Forks In the Road

On Saturday, Dr. Hadler delivered the commencement address at the University of Michigan Medical School.  THCB is pleased to feature his remarks. 

Nortin HadlerThank you, Class of 2015, for the privilege of sharing this special occasion with you, your families and the community that has come together to celebrate with you. This is a rare day of pure self-indulgence. Our professional life allows little room for self-indulgence and seldom applauds when one of us makes the room. For those of you who are drawn to a career anchored at the bedside, the trade-off is the quiet, internalized quest to become the best physician you can be. I have pursued this goal nearly all my life – literally, I have been working in hospitals since I was 12. If I had it to do over, I would pursue the same goal.

This goal demands expertise. Expertise requires intellect and discipline. I have a superabundance of both and so do you. Expertise is necessary but not sufficient.  More than expertise, one must understand myriad contexts in which illness plays out.

Medicine is not a science. Medicine is a philosophy informed by science.

I was a medical student when this dawned on me. Like you, I entered clinical rotations brimming with the pathophysiology of all those diseases that are poised to smite a mighty blow. Was I missing the forest for the biochemistry? Many of our patients are elderly patient and plagued by more than one serious disease. As we set to the task of confronting each in turn, it occurred to me that I might not care as much about what kills me as I care about when, and what the journey was like? Today, we have a good handle on that “when”. I can make a strong argument that if you manage to stay well to 85, you’re off warranty.

Notions of “fatal diseases” and of “saving a life” demand a temporal component.  Realize that in America, you can’t die without a diagnosis. In the mid-1980s, I started to sign the death certificates of frail elderly patients with “It was her time.” I would get a call from Raleigh; Doctor Hadler you can’t do that. I’d respond, “Which of the several diseases vying for the honor do you want me to list?” Whenever you hear of the epidemic of cancer or heart disease or stroke, ask the “When” question.

About 20 years ago I published Four Laws of Therapeutic Dynamics. The first, rephrasing my “what v. when” conundrum, was “The Death Rate is One per Person.” Since my “Four Laws” are published, I won’t belabor them today, except to mention that the second law was “There has never been a quack without a theory.” The third, “Never Poke a Skunk”.

I’ve collected many more than 4 over the years. I don’t need to call them laws. How about guideposts for the perplexed physician? Here are some I cherish most:

Guidepost I. Curb your dogma.

This is not just about the contributions of scientific evidence to clinical practice. There’s also concrete symbolism. The term “curbside consult” had been clinical vernacular for generations. The idea is we should informally button-hole a respected colleague when we have a clinical challenge. The curbside is the antidote for the malignant granularity of EPIC. This dialogue is the essence of professionalism and the only valid form of Continuing Medical Education. Furthermore, the curbside is where you can also care about your colleague’s wellbeing. It’s where eye contact can reveal the pain of disaffection, substance abuse, even suicidal ideation. Ours is a stressful mission and beneath the white coat beats a very human heart. For us, collegiality has a therapeutic dimension.

Guidepost II. Health Care is not an Industry or even a System. 

Today, health has become a commodity, disease a product line and physicians are the sales force. And the infrastructure has become the superstructure.

No one who is ill wants to be considered a “unit of care” and no one who cares wants to be called a “provider.” You may go to clinic, or the operating room, or the office but you don’t go to work.  And you don’t bring work home; the same critical and empathic mindset walks through the door at the end of the day as did at the beginning. You are expected to participate in valuing options in complex situations at the bedside; you are fortunate to have such skills to bring home. If complexities are overwhelming, find the appropriate curbside.

Health Care is an interactive community of unique professionals which exists for one purpose, to care for the unique individuals who present for caring. That’s why you went into medicine. Don’t lose sight of that in the six-sigma sophisms.

Guidepost III. Health is not a diagnosis.

Americans believe that they should be free of morbidity from birth till that fateful 85th birthday. Americans and their physicians need to be disabused. We now have a science that informs the definition of health. One of the pioneering studies, the Health in Detroit study, was published nearly 40 years ago by Lois Verbrugge and her colleagues here in Ann Arbor. They asked some 600 people to keep a diary for 6 weeks in which, at bed time, they record every miserable thing that happened to them that day. We now have a great deal of information of this nature. If anyone goes a year without a backache, it’s abnormal. Three years without a month of knee or shoulder pain, that’s abnormal. If you go a year without headache, heartache, heartburn or something unpleasant with your bowels, that’s abnormal. Health is not the avoidance of morbidity. Health is having the wherewithal to cope with the next predicament and to cope so well that it is not long memorable.

That requires an inherent sense of invincibility. This sense of invincibility is far more fragile than organ-system homeostasis. This sense of invincibility has always been a target for medicalization and never more so than today. Everyone is burdened by baggage garnered from the internet, television, Oprah, Dr Oz, and all the other new age oracles who proclaim the scare of the week and the miracle of the month. You can’t eat, drink, or breathe anything without considering its implications for your health. That’s why so many are comfortable shopping in the placebo aisle at Whole Foods. This is a cacophony that challenges coping. The next predicament can seem the last straw and recourse, even recourse to a physician, the only sensible option.  If it’s to a physician, the mandate is to understand the dialectic. For example, when one seeks medical care for “My back is killing me, doc”, could it be that the chief complaint is “My back is killing me, doc and I can’t cope with this episode”?

Guidepost IV: Fees for Serving

No one chooses to be a patient for the fun of it. Short of catastrophe, it’s because of a failure to come up with a satisfying differential diagnosis and therapeutic plan on one’s own. Every symptom has been tempered by your patient’s preconceptions and distorted by yours.  If you are not prepared to listen, you will be misled by surrogate symptoms. For example, consider grandma’s knee pain.  If you compare the knees of elderly women who choose to be patients with knee pain with the knees of elderly women with knee pain in the community who do not seek medical advice, there is no important anatomical difference. The difference between the elderly woman with knee pain who becomes a patient and the elderly woman who remains a person is often contextual; it reflects a compromise in coping ability. Perhaps there is unresolved grief or consternation when social or physical support has diminished. The arthroscope is not a reasonable solution. Isn’t the arthroscopist more valuable for realizing that than for performing arthroscopy?

Guidepost V. No patient should ever ask, “What would you do, Doc?”

The 21st Century can support a new doctor-patient relationship, one where the patient is captain of the ship and the doctor is the navigator. The patient should understand the limits of certainty regarding medical options and be in a position to value options most personally. Furthermore, when faced with uncertainty, the question in the 21st C is “What would you do, doc, if you were me?” The value-laden response requires a trusting and trustworthy relationship. And a trusting relationship is always palliative. Don’t ever imagine that your demeanor, eye contact, attentiveness, and persona are not essential to any treatment act. In one of my books there’s a chapter titled, “My name is Nortin and I’m a placebo.” Usually, we call it bedside manner.

Quo Vadis

I started out talking about my Four Laws of Therapeutic Dynamics, but I only mentioned 3. The 4th paraphrases Robespierre:

Institutions Die, People Live

And I’m here today talking about living life as a physician. I am a serious believer in your generation and what you will accomplish for patient care. There are more guideposts I could discuss and many more you will discover. All you need is a commitment to caring about and for those in need.

There is a tradition in medical school commencements of taking an oath to that effect. You are about to offer up a modernized version of the Hippocratic Oath. I actually prefer “The Morning Prayer of the Physician”; a legacy of the Eastern Caliphate often ascribed to Maimonides and handed down by word of mouth till 1793 when Marcus Herz penned a version. Herz was a student of Immanuel Kant and physician to Moses Mendelssohn. 

There is another version, written in 1953 that is particularly relevant for the 21st Century. I first heard it while working as a visiting scientist in London in the 1970s. Sir Robert Hutchinson was one of those larger-than-life British clinicians, a pediatrician at Great Ormand Street who wrote this prayer in a letter to the editor of the British Medical Journal:

“From inability to let well alone; from too much zeal for the new and contempt for what is old; from putting knowledge before wisdom, science before art, and cleverness before common sense, from treating patients as cases, and from making the cure of the disease more grievous than the endurance of the same, Good Lord, deliver us.”

Colleagues of the class of 2015, I wish that on your 85th birthday you can look back on a career as a physician and smile. And as long as I am able, you can find me at the curbside. Bon voyage.

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2 replies »

  1. “Medicine is not a science. Medicine is a philosophy informed by science.”

    The roots of “Philosophy” are “Love of” (“philo,” “filial”) “Knowledge” (“sophia”). It’s not about spewing inscrutable opinions proffered in obtuse $50 words and phrases, it’s about trying to adduce facts.

  2. Best line in the piece —

    “You can’t eat, drink, or breathe anything without considering its implications for your health. That’s why so many are comfortable shopping in the placebo aisle at Whole Foods.”

    The WHOLE STORE is a placebo aisle!

    * Disclaimer. I read this line while standing in line for my sustainably grown organic coffee at my local Whole Foods. I also eat Kale.