On Becoming a Healer

It is difficult to overstate the achievements of Richard Clarke Cabot (1868-1939) a relatively little-known, old-moneyed physician of the early 20th century who was far ahead of his time in how much he contributed, and how willing he was to question his own limitations. Cabot's achievements include: creation and self-funding of the first medical social work service and establishment of the fields of clinical pastoral care and medical ethics. His work offered seminal contributions to the fields of hematology, cardiology, infectious disease, and medical education – including the clinical pathologic conference, case-based learning and the differential diagnosis; the first large-scale randomized experiment in the history of criminology; the science of medical error; and introducing the concept of a group insurance plan. He authored countless books, articles and textbooks.  Most remarkable, considering Cabot's extraordinary intellect, was his openness to reflecting on his own deficits as a physician, including getting diagnoses wrong, and describing his own failures in seeing the humanity of his patients.  Joy, curiosity, and generosity were among his distinctive personal characteristics.  So, why is he not more widely remembered? Perhaps because of one of his greatest attributes: he pointed out things about his profession that the medical establishment didn't want to hear.

In an April 23rd executive order (EO), the president of the United States alleges that the Liaison Committee for Medical Education (LCME) and the Accreditation Council for Graduate Medical Education (ACGME) are requiring medical schools and residency programs to pursue unlawful discrimination through DEI policies. The EO calls for the US Department of Education to “assess whether to suspend or terminate” them, and to “streamline the process” for recognizing new accreditors to replace them.  In addition, medical journals, including the New England Journal of Medicine, are getting letters from a US Attorney, calling them “partisans in various scientific debates,” and requesting information.  As a follow up to our last episode on authoritarianism and its implications for the medical profession, we consider these new developments from two perspectives: On the one hand we look for evidence to support the government's claims; and, on the other, we consider how they fit into the authoritarian's playbook of capitalizing on polarization to breakdown civil society and consolidate power.  There are things physicians and other health professionals can and should be doing now – and we propose a few -- to protect our profession from an authoritarian incursion that threatens our commitment so scientific integrity, and to a medical education system that, however imperfect, is informed by expert knowledge and professional values.

The record of physicians standing up for their values as healers under authoritarian regimes is not good, whether it's Nazi Germany, the former Soviet Union, or Iraq, with behaviors ranging from assisting in torture, to psychiatric hospitalization for political reasons. And sadly, it's often without any coercion. More subtly, physicians may go along with authoritarian regimes' demands, thinking they can just "stay above the fray."  But is that possible? Already, other professional institutions, including academia and law, have struck deals in the hope they they can move on, rather than defend academic freedom or long-standing legal principles.   What's in store for medicine? Some might say “not much” -- physicians must simply continue to take good care of their patients. But some are already acceding to orders to abandon care to certain populations, including trans people and refugees; or to compromise privacy. And professional organizations are saying little about looming cuts that would curtail access to care for millions of Americans. One scholar of authoritarianism, Timothy Snyder has written, “When political leaders set a negative example, professional commitments to just practice become more important. Authoritarians need obedient servants.” In this episode, two physicians wrestle with what those commitments are, and how we hold on to them.

Prescription Drug Monitoring Programs (PDMPs) were originally designed for law enforcement to monitor patients and physicians for criminal behavior before it became available to health care professionals. Physicians and pharmacists often find PDMPs helpful because they can verify what a patient tells them and will often decide not to prescribe or dispense opioids if they discover their patient has been going to multiple providers and pharmacies. But is that health care or policing? Who benefits and who is harmed? Those are questions we consider with our guest, Elizabeth Chiarello, PhD, sociology professor and author of Policing Patients: Treatment and Surveillance on the Frontlines of the Opioid Crisis. The themes we discuss are not unique to PDMPs. This is at least our fifth episode exploring how the criminal justice mindset has crossed into medical practice with harmful effects. Prior ones include: ·       Opioids and the physician-patient relationship: What are we getting wrong? March 2022 ·       Urine Drug Screening: How it can traumatize patients and undermine the physician-patient relationship without helping anyone August 2022 ·       My patient's in shackles: Can we take these off? April 2023 ·       Drug testing at time of birth: How physicians are co-opted into harming families while thinking they are doing the right thing. Nov 2023

There are a lot of videos on YouTube that feature typically young physicians explaining why they decided to leave the profession after years of dedication and hard work.  For some it appears that they were so successful at building a social media presence and related businesses, that they quit medicine. Others seem to just want to share their experience in the hope it might help others. They describe how a sense of exhaustion, dreading work each day and discovering that it wasn't what they imagined when they dreamed of becoming a doctor drove them away.  What they have to say feels quite convincing, and thousands of comments affirm them.   At the same time, there is something missing. They rarely talk about their relationships with patients or how medicine, no matter how corrupted it is by profit seeking, really is a special and unique profession that is worth fighting for. We reflect on what to make of this blind spot, trying very hard not to sound preachy.  

In December 2024, the three organizations that oversee medical school (MD and DO) and residency education released a set of “Foundational Competencies for Undergraduate Medical Education,” that represent a consensus on the observable abilities medical students should exhibit as they begin practicing medicine under supervision. Not surprisingly they include taking a relevant patient history, performing a relevant physical exam, and creating and prioritizing a differential diagnosis.  But a new one – and it's the first one under Patient Care -- entails integrating patient context and preferences into patient care. Stefan interviews co-host Saul Weiner who has documented a strong correlation between contextualizing care and patient health care outcomes in thousands of encounters. Saul reflects on how contextualizing care is a deeply human but teachable process that AI can't replicate and that makes care measurably more effective for patients, and more meaningful for doctors. The Institute for Health Care Improvement's new online course on contextualizing care is accessed at Contextualizing Care 101. For bulk orders email OpenSchoolSubsribers@ihi.org

At a moment of increasing isolationism and xenophobia and -- for physicians – burnout, in a highly bureaucratic and profit driven health system, service in low resource high needs settings can be an antidote for what ails America and American medicine, at least for the individual clinician. John Lawrence has spent decades serving all over the globe as a pediatric surgeon, most recently in war torn Gaza and South Sudan.  He explains how he headed to college with plans to become a mathematician and then got diverted from that career trajectory while teaching math to Native American youth in Montana and seeing the consequences of poor access to needed healthcare.  As cliched as it may sound, physicians are supposed to serve humanity rather than just the well insured, and John exemplifies that point of view on a global scale.

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

To commemorate the start of our fifth season, we revisit a conversation we had almost two years ago about the wisdom of Simon Auster, MD. Simon was a family physician and psychiatrist who inspired the conversations we've been having with each other and with guests on every episode.  “Simonisms” embody Simon's insights: pithy observations about the practice of medicine that are never cliché, challenge commonly held assumptions and offer fresh perspectives. We share -- and reflect on -- these pearls because we believe they can help many doctors, those in training, and those who train them, find joy and meaning in their work.  You can learn about Simon, who died in 2020, in an online (open access) essay about his life, published in The Pharos, the journal of the AOA medical honor society. 

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

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

There is an idealized version of physician-patient communication that is taught in medical schools, reinforced with acronyms like PEARLS, SPIKES, and LEARN, but what resemblance does it bear to how doctors actually sound in the exam room?  Co-host Saul Weiner leads a research team that has audio recorded and analyzed thousands of medical encounters. In this episode, he and Stefan read a transcript from a typical visit, portraying patient and doctor, respectively, breaking out of role periodically to reflect on what's just happened. Throughout, the physician interacts with the computer, peppering their patient with questions while conducting data entry. On the one hand, the visit is unremarkable. The physician seems reasonably conscientious. On the other, it is disturbing for their lack of engagement even when the patient shows signs of distress or confusion. What can we learn and teach by studying transcripts of real doctor-patient interactions, warts and all?  Saul has posted over 400 of them, all de-identified, on a public website for those who would like to find out (note: an updated version of the transcripts with fewer missing words will be uploaded shortly, as soon as a software glitch on the site is fixed).

The National Institute on Drug Abuse defines addiction as a “chronic disease” occurring in the brain – Many believe this definition can help to reduce stigma. But, is it helpful in the care of individual patients? In this episode we discuss what we gain and what we lose when we speak of people with addiction as having “diseased brains.” The view of addiction as a chronic disease has traction, supported first by mid 20th-century alcoholism research, and then by a flood of brain imaging and neurophysiologic studies. Functional MRIs highlight changes in the brain, whether the addiction is to a substance like alcohol or opioids, or to a behavior such as gambling or disordered eating. Many authorities suggest that the “brain disease” designation is not only correct on scientific grounds, but that it also advances a social priority: to blunt stigmatizing concepts of addiction as a weakness or moral failing. However, many neuroscientists disagree with the brain disease model. Without disputing the brain science, they note that all learned behaviors change the brain, not just addiction. Also, people who reduce or stop use often report they chose to make that change because of new opportunities or intolerable consequences.  The brain disease argument invites a second criticism:  arguably, it lets unfettered capitalism off the hook – predatory industries spend billions to get people addicted. Calling it a disease of an organ conveniently focuses attention away from a predatory system.       Why does this debate matter for clinicians and patients?  Saul interviews co-host, Stefan Kertesz, who is a primary care doctor and a board-certified addiction medicine specialist.  Together we consider how addiction is a part of the human condition, which includes how we learn, how we relate to the environment in which we live, and how we are shaped by experiences.  Nearly everyone has habits that are problematic to varying degrees. How we think about addiction can shape our approach to patient care across a wide range of clinical interactions.

In his book, The Present Illness, American Health Care and Its Afflictions, physician and historian Martin Shapiro, MD, PhD, MPH presents a scathing critique of a profession suffused with status, money, and power. At the same time, he also describes many deeply caring and rewarding patient care experiences, his own and those of colleagues.  But these relationships are only possible when the clinician has a clear understanding of the pernicious corrupting forces in medicine and consciously rejects them.  This is a moral act that must be renewed continuously. They also require a capacity to confront one's own insecurities -- Dr. Shapiro describes years of psychotherapy that were essential to his own growth as a physician who can be fully present in the face of suffering.   Martin indicts the profession for producing far too many doctors who want to get rich and who are unprepared, through a faulty process of selection and training, to be truly caring towards those they serve.  Martin reminds us that the motives of the profession have long been suspect, quoting Plato's Republic in which Socrates asks, "Is the physician a healer or a maker of money?" Never before, however, and nowhere on the scale found in the United States has health care become such a massive industry, one that keeps growing. Martin argues that the profession can only heal itself if it confronts its demons honestly and openly, beginning at the earliest stages of medical training. 

A recent NEJM article and accompanying podcast episode (“Tough Love”) authored and hosted by the Journal's national correspondent sound the alarm that a culture of grievance among medical students and trainees about the discomforts of medical training is threatening to undermine both their medical education and patient care. She also describes widespread anxiety among medical educators who feel fearful of speaking because of concerns of retaliation on social media.  Absent from the discussion, however, are the voices of students and trainees who, in the podcast, are referred to as “our children.” Medical Students and trainees we spoke with did not feel that their concerns are experiences were accurately characterized. We propose that medical educators are ill prepared for the shifting power dynamics, both in terms of knowing how to listen and how to lead.

“Sonny's Blues” is a 1956 story by the author, James Baldwin, about a “sensible” and pragmatic algebra teacher and his younger musically gifted younger brother (“Sonny”), who struggles with heroin addiction. Both of them, raised in Harlem, are deeply affected by anti-Black racism.  Although the older brother, who narrates the story, feels responsible for Sonny, he struggles to relate to him. With the help of an English professor, Laura Greene at Augustana College, we reflect on some of the lessons of this story for the physician-patient relationship, especially when caring for individuals with substance use disorder. We explore the cost both to patients and to ourselves, as healthcare professionals, of holding patients at arm's length because we fear engaging, especially in the face of suffering. A PDF of “Sonny's Blues,” can be accessed from the story's Wiki page (scroll down to external links).

In a 2021 episode that we reran last month, “About me being racist: a conversation that follows an apology,” Saul talked with a former Black colleague after apologizing to her for something racist he had done twenty years earlier that hurt her for a long time.   Since then, Saul has been thinking about how he got exposed to racist ideas and notions of power as a white male growing up in the United States (in his case in a liberal, highly educated community) and suggested that he and Stefan talk about it, taking to heart Toni Morrison's admonition that, “White people have a very serious problem, and they should start thinking about what they can do about it – and leave me out of it!” Also, next month we'll de discussing a short story by author James Baldwin with a special guest, and would like to encourage listeners to read “Sonny's Blues,” which can be accessed from the story's Wiki page (scroll down to external links).

We are re-running this episode from 2021 because we're releasing a sequel next month in which Saul reflects on his journey confronting racist ideas he'd absorbed and that became impossible to ignore after he'd acknowledged his role in the incident described here.  We are also re-running the episode because it exemplifies our commitment to facing things -- about ourselves and our profession – to enhance our wellbeing, and our relationships with colleagues and patients.  Rather than disheartening, we find such conversations and the changes they bring rewarding and healing.

For years, when physicians order tests to assess lung function, or blood work to determine kidney function, or look up guidelines for managing high blood pressure the results have been adjusted for race. This practice has been based on studies that seemed to indicate that the same result means different things if the patient is Black vs white. So, for instance, an “uncorrected' creatinine of 1.6 was thought to be less concerning in a Black than white patient as Blacks were thought to have greater muscle mass (not true). These correction factors masked underlying environmental and social stressors disproportionately affecting Black Americans. Regrettably they also contributed to delays in care for chronic conditions, as Black patients had to be sicker than white patients to trigger therapeutic interventions – further exacerbating disparities. We talk with two physicians who lead an anti-racism equity committee based in a Chicago VA hospital to understand the history and science that led to these “corrections,” and how they have successfully been removing them through education and advocacy across their organization and nationally. Their activism is especially meaningful because of its immediate, tangible, benefit for affected patients. The views expressed in this episode are those of the participants and do not necessarily reflect the position or policy of the Department of Veterans Affairs or the United States government. 

The practice of urine drug testing during pregnancy and then often reporting positive results to Child Protective Services triggers a cascade that can result in separation of mother and newborn, with devastating consequence for both. These practices are more common when patients come from marginalized communities even when baseline substance use rates are the same. As our guest -- obstetrician/gynecologist and addiction medicine expert Mishka Terplan MD, MPH -- points out, illicit substances are not teratogens in comparison to, say, alcohol, tobacco or lead exposure. So why do we order these tests? He also discusses how talking with patients about substance use behaviors, especially with the help of screening instruments, is the only way to characterize substance use behaviors and formulate treatment strategies. This is the third episode in which we learn of common clinician practices in which clinicians are co-opted into punitive and even carceral systems of oppression.

Direct, covert observation of health care is a novel and underutilized tool to assess health care trainees and clinicians. In this episode we talk with experts about two such approaches: the unannounced standardized patient and patient-collected audio. In the former, actors are sent incognito into practice settings, and in the latter real patients volunteer to record their visits on behalf of a quality improvement team.  Both approaches address the question, “How are our learners and experienced clinicians performing in the real world?” They also identify those who may do well on simulations but underperform in the clinical setting. As one of our guests observed, “If McDonalds is using secret shoppers to improve services, shouldn't we be doing the same in health care (but with a lot more rigor) where the stakes are so much higher?”

In the prior episode we learned that there is no evidence that time-limited testing improves test validity and that, in fact, there is ample research showing that it makes tests less valid and less equitable. In this episode we discuss how, despite the data, the NBME denies accommodations on the USMLE exams to over half of medical students who have a documented learning disability and are approved for accommodations at their medical school (e.g., extra time). We talk with a leading medical educator about a national survey she and her colleagues conducted to assess the scope and impact on medical schools and their students. And we conclude with a discussion about how the NBME could make the test fair and valid for everyone. 

There is a widely held perception that being able to complete a test quickly is an indication of mastery when compared with those who need more time. As a result, it is often difficult to obtain accommodations on high stakes examinations, including the USMLE exams.  Many students who request extra time because of a disability are denied accommodations and many other students who need it aren't eligible (e.g., English is a second language) or are inhibited from applying (e.g., Veterans, students from certain cultural backgrounds). But what does the evidence show? In this episode we interview an expert on the topic about a paper she authored titled Four Empirically Based Reasons Not to Administer Time-Limited Tests. The implications are profound because this is a problem we can fix, significantly improving high stakes assessment, equity, and inclusivity. 

Stefan interviews co-host Saul about his experiences becoming a doctor with a learning disability.  This episode, first run in 2020, sets the stage for two that will follow – in August and September, with experts on the science of student learning assessment and its implications for the USMLE examinations. These will address questions such as: Does struggling with multiple-choice tests under time pressure predict anything about future performance in the clinical setting? Do time limits make tests more or less valid and reliable?  What are implications of denying so many students accommodations on the USMLE examinations?  And, most importantly, what can we do about the documented perverse effects of our current system of assessment on equity and inclusion and, ultimately on the quality and diversity of our physician workforce? 

A recent New York Times article, titled "When Doctors Use a Chatbot to Improve Their Bedside Manner," should raise questions about why physicians are turning to artificial intelligence for help talking with other humans. While GPTChat can generate things to say, what comes out of AI is impersonal, as it knows nothing about the individuality of the doctor asking them, or of their patient, or of the relationship between the two. Much of the joy of being a physician is forming personal, healing connections with patients. Are physicians unprepared to cultivate them? US Medical schools now teach physician-patient communication, with the help of standardized patients and various acronyms like "PEARLS" and "SPIKES," that are designed to guide clinician-patient interactions.  But are we failing to help physicians find their own voice -- specifically, to form personal, relationship centered connections that they can draw on, especially during challenging times?  

The narrative that getting patients with chronic pain off opioids makes them safer was reinforced by a recent paper that got substantial media attention showing an association with reduced suicide rates at the population level -- But other data, at the patient level, shows an increased rate of suicide.  Which is closer to the truth? And, if there's an answer, how does it apply to the individual patient? Is it ever okay to taper a patient when it's not a shared decision?  How do you talk about it, and does the power dynamic between doctor and patient affect such conversations? Are patients with opioid dependence too impaired “to know what's good for them”?    How does one navigate what can feel like a minefield: legal risks, angry patients, moral injury and, above all, wanting to do the right thing? Do the answers to these questions have broader implications for the physician-patient relationship and good doctoring?  (This episode refers several times to "engagement" and "boundary clarity." Check out episode #15 for an exploration of these concepts.)

We might assume that a patient who is chained to their hospital bed must be restrained for good reason, but our guest challenges that assumption in a published account of a man in shackles who is intubated, sedated, and paralyzed in the ICU.  He and his co-author write that "Over-policing and mass incarceration have led to Black prisoners being disproportionately represented in jails and prisons. Those of us in positions of power may disregard the shackle, or not question its purpose, or even propose that it is justified."  But how often do incarcerated patients actually try to escape while receiving medical care?  Should a physician ask the guards to take off the shackles? What are the legal and ethical consequences of doing so? What is the right thing to do? What are the implications of not speaking up? We explore these questions and more.   

In this second of a two-episode series on medical student mistreatment, we discuss its impact on burnout with a colleague who is working to change the culture of medical education and practice through research and leadership.

How is it that a healing profession -- medicine -- has such a deeply ingrained culture of harming its own?  And what can we do about it?  In this first of two back-to-back episodes on medical student mistreatment we consider the scope of the problem and attempts to confront it. We hear from one medical school that, with external funding, developed a program with online resources available to any school that are designed to foster discussion and self-reflection among all stakeholders: attendings, residents, students, and other health care professionals in the ecosystem. We share here links to resources and papers discussed in the episode: #MDsToo: A student mistreatment prevention curriculum for faculty members and residents - PubMed (nih.gov) To access the UC Irvine video series JAMA IM paper Eradicating medical student mistreatment: a longitudinal study of one institution's efforts - PubMed (nih.gov)

Simon Auster, MD, was a family physician, psychiatrist, and medical educator who had extraordinary insight about practicing medicine but absolutely zero interest in drawing attention to himself. His students and patients had the good fortune of having him as their teacher or doctor but far too few have benefited from his wisdom. Today we discuss some of Simon's saying's -- "Simonisms" -- that are remarkable because they are not the usual cliches one hears. Some challenge us to reconsider our assumptions. We share and discuss them because we believe they can help many doctors, those in training, and those who train them find more joy and meaning in their work. You can learn about Simon in an online (open access) essay about his life, published in The Pharos, the journal of the AOA medical honor society. 

Medical training and practice habituates physicians to a culture that narrows the possibilities we see for finding joy and meaning in our work. We often become efficient task completers, stuck in routines, and prone to burnout.  Saul and Stefan discuss a set of questions that challenge physicians to look at their work and themselves in fresh ways, can be used for mentoring or teaching purposes, as prompts for reflective writing exercises, or to engage thoughtful colleagues (perhaps over a beer).  10 Questions (selected from On Becoming a Healer: The Journey from Patient Care to Caring about Your Patients)  Think about a brief account of a patient interaction you recently had in which you think you functioned as a healer rather than just a task completer – meaning that you were able to help the patient beyond the narrowly biomedical aspects of care? Was there something you learned from this visit that you could apply more broadly? Think of interactions with patients that are rewarding and meaningful? Are they rare or common? Can you think of a specific one? Was there something you did differently that made the encounter memorable? If so, can you think of ways you could modify how you practice and interact with other patients so that more of your interactions are as satisfying? Do you see yourself as someone friends turn to when they are in distress or need guidance? If so, what is it that you offer them that enables you to be such a valuable resource? Is that part of you accessible to your patients during medical encounters? Can you think of an example? If not, why do you think that is? If you couldn't be a physician, what would you most want to do instead? How would it be similar or different from what you have sought in a medical career? Can you draw connections between your second choice and medicine to gain perspective on what you most love to do? Assuming you stay in medicine, how can you be sure you are most likely to find it? What's happened to your curiosity during medical training? What are you more curious about? What are you less curious about? Specifically, what questions do you find yourself asking or wanting to ask as you go through the day? How do you think your curiosity or lack of curiosity affects how you relate to and care for your patients and how you feel about your work? Do you feel your patients are benefiting from the distinct qualities that make you the unique person you are, or is that uniqueness not really a part of the way you relate to them? Do you feel you are interacting with patients in a manner that gives you a window into what makes each of them unique? Are many of your interactions rewarding? If so, in what ways? Are there certain types of patients who “get under your skin,” making you cringe when you see their names on your appointment calendar? Consider what might be going on during your interactions with them, utilizing the framework described in this chapter. Is it that you can't engage with them? Do you struggle with maintaining boundaries when they make incessant demands? How might you alter your behavior so that these encounters become opportunities to model healthy interaction and to provide them a brief respite from the chaos that is likely present in their other relationships? Have you ever felt resentment that a patient didn't show appreciation after you significantly helped them? If so, why do you think their show of gratitude is important to you? Does the doctor-patient relationship include an expectation that patients make their doctors feel good too? Could their indifference reduce your investment in their care? What if you learned from a patient's family member that the person actually does appreciate you but just isn't able to show it? Given what you know now, do you think you can have a career in medicine in which you find patient interaction rewarding and meaningful much of the time? If yes, are you on course to experience those rewards, or do you need to make some changes? If the latter, what are you going to do to make those changes? Are you going to live with low expectations or look for something more rewarding? Many, if not most, work environments have a fair amount of hassle, meaning you spend a good deal of time doing nuisance work and coping with difficult colleagues and bosses. These are manageable challenges, and they even provide an opportunity to learn to negotiate and adapt. Sometimes, however, workplaces become too dysfunctional to do your job effectively or facilitate meaningful change. They are beyond repair. How would you know when that line has been crossed? Have you experienced either or both of these situations? How did you respond? What did you learn? Saul J. Weiner, MD; sweiner@uic.edu 

In October, the New York Times published the first of several articles about an eminent professor at NYU who was dismissed after his students complained that his organic chemistry class, essential to medical school admission, was too hard. Thousands of comments were unsympathetic saying, essentially, that students who couldn't hack it shouldn't be doctors. But is that really true? Saul and Stefan debate not only whether organic chemistry should be a gateway into medicine, but what else is questionable in how we train physicians -- and why it matters. Are medical students spending massive amounts of time jumping through hoops when they could be acquiring vital skills? What are some indicators that medical education needs substantial redesign? 

Today, Stefan talks with Saul about his favorite topic (and life's work), contextualizing care. We're re-releasing this conversation (from January of last year) because Saul's research team has just published a new study -- an RCT, titled "Effect of Electronic Health Record Clinical Decision Support on Contextualization of Care: A Randomized Clinical Trial," which is open access, so you can read it by clicking on the link. This episode provides a brief "one-stop-shop" for anyone who wants to understand what it means to contextualize care and why it matters.  

Recent articles in mainstream media about "medical gaslighting" have struck a nerve with thousands of comments on social media platforms. People are complaining about how their doctors are treating them, with women and underrepresented minorities disproportionately telling some of the worst stories.  Meanwhile physicians are responding, mostly on the defensive. They're saying their jobs are too tough and patients are unreasonable. We explore what's going on. 

Urine drug screening (UDS) is used in the care of patients with opioid use disorder, and for patients receiving opioids for chronic pain. There's no strong evidence that testing helps patients, however, and no consensus on what to do with the results anyway. These tests, often mandated, may cause serious harm when physicians don't realize how often there are false positives or react punitively by cutting off treatment. Testing can resemble a criminal justice encounter, where failing could result in jail time. In a conversation with an expert, we reflect on how urine tests can be helpful, but only if we understand what our role as a physician is in caring for vulnerable, marginalized, and traumatized patients who desperately need us to care about them.

Making it into and through medical school is tough even for those who have all the advantages: excellent schools starting at a young age, well-educated parents who may be doctors themselves, lots of role models and…white skin.  In this episode we hear from two pre-meds and one newly minted physician, all Black, about their journeys with few of these advantages.  Despite their remarkable optimism, their burdens are evident, and many do seem tied to race, as it is understood in the US. The extreme underrepresentation of Blacks in medicine should be a source of deep concern for the profession and for society, as a matter of social justice as well as patient care. The passion of these young men and woman is inspiring, and the mentorship opportunities provided by pipeline programs like the I Am Abel Foundation which has been central to their lives, offers hope. To learn more about I Am Abel, check out "Season 1, Episode 6: Hope and Healing for Those Who Follow" of our podcast. To support the Foundation's commitment to mentoring talented students see: https://www.iamabel.org/donate  Guests: Korinne Carr, Josh Leake, Eseosa (“Sosa”) Aiwerioghene

Medical students may be subject to professionalism review by committees, most commonly for “unreliability” such as not responding to emails, falling behind on compliance requirements, showing up late for assignments and so on. Then they hit the wards, and frequently experience mistreatment by residents and attendings (many of whom also don't answer their emails etc…), most commonly in the form of public humiliation. This seems like a recipe for cynicism and burnout, rather than growth as a professional. In this episode we talk with our guests, experts in a more nurturing approach, about alternatives. We hear about “cup-of-coffee conversations” and other relationship building approaches to cultivating civility, collegiality, and professionalism.

Many residents are not doing well, psychologically, and sometimes physically -- and with good reason. High levels of mistreatment and harassment, patient care that some experience as moral injury, and a lack of voice in the workplace, contribute to burnout and can adversely affect the kind of physicians people become.  A growing path to empowerment is unionization. What are resident and fellow unions doing to create healthier training environments? Today we hear from a recent residency program graduate who served as president of a resident union at a large academic medical center. 

The opioid crisis was precipitated by physicians overprescribing opioid pain medication, egged on by the pharmaceutical industry, contributing to suffering and death from addiction and overdose. Now, many physicians are forcibly cutting patients off of opioids and refusing to prescribe in the setting of a backlash, contributing to suffering from pain, and death from suicide. Saul and Stefan consider some of the striking similarities in how we -- the medical profession -- are getting it wrong on both sides of the crisis, why, and what we can do about it. 

On January 1st, the New York Times ran a story about prenatal genetic tests that are "usually wrong" -- but they got it wrong. These are actually just tests to tell if someone is high risk. The real story is that clinicians are not communicating with patients about what these tests mean, causing confusion and trauma. This happens across medicine and we discuss how to avoid it.

There are two qualities we may experience in others who comfort and ground us when we feel vulnerable and lost.  First that they engage with us, meaning that they are fully present with a sense of shared humanity. Second, that they respect our personal boundaries and know their own. Such boundary clarity makes them a safe sounding board. In this episode, first aired last May, we explore the interdependence of engagement and boundary clarity and their essential role in healing interactions.

Lately we've been hearing about bad behavior on airplanes. Here we discuss an incident in which a passenger unselfconsiously stepped up at an inconvenient time to assist a group of passengers in a tough spot. Saul and Stefan reflect on the qualities of people who go through life making the world a better place in small ways.  As millions travel during Thanksgiving, we thought this episode (originally released last year) might inspire  those flying the not-always friendly skies.     

Our guest, a physician a few years out of residency, describes an experience from her training when an attending yelled at her and hung up the phone when they were discussing a patient.  We talk about resident abuse, its impact on patient care, and what can be done about it. 

Our guest, a resident physician, describes her reaction and what followed, when she discovered a symbol of hate tattooed on her hospitalized patient's leg.  Most of us appreciate that as physicians we don't get to choose who are patients are, and that all deserve good care. But is there more to it than that? Can one grow as a physician and person, and even feel privileged when caring for patients who one might otherwise shun?  

Saul reached out to a former colleague whom he worked with closely so that he could apologize for something he did many years ago that he now sees as racist. Saul is a white man and his former colleague, a subordinate at the time, is a black woman. Because of his apology, along with their longstanding relationship, they are able to have an open and honest conversation about how it affected her life, why it happened and how to prevent and respond to racist behavior in the workplace. Stefan moderates the conversation. Guest: Chanel Brown

In a widely reported incident, Dartmouth Geisel School of Medicine accused, suspended and expelled medical students for cheating based on faulty data -- and then retracted the decision amidst a large public backlash. During the episode students were allegedly given only 2 minutes to defend themselves and were encouraged to plead guilty. When they complained about the administration online, the school passed a policy on social media that would ban some forms of communication. In this episode, Saul (@SaulWeiner) and Stefan (@StefanKertesz) discuss whether what happened at Dartmouth was an anomaly or  emblematic of a dysfunctional and even toxic culture within medical education.   And, to the extent that it is the latter, they consider how physicians can be scarred and stunted in ways that diminish their potential as healers.  Finally, they reflect on what it would take to bring about transformative change. 

A primary care doctor in solo practice in a small mid-west city who is deeply trusted by his patients talks about talking about vaccine hesitancy.  

We feel safe and can open up in conversations when there is full and open engagement combined with a clear, respectful sense of personal boundaries.  Why are such exchanges so rare and yet so important to medical practice and to the good life? 

Physicians are neither judges nor God, and yet we seem prone to judge our patients...and ourselves. Saul and Stefan discuss. 

Saul and his research team have listened to and analyzed thousands of audio recordings of medical encounters for clinician attention to the life context of each patient when planning their care. Here is what they've learned.   

In Part 2 of our interview with Dr. Bhalla, hear what makes for a good fit for a long term career practicing medicine and leading projects in international settings