Routine Miracles: Personal Journeys of Patients and Doctors Discovering the Powers of Modern Medicine

PART 1

Practicing Alchemy on

the Streets of New York

CHAPTER 1

The Heart of the Matter

Physician Dissatisfaction and How to Cure It

PUT ON YOUR HELMET, and remember the sweat that poured off you in summer practice! You are the best! You are winners! Now act like it and knock those guys off the field! our high school football coach would say. If we’d lost against the opposing team the year before, he would remind us: You’ve done a lot of work since last year. You are not the same individuals, the same team you were before. You have grown. You are the best team we ever put out there. Today belongs to you!

I can’t imagine any sports team succeeding at any level with a coach saying, You’re weak and wimpy compared to me when I played the game. You’re not as good as my teammates were! And, most of all, you won’t enjoy the game as much as we did 25 years ago. Now go out there and take a beating! Yet if medical school faculty were football coaches, this is exactly what they would sound like.

There is a chorus of older physicians’ voices that is having an unhealthy sway over medical students. Has anyone here been told you are the best, better than the faculty? I ask a class of mine. No hands go up. Has anyone here been told you are worse than students in the past, that you are not as diligent, devoted, or hardworking? Eighty percent of the hands go up. Eighty percent of my students have been actively discouraged by their coaches—and just look who is playing for the other team: cancer, diabetes, heart disease, stroke, rheumatoid arthritis, AIDS, psoriasis, reflux disease, fibroids, epilepsy, kidney disease, and loss of hearing, sight, limbs, and spirit. Talk about a formidable opponent!

Dr. Sheldon Landesman, the assistant dean of education at SUNY Downstate Medical Center in Brooklyn, New York, is one of those coaches. Sheldon graduated from medical school more than 35 years ago. He is a tall man in his early sixties with graying hair and a quick wit. I have known Sheldon for more than 10 years. He is good-natured and actually quite devoted to his students, but he gives them the distinct feeling, not indirectly, that medical students of his generation were more committed, more studious, and more serious than students today are.

Sheldon and I both did our internships in the years before the death of a young woman named Libby Zion in a New York City emergency department led to the regulation of duty hours in training. When we were on call, we were in the hospital for 24 to 36 hours at a stretch. Going without sleep for so long, we had the same judgment levels and psychomotor skills as if we were legally drunk. But internships had been structured like that for the past hundred years; long duty hours were a rite of passage that lent a Superman mystique to the profession.

Interns now can work no more than 24 hours at a time, no more than 80 hours a week. Despite the effects that sleep deprivation has on performance, many thought leaders in medicine, including Sheldon, bemoan the degradation in training that they feel comes with duty-hour limits. Where is the continuity of care? Where is the devotion to your profession and medicine? they ask. Don’t you want Iron Man to take care of you, not just some ordinary citizen who needs to sleep eight hours before he can do your bypass surgery?

Even I still feel macho about the long hours I worked during my internship. I mention it every chance I get, followed by an exposition on the dangers of sleep deprivation. If I were a veteran, I’d be saying, War is hell; all war should stop. Now let me tell you what I did in the war.

Duty-hour limits are only part of the mentor generation’s complaint. When I ask Sheldon for his help on the research project on which this book is based, he jumps to my side. Sheldon is an exemplar of academic productivity and research activity. He has repeatedly won million-dollar National Institutes of Health grants, becoming over the years the most well-funded researcher in the Department of Medicine at SUNY Downstate Medical Center. He is single-handedly responsible for one-fifth of the entire curriculum in the second year of medical school.

What are you studying? he asks.

I explain to him that I am examining why many of our students, residents, and physicians think that our profession was better 25 years ago. Not only do I want my students to become clinician-scientists devoted to finding cures, but I also want them to recognize that they are at the peak of civilization, the top 1 percent in intelligence, education, experience, and capabilities.

They can accomplish anything they set their minds to, I say. I want them to feel this, and I want to know why they don’t feel it.

Sheldon says, Because it is not true.

What? I ask him.

"Medicine was better before."

But, Sheldon, I say, that doesn’t make sense. I start to remind him about the things doctors can do now that people once thought you had to be a biblical figure to accomplish—restore sight and hearing, fix broken hearts, make arthritis patients walk, end epileptic seizures, even cure some cancers.

Sheldon, seeing things from a doctor’s point of view, not the patient’s, stops me short. Medicine is worse now. It is less satisfying.

What, then, are the sources of doctors’ dissatisfaction?

In the past, Sheldon says, the doctor was in charge. We had autonomy. We controlled things.

Autonomy is a big issue for the older generation. In the course of conducting interviews for this book, I meet Dr. Erick Lang, who performed the world’s first angiogram of the coronary arteries in 1959 and remains at the cutting edge of interventional radiology. I ask him why he thinks so many students and young physicians say things were better 25 years ago.

It has always been this way, he responds. There is always the feeling that your golden days are always behind you. In 1959, they told me it was better 25 years before that.

I ask him why we are not more satisfied with medicine, considering how much more we can do in treatment.

Now new advances are done by whole teams of investigators, he says. There is less personal glory. When one man did the work before, it gave a greater feeling of accomplishment. The sense of personal satisfaction has been removed.

Another area where the older generation feels its autonomy is threatened is patient empowerment. We are entering an age where it’s possible again for doctors and patients to have a dialogue, thanks largely to the Internet, which allows patients to research their diseases and follow up at the doctor’s office with intelligent questions. Yet many senior physicians lament their lost status; they either don’t realize or don’t care that it is through patient empowerment that patient trust has risen to an all-time high.

Doctors are devoted as ever. The commitment of physicians to the art of medicine and to humanity is not in question. When asked whether they would still practice medicine if they did not have to work for a living, 80 percent of respondents said yes. That is devotion! But the irritations and complexities of our current method of practice sorely test that devotion. Physician income is high, but not high enough to compensate for the difficulties of practice.

Sheldon brings up another point: Medical students are graduating with phenomenal amounts of debt. How do you expect them to choose some altruistic practice or clinician-scientist job and be saddled with this for decades to come?

Much of the reason for physician dissatisfaction despite greater treatment breakthroughs is related to how we finance medical school education. Student debt is a huge barrier to a young graduate’s pursuit of a career in research or primary care. For years, 25 percent of a typical graduate’s income will go toward repaying student loans, sometimes amounting to hundreds of thousands of dollars.

At the same time, faculty at medical schools have seen drastic cuts in financial support for their research and teaching. To make a living, these clinician-scientists are compelled to see patients in private practice while also fulfilling their duties as teachers. This is a serious defect in the system.

If Americans want to expect top-notch medical care in the coming decades, the public must act now to reform the financing of medical education. Faculty need financial freedom to teach and to continue to do the kind of research that has made the United States the world’s most technologically brilliant society. Faculty have grown increasingly angry and resentful of greater work with less support, and students are turning away in droves from research and primary care.

Sheldon Landesman points out that students want easier specialties. In 1972, when I graduated, he says, the best and brightest went into internal medicine. Now they want dermatology, radiology, and emergency medicine. All of these specialties are lifestyle specialties. The hours are controlled. The responsibilities are limited.

Do we want the best and brightest of our society to pursue medical research? Or do we want them merely to be clearing up acne and performing standard X-rays?

Before we can answer those questions, we must address one more issue related to doctors’ dissatisfaction, one that is bound up with the issues of autonomy and financial constraints: health insurance companies.

Everything is controlled by the insurance companies, Sheldon Landesman says.

Sheldon, I reply, in 1968, the year you entered school, 93 percent of health care expenditures were out of pocket. Now 85 percent are from third-party payers, insurers. Isn’t that better? I ask.

That is the problem, he answers. We are not free to do what we think is right.

To say that students identify dealing with health insurance companies as problematic is an understatement. When asked about their least satisfying, most painful experience, 92 percent of physicians and students agreed or strongly agreed that dealing with insurance companies made medicine less satisfying and less attractive to practice. Put another way, only 8 percent did not feel that the single greatest source of dissatisfaction in medicine was the health insurance industry. Society and our government will ignore this fact at their own peril.

Students who get accepted into medical school are in the top 10 percent of their college class. These are people who have options. We must make medicine more satisfying and attractive for them. If we want the best and brightest to see healing people as the most desirable thing to do with their talents, the obstacles of fighting with insurance companies must be fixed. We should not every year see a fight in Congress to prevent a reduction in hospital reimbursements. We should not have to save Medicare in a last-minute rescue.

It is my sincere hope that the United States will soon provide universal health insurance coverage for all its citizens. In the 1960s, physicians were actually opposed to the Medicare system because of the fear of this scary thing called socialized medicine. Even in the 1990s, when there was a major push to have universal coverage, physicians were still resistant. But now, however, the medical profession has come around to the fact that we must achieve the goal of insuring all U.S. citizens. U.S. physicians, their major professional groups, and their academic leadership are now on board.

DR. SHELDON LANDESMAN and I agree on some things. Doctors today face formidable obstacles in their practice. They are having to fight cancer, heart disease, stroke, and so on, and at the same time deal with managed care, lack of insurance, fear of malpractice, debt, and the demands of a family. As a result, many more students than in the past choose specialties where these problems are not as likely to affect their work. They are giving up on research, which just doesn’t pay. The best and brightest are deciding to pursue dermatology instead of tackling diabetes.

Meanwhile, their teachers are making it easier for them to make such decisions by saying the equivalent of You’re so weak and whiny, you’d never cure diabetes anyway.

This is where I part ways with Sheldon. Sure, it’s difficult to practice today. Managed care is the bane of my existence. But that’s all the more reason to celebrate our students, to give them encouragement in the face of all these obstacles, to say to them not that the profession is at its nadir because we have lost our machismo to duty-hour limits, our autonomy to teamwork and patient empowerment, and our freedom to financial burdens and insurance companies, but rather that this is actually medicine’s finest hour because we are making advances at exponential rates. Rather than teach students to complain, resist change, and blindly follow authority, we should be teaching them to keep an open mind at all times. That is the way to have hope. By being open-minded and creative, doctors can again find satisfaction in their work. I want to get to the bottom of all the narrow-mindedness, because I want more students to be physician-scientists who fight over the best research positions rather than the highest-paid positions. I want them not to have to worry about money for loan repayment, so that they can choose a life of investigation and medical discovery as physician-scientists, academic doctors. I want the main goal of our students to be eradicating disease, not finding an easy, high-paying job in a subspecialty. I think if we tell students, You are the most knowledgeable, most expert people ever to leave our doors, it would give them the audacity to feel that things like curing cancer and getting universal health insurance are possible.

I want to restore my students’ faith and hope in medicine by showing them all the amazing things their predecessors have done, not for the sake of celebrating their predecessors, but to inspire them to go beyond even those remarkable advances. I want students to feel blessed that they can raise the dead, restore sight to the blind, restore hearing to the deaf, and cure leprosy for $1.59. I want them to feel blessed to have patients who are grateful and well-informed. But how can they be aware of these blessings when faculty members, their role models, are selling them on the idea that it is worse to be in the profession compared with 25 years ago?

I tell my students, I think you guys are better than I am. Sometimes I say it twice, because of the stunned-ox looks I get: Many of you are smarter than I am. I may be more knowledgeable than you are now, because I have more experience, and I have been doing it longer, but that does not make me smarter than you. I want each of you to make one meaningful contribution to the art of medicine as a whole. One new treatment. One new test. You can do it, because you are better than I am.

Medical students are more knowledgeable now than at any time in history. Every objective measure of student achievement shows an improvement in their quality. Current students in medical school have the same amount of time that their predecessors did—four years—to learn a mountain of information those predecessors never had to learn. I tell them, "You have to learn everything I did in school, and you have to learn about everything developed recently."

Even so, the pass rate on the Internal Medicine Boards is 30 points higher than it was in the past, and the average score on the United States Medical Licensing Examination is constantly rising. Newly graduated residents must stay continually current, because recertification is the law of the land every 10 years, whereas those graduating residency 25 years ago had to pass the test only once and never have to prove themselves again. Scores on the boards have risen year after year, so much so that the National Board of Medical Examiners has had to raise the minimum passing score lest the test become too easy.

Beyond their objective knowledge, today’s students are also better than their predecessors in the area of patient communications. When I was a student, we had no training in empathy. If bedside manner didn’t come to us naturally, we learned it on the fly or not at all. Training in communication, giving bad news, expressing empathy, and trying to take in the whole person is becoming a standard and accepted part of the medical school curriculum. It is an essential part of training because so often in our efforts to provide no false hope, we doctors provide no hope at all. In many patient interviews, I encountered people who had been healed only to go on and suffer from continuing anxiety and depression because of the pain and despair they had experienced.

Medical students must still complete gross anatomy lab and memorize reams of data on biochemistry, but today many schools also go to considerable lengths to try to get students to cultivate and retain sensitivity. This tradition goes back to the father of medical training, the great 19th-century Canadian physician Sir William Osler, who declared, Medicine is an art, not a trade. My own school is one of many that routinely employs actors as standardized patients so that students can practice interviewing patients, giving bad news, and generally being a decent human being.

At SUNY Downstate, where I teach, second-year students are required to take a course called Essentials of Clinical Medicine, which includes students themselves acting as patients with problems ranging from heart disease to erectile dysfunction. More of the year is devoted to sensitivity training and communication (20 percent) than to cardiology (less than 5 percent).

One morning, on the floors at Kings County Hospital Center, the largest municipal hospital in New York City, a student was presenting a case to me. She told me the patient’s age, gender, marital status, employment, hobbies, religion, sexual orientation, mood, and status of his relationship with his family and friends. I finally had to interrupt to ask, What is the patient here for? The answer: a routine kidney infection. Although I was a little frustrated, I realized that this was an enormous success. The student was following her training to see even a routine patient in terms of his entire life situation. More than at any time in the past, we are training well-rounded physicians; men and women who are truly practicing Osler’s art in their attention to patients, body and soul.

It was once considered impossible for humans to break the four-minute mile. Now the top speed is more than 10 seconds less than that. I contend that the same is true in medical education. With years of efforts, I believe that the top-rated students have greatly exceeded their forebears. I think we could expect even greater achievements from them, if they were encouraged.

WE SADDLE MEDICAL students with hundreds of thousands of dollars in student loans; they accept that. We ask them to learn mountains of information; they accept that. We ask them to learn communication and sensitivity in a way never asked of me in school 20 years ago; they accept that, too. Then, when they stagger over the finish line, we basically say, You haven’t seen anything! We were the real thing. You are going to be miserable. No wonder they flee primary care and take refuge in high-paid subspecialties. No wonder that not even 2 percent of physicians choose the physician-scientist road that devotes them to a life of science as well as service. If we want, as I do, to have students who are not only able but willing to assault incurable diseases, we need to support and encourage them.

In the fight to see students better regarded and treated more respectfully, I expected the old-guard physicians like Sheldon Landesman to be my enemy and the students to be my allies. But I have heard second-year students argue for an hour about how it was all better in the past. Where did they hear such a thing?

When I approached the Organization of Student Representatives of the Association of American Medical Colleges (AAMC) about distributing a survey on student satisfaction, the student reps rejected it, saying, This is not an issue of national importance. Think about that: the students themselves believe that it is not an important national issue that today’s medical students, the flower of this generation in terms of intelligence and ability, are being systematically demoralized by their teachers.

Henry Sondheimer is the director of the Student Affairs Section of the AAMC, which sets the goals and objectives for training in every school in the country. Henry is warm, sympathetic, and entirely in agreement with me that today’s medical students are somehow being poisoned with the narrow-mind virus. Henry says, It’s from faculty who are very negative. They see the amount of clinical work they have to do to support themselves increasing, and the faculty don’t like it. So they pass that attitude on to the students. It is older physicians lamenting what they feel is an increased workload on them. The truth is just what you said. There is more great stuff to do for patients all the time, and the education gets better and better, but somehow this doesn’t translate into a better feeling about medicine. What we need is a national cheerleader to point this out to them. To get them excited about the great things going on in medicine.

I expected the AAMC leadership to be some evil oligarchy perpetuating old narrow-minded views. It turns out they are just as frustrated as I am by students stuck in this attitude.

The survey I’d proposed to the AAMC’s student representatives consisted of two simple questions: Do you feel medicine was better to practice 25 years ago? If so, where did you get this idea? Although that group chose not to respond, I have sent the same survey to all the students I have had in my classes around the country and to all the people who have read my books, and I have asked them to send it to their friends as well. Of the more than 3,000 responses, 80 percent have said that they believe that medicine was better to practice 25 years ago, and 75 percent of those respondents have identified older physicians or teachers as the main source of this opinion. Our students are the best generation, ever, to come out of school, and it is the responsibility of the American Association of Medical Colleges to address the issue that older physicians and faculty are poisoning our next generation of doctors.

It is time for medical school faculty to eschew dogma and look at the facts. It is time for them to become true coaches for their students. It is time for all of us to take healing the minds of medical students as seriously as we take preventing myocardial infarction.

It is not true that medicine was better 25 years ago. In residency 25 years ago, a physician was allowed to work 100 hours a week or more and have the functional capacity of someone legally drunk. Is that what we are proud of? Doctors 25 years ago thought that acid caused ulcers; now we cure ulcers with 10 days of antibiotics. Doctors 25 years ago had more autonomy, but studies have shown that allowing doctors to use individual judgment is worse for patients than requiring them to work in teams. The evidence is that uniform, standard, regimented care plans according to algorithms is better.

It is time to stop teaching medical students to feel sorry for themselves because of managed care and start making them feel that they have the power to do something about it. The health insurance industry is impeding the best scientific minds of our generation and, by extension, the general welfare of millions of Americans. Physicians, who as a group are generally conservative, have been waiting passively for people outside the profession to find a way to insure every American. Instead of complaining about managed care and lack of coverage, physicians need to tackle these issues themselves. They need energy and enthusiasm to defeat this monstrous problem. Young doctors in particular need encouragement from their mentors to do something about it. They don’t need to hear about how great it was in the good old days before managed care. They need to hear that managed care is a problem and that they, as the best and brightest, can and should take a lead role in helping government and society solve it.

A chorus of narrow-minded voices is drowning out the good news that doctors today are able to cure more diseases, heal more people, and relieve more suffering than ever before in human history. The popular press is packed with works describing our failures, our weaknesses, and a method of drug development that is so often illogical and unproductive that it would not take a paranoid person much to envision conspiracy. If you go to a bookstore and look at the medical section, you will find many works on how doctors and pharmaceutical companies are geared more toward making profits than toward finding new, meaningful therapies.

It is not that such voices are wrong. I simply seek to bring some balance to the discussion. The medical profession faces difficult challenges both in curing life-threatening illnesses and in helping solve the nation’s health insurance crisis. My hope is that a crescendo of understanding of how far we’ve come will deafen students to their teachers’ discouraging words. My hope is that this volume will open young minds to the idea that it is possible to beat heart disease, stroke, cancer, and all disease that plagues humanity. This book covers, in a purposely euphoric manner, medical advances that would once have been called miracles but are now merely routine. My interviews with physicians and patients have yielded stories of hope and optimism and triumph. This is the best time ever to come out of medical school and training. And that is a fact to inspire and uplift not only students, residents, and young doctors but all of us who must, at some point in our lives, rely on the art of medicine to see us through.

CHAPTER 2

A Vocation to Satisfy the Soul

IAM AN INFECTIOUS diseases doctor. I have been taking care of HIV-positive patients for 20 years. I first heard about HIV while in college in 1982; I was 19 years old, working as a teaching assistant for physiology professor Dr. Phillip Stein. He was an enormous character, a classroom performer who told completely unfunny jokes with such good humor that we laughed just to make him happy.

They say it will achieve bubonic plague proportions, he said one day in his office.

What will? I asked.

AIDS, he said. I just got back from a meeting. It’s all they are talking about.

I was typing up his class notes and doing research on thyroid glands for a reason I cannot remember, but even then I knew I had to go to medical school. Looking back, I now understand that the word calling means something you simply must do, for reasons you cannot name.

My major concerns were getting the grades I needed to get into medical school and finishing college in three years; the latter because I knew everything else would be long. I had rarely been in a hospital. No one in my family was sick. No one had an incurable disease that I felt driven to cure or treat. But I was in a mad rush to become a doctor.

I want to change the world. I want to make a difference. I rehearsed statements like that in a mirror while preparing for medical school interviews. It would take at least another ten years before I stumbled on the reason for my calling.

I graduated with distinction from the State University of New York at New Paltz. I had the honor of being named Outstanding Senior in two departments. I was very proud to have this honor, a rare achievement. Yet I also felt sorry for myself: I was on the waiting list at two medical schools but had received no acceptances.

My father was a New York City police captain, by way of law school, nursing school, and finally a degree in economics. He said that he would help me, that he had it all arranged.

I was stunned. My father was a difficult man. When my mother wanted to teach my brothers and me the language of her parents, he’d blocked it, saying, We’re in America now. If that country was so great, why did they leave? Read Shakespeare.

I had not exactly gotten encouragement from my father when I told him I wanted to be a doctor.

What the hell do you want to do that for? he said. Doctors are nothing but specialized mechanics.

This really helped my drive. One thing I can say about my father was that he taught me never to be dissuaded from my goals, often by strengthening my resolve to oppose him.

But here I was, hearing my father say, The dean of admissions at a certain medical school recently got into trouble. Your father—he loved referring to himself in the third person—was in a position to do this person a favor and extricate him from his difficulty. He owes me a favor.

Huh? All of a sudden I felt I had entered a movie. What do you mean? I asked.

Your father has arranged it for you to get a position in medical school. I have put in the fix for you.

I was furious. I won’t go. If I can’t get in on my own steam, I won’t go. My father was in enormously good physical shape. Telling him no was a scary thing.

What? Your father is offering you a favor and you turn him down? I am expecting the call within the hour to confirm it.

Now I knew what movie I was in—The Godfather.

You are spitting in my face, he continued. This is what love means. Your father is taking care of you.

My father was, and is, one of the least compassionate, least sympathetic people I have ever known. When my heart is bleeding about some issue, such as HIV, he’ll say, It’s a form of population control, kid.

I remained adamant. I won’t go, I said. I didn’t want to owe my father a favor, and I didn’t want to achieve my calling in this way. My father