.
• In the context of Chagall’s personal history, having lived through World War I, the Russian Revolution, and World War II, the painting can also be seen as a commanding testament to the enduring nature of love and beauty amid turmoil and change.
• “Lovers with Bouquet of Flowers,” much like numerous other pieces by Chagall, evokes the essence of a gorgeously narrated, wis ful tale.
• (February 20, 2024)
• Afterword Live Longer, Die Shorter: The Surprising Health Secrets to a Vital Old Age
• Over a decade ago, a landmark ten-year study by the MacArthur Foundation shattered the stereotypes of aging as a process of slow, genetically determined decline. Researchers found that 70 percent of physical aging and about 50% of mental aging are determined by lifestyle and the choices we make every day. Additional research showed that people who live longer often experience shorter periods of decline before death, a phenomenon sometimes referred to as “compression of morbidity.” That means that if we optimize healthy lifestyles, we can “live longer and die shorter,” i.e., condense the decline period into the very end of a fulfilling, active old age.
• Some studies do not support compression of morbidity when morbidity is defined as a major disease and mobility functioning loss. However, whether or not the concept is valid, no one can argue that living longer and dying shorter emphasizes the goal of maintaining good health and quality of life for as long as possible in order to minimize prolonged suffering or chronic illness. Living long and dying short is a concept that underscores the importance of not only extending one’s lifespan but also ensuring that the years lived are marked by health and vitality with minimal burden placed upon loved ones. Achieving this ideal involves an approach that encompasses physical, mental, and emotional well-being.
• Understand that maintaining physical health is paramount. This involves regular exercise, which helps in managing weight, improving cardiovascular health, and boosting overall energy levels. A balanced diet rich in fruits, vegetables, whole grains, and lean proteins provides the necessary nutrients for the body to function optimally. Regular medical check-ups and screenings are essential to detect and address potential health issues early, preventing them from developing into more serious conditions. Additionally, avoiding harmful habits such as smoking and excessive alcohol consumption can significantly reduce the risk of chronic diseases.
• Mental health is equally important in the quest to live long and die short. Engaging in activities that stimulate the mind, such as reading, puzzles, or learning new skills, can help maintain cognitive function. Social connections play a crucial role in mental well-being; maintaining strong relationships with family, friends, and community can provide emotional support and reduce feelings of loneliness and depression. Stress management techniques, such as mindfulness, meditation, and yoga, can also help in maintaining mental equilibrium.
• Emotional well-being is another critical component. Finding purpose and meaning in life, whether through work, hobbies, or volunteering, can provide a sense of fulfillment and satisfaction. Practicing gratitude and maintaining a positive outlook can enhance emotional resilience, helping individuals to cope better with life’s challenges. It is also important to seek help when needed, whether through therapy, counseling, or support groups, to address emotional issues and maintain overall well-being. Reaching the “integrity versus despair” stage of life (>65 years in Erikson’s schema) means you have resolved the key conflict of questioning whether or not you have led a meaningful, satisfying life.
• Lastly, adopting a proactive approach to aging can help ensure that the later years are lived with quality. This might involve making necessary adjustments to living environments to ensure safety and accessibility, staying engaged in social and community activities, and continuing to pursue passions and interests. By focusing on preventive care and maintaining a healthy lifestyle, individuals can reduce the duration and severity of decline at the end of life.
• Living long and dying short is about more than just adding years to life; it’s about adding life to years. Through a combination of physical health, mental stimulation, emotional well-being, and proactive aging, individuals can strive to live vibrant, fulfilling lives, minimizing the period of decline and ensuring a dignified end without burdening families.
• Here are a few pointers health care practitioners can discuss with their patients:
•  Recognize just how expensive the unplanned alternative is, i.e., reactive, after-the-fact, aging at home.
•  Empower older adults to take charge of their health and proactively manage their chronic conditions before they’re in need o round-the-clock care. Engage those who express disinterest in routine care and medical exams.
•  Offer alternative viewpoints to fatalistic attitudes and perceptions that view declining health is an inevitable part of agi g.
•  Educate older adults who might feel overwhelmed by the complexity of modern health care, preferring to rely on familiar, albeit outdated, practices.
•  Highlight success stories of older adults who have benefited from proactive health measures; and realling messages from essay 7:
•  Encourage people in their 40s, 50s, and 60s to adopt healthy lifestyles that will allow them to avoid or at least delay loss of mobility or cognitive function.
•  Remind patients that what we used to think of as diseases of aging, such as high blood pressure, atherosclerosis, heart attacks, and cancer, we now see in much younger people.
• If we take the right steps, many more Baby Boomers and Gen-Xers will have the opportunity to “live long and die short.” More older adults will have the opportunity to age gracefully and die with dignity rather than spend 10 or 15 years of progressive, debilitating, and costly decline. Older adults need to become more proactive in planning for their future. They need to seize the opportunity now.
• (October 17, 2024)
• Notes and Sources
• Prologue
• 1. JAMA letter: https://jamanetwork.com/journals/jama/fullarticle/1031781
• Essay 1
• 1. Commonwealth Fund report: https://www.commonwealthfund.org/publications/fund-reports/2024/sep/mirror-mirror-2024
• Essay 2
• 1. Malpractice award: https://www.washingtonpost.com/local/anesthesiologist-trashes-sedated-patient-jury-orders-her-to-pay-50000/2015/06/23/cae05c00-18f3-11e5-ab92-c75ae6ab94b5_story.html?noredirect=on&noredirect=on
• Essay 4
• 1. Medical students’ empathy: https://bmcmededuc.biomedcentral.com/articles/10.1186/s12909-020-1964-5
• 2. “Comparing Physician and Artificial Intelligence Chatbot Responses to Patient Questions Posted to a Public Social Media Forum”: https://pubmed.ncbi.nlm.nih.gov/37115527/
• Essay 5
• 1. Allen Rosen, DO, quote and YouTube video: https://doctorsonsocialmedia.com/confessions-of-a-gen-x-surgeon-my-battle-with-me tal-illness/
• 2. Adam Cifu, MD and Vinay Prasad, MD, MPH, debate: https://www.sensible-med.com/p/should-doctors-voice-their-own-mental
• Essay 6
• 1. Myles Greenberg, MD, MBA, quote: https://www.annemergmed.com/article/S0196-0644(21)00775-7/fulltext
• 2. Washington Post article: https://www.washingtonpost.com/dc-md-va/2024/10/03/will-west-doctor-gwu-suicide-note-mental-health/
• Essay 7
• 1. “Impact of Healthy Lifestyles on Life Expectancies in the U.S. Population”: https://www.ahajournals.org/doi/10.1161/CIRCULATIONAHA.117.032047
• 2. Grant Study: https://www.adultdevelopmentstudy.org/
• Essay 9
• 1. Impact of private equity on health care: https://hmpi.org/2024/06/19/an-update-on-impacts-of-private-equity-ownership-in-health-care-extending-a-systematic-review/?pdf=4765
• The Prologue was adapted from Alpha Omega Alpha Pharos, 77(3):34-37, 2014, with permission.
• Essays 11, 12, 14, 15, 21, 23, 24, 25, 26, 30, 31, 32, 40, 41, 42, 43, 44, 50, 53 appeared in Every Story Counts: Exploring Co temporary Practice Through Narrative Medicine, copyright © 2023 American Association for Physician Leadership®, 800-562-8088, www.physicianleaders.org, reprinted with permission.
• All “selected” essays were previously posted online at one of several websites: KevinMD, MedPage Today, and Doximity. They underwent minor editing and updating and were cross-referenced during the book’s production. References to medical research, scientific studies, and quotations were intentionally omitted in order to improve the continuity of reading. To access source informa ion, readers can search the essays by their titles on the internet and click on hyperlinked text within each essay.
• About the Author
• Arthur L. Lazarus, MD, MBA, is a healthcare consultant, certified physician executive, and nationally recognized author, speaker, and champion of physician leadership and wellness. He has broad experience in clinical practice and the health insurance industry, having led programs at Cigna and Humana. At Humana, Lazarus was vice president and corporate medical director of behavio al health operations in Louisville, Kentucky, and subsequently a population health medical director in the state of Florida.
• Lazarus has also held leadership positions in several pharmaceutical companies, including Pfizer and AstraZeneca, conducting clinical trials, and reviewing promotional material for medical accuracy and FDA compliance. He has published more than 400 articles and essays online and in scientific and professional journals and has written and edited 11 books, including 7 related to the field of narrative medicine.
• Born in Philadelphia, Pennsylvania, Lazarus attended Boston University, where he graduated with a bachelor’s degree in psychology with Distinction. He received his medical degree with Honors from Temple University School of Medicine, followed by a psychiatric residency at Temple University Hospital, where he was chief resident. After residency, Lazarus joined the faculty of Temple University School of Medicine, where he currently serves as Adjunct Professor of Psychiatry. He also holds non-faculty appointments as Executive-in-Residence at Temple University Fox School of Business and Management, where he received his MBA degree, and Senior Fellow, Jefferson College of Population Health, Philadelphia, Pennsylvania.
• Well known for his leadership and medical management skills, Lazarus is a sought-after presenter, mentor, teacher, and writer. He has shared his expertise and perspective at numerous local, national, and international meetings and seminars.
• Lazarus is a past president of the American Association for Psychiatric Administration and Leadership, a former member of the oard of directors of the American Association for Physician Leadership (AAPL), and a current member of the AAPL editorial review board. In 2010, the American Psychiatric Association honored Lazarus with the Administrative Psychiatry Award for his effectiveness as an administrator of major mental health programs and expanding the body of knowledge of management science in mental health services delivery systems.
• Lazarus is among a select group of physicians in the United States who have been inducted into both the Alpha Omega Alpha medical honor society and the Beta Gamma Sigma honor society of collegiate schools of business.
• Lazarus enjoys walking, biking, playing piano, and listening to music. He has been happily married to his wife, Cheryl, for over 40 years. They are the proud parents of four adult children and the grandparents of six young children.