My new book, "How Medicine Works and When It Doesn't" was just published. January 2023.
The reactions have been great. It's a book about medical research, medical misinformation,
why people make bad choices about their health and, in many ways, about how doctors and the
healthcare system have failed to meet the needs of the public that we are trying to serve.
And how we can fix all of that. And I thought maybe I would do a brief reading here so that
people can get a sense of it and maybe a sense of what I'm talking about. Although the book is a lot
of facts and figures and research, because I'm a researcher, as well as a physician,
it has a lot of personal anecdotes too that I think illustrate some of the central problems
and that's what I'm reading to you today. From chapter 11 which is called "Moving Together".
“You can ask her about the cancer, or how she’s feeling, or about herself,
or whatever. Just spend some time.” It was my first year of medical school, and I knew
nothing. And yet here I was, at Calvary Hospital, an inpatient hospice facility in Brooklyn.
My supervising physician, a palliative care doctor, had assigned me Ms. Ewing, a 50-year-old
with widely metastatic breast cancer who had been in hospice for a little over ten days. With those
words my supervisor sent me on my way to have one of my first direct patient interactions. I was not
required to draw blood, take a blood pressure, or even conduct a formal medical history. Really, I
was just supposed to spend time with some patients who were dying. In so doing, I would learn about
the dying process and they, well, I suppose I hoped I would make things easier on them.
I remember thinking at first that hospice must be boring, and passing the time,
even with a stranger in a short white coat, would be better than nothing. But my brain
hitched at the thought – pass the time to what? Every single patient, near enough,
who came to Calvary hospice would die at Calvary hospice. Ms. Ewing was here so
she could be comfortable when she died. It was no more or less complicated than that.
Calvary may have been the best-run hospital I have ever seen. The hallways and rooms were immaculate,
bright, and airy. The staff took their jobs seriously, but with a gentle grace that was
instantly recognizable. When anyone – doctor, nurse, housekeeping – entered a patient’s room,
they smiled and said hello. They asked how the patient was feeling. If a patient wanted water,
they would stop whatever they were doing and get the patient water.
If you’re ever in the hospital and ask your doctor for a glass of water, and they stop and get you
one, you have a special doctor. I was blown away. I was also terrified. I knew what cancer was,
of course. And I knew what hospice was, at least in theory. I knew that, in this place,
the goals of care were different. We weren’t trying to cure, we were just trying to comfort.
It freed us in many ways. Blood draws hurt, so we didn’t do blood draws. When a patient was in pain,
we gave pain medication. When a patient was short of breath, we gave oxygen. There were
no dietary restrictions, no collection of urine and stool for analysis, no beeping IV poles,
no cardiac monitors. And when a patient died, they simply died. No rapid response. No code blue.
Death with a period, not an exclamation point. Still, as I stood outside Ms. Ewing’s door,
knowing that my task was to simply talk to her, I felt paralyzed. I didn’t know where to begin. For
the first time in my medical career, but certainly not the last, I opened the door without a plan.
She was pretty. She lay in bed propped up on three pillows, a book in her lap, with her reading
glasses on. Her head was wrapped in a scarf – hair loss from the chemotherapy that she would
no longer be receiving – and her skin, without makeup or adornment was nevertheless luminous. Not
pale. She didn’t “look like death” as the saying goes. She looked like a woman, reading in bed.
She smiled and I thought – is this what it is like if you know you are going to die? Of
course, what else is there? We tell ourselves to live each day as if it is our last. Maybe
the converse works as well. When you’re on your last days, live as you always have?
We chatted. That was it. I made sure to get her a glass of water when she asked for one. I told her
about myself, about my year as a singing waiter in a restaurant in Paris. She told me about her
job – a marketing executive, before. Her kids – two – in college. Her husband – coming later.
But about twenty minutes in, I froze. It was like my brain had been wiped with a dry-erase marker. I
couldn’t remember what we had talked about, what I wanted to ask her next. It felt like a discussion
of her medical condition would be horribly out of place at this point, so I did the only thing
I could think of to do. I checked my watch, told her it was nice talking to her, and left.
There was still an hour and a half before I was supposed to meet with my supervisor to discuss the
experience. Ninety minutes left. I hid in a back stairwell. I sat, and thought about Ms. Ewing,
and how I was a terrible medical student, and how – despite being a singing waiter – I am really an
introvert and don’t do well being thrust into situations like that with people I don’t know,
and how I would die someday and so would everyone else, but that it seemed so much worse to know it
was happening soon. Or perhaps it wasn’t. Perhaps, if you’re going to die anyway, you’d rather know.
At least then you could set things to rights. And what would I set to rights if I had to?
And what if I couldn’t even if I wanted to? “We had a nice talk,” I told my supervisor,
who, thankfully, didn’t ask me too many more questions about it. I resolved, internally,
to do better tomorrow. I’d spend more time with Ms. Ewing. I’d have topics. It would be easier.
The next day, Ms. Ewing was not available. I never found out why. She may have been feeling
sick. She may have told them that she didn’t much feel like talking to the awkward med student.
I never got to speak with her again actually; she died a few days later. I added one to the list of
things I’d never be able to set to rights. Midway through my time at Calvary,
my preceptor decided to observe me with a patient. An older man with pancreatic cancer,
Mr. Lane was bearded and had clearly been on the heavier side before his diagnosis,
but his sunken temples and bony hands bespoke the catabolic nature of cancer – the wasting disease.
Affable enough, he was happy to talk with me while my preceptor sat on the other side of the room,
trying to be as unobtrusive as possible. It went well. Instructed to get some more
details about his medical history, I had a path to follow in our conversation. The initial symptoms,
the diagnosis, the treatments, and of course where he is now and what his goals would be.
The conversation flowed smoothly and we took some detours to discuss the parts of our lives that
made us feel more like real humans: our families, prior jobs, mutual love of New York-style pizza.
Eventually, as Mr. Lane was getting a bit tired, we wrapped things up. I
thanked him for his time, wished him the best, and left with a “see you later.”
“Will you see him later?” These were the first words out of my
preceptor’s mouth when we left the room. “I… um… I didn’t really mean anything by it.”
“Patients listen to every word you say,” she said. “If you say ‘see you
later,’ he’ll expect that you’ll see him later. We don’t lie to patients.”
This was difficult feedback for the young go-getter I was at the time. Medical school
had just started, and already I felt like maybe I didn’t have what it takes. Sure,
I could memorize names of muscles and pills and cellular receptors – but to talk to patients
and really connect with them would require a whole new mindset. It was a tough realization.
The doctor-patient relationship is unlike any other relationship in the world. For one, there is
a level of intimacy that goes beyond what people have even with many of their closest loved ones.
At the same time, we are not on equal ground. The doctor comes armed with years of training,
with more facts and information, and with access to a prescription pad. With that pad the promise,
often the only promise, that the ailment can be taken away.
The doctor is somehow scientist, priest, and shaman all in one. And yet, to function properly,
we must somehow transcend the wall of that knowledge, that promise and hope.
It would take me years before I felt comfortable doing it, and, truth be told, I’m still learning.
I did see Mr. Lane later, by the way. I made sure of it. And when I left his room that time,
for the last time, I said how wonderful it had been to meet him. And I said goodbye.