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.
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Emboldened Bullies Come for Medical Education
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.
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Physicians and Authoritarians: Are We Too Obedient?
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.
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Caring for Patients or Policing Them? Prescription Drug Monitoring, Doctors and Opioids
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
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What can we learn from all those "Why I quit medicine" videos on YouTube?
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.
Doctors and other health care professionals are too often socialized and pressured to become “efficient task completers” rather than healers, which leads to unengaged and unimaginative medical practice, burnout, and diminished quality of care. It doesn’t have to be that way.
With a range of thoughtful guests, co-hosts Saul Weiner MD and Stefan Kertesz MD MS, interrogate the culture and context in which clinicians are trained and practice for their implications for patient care and clinician well-being. The podcast builds on Dr. Weiner’s 2020 book, On Becoming a Healer: The Journey from Patient Care to Caring about Your Patients (Johns Hopkins University Press).
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