Those of us in medicine have all seen the famous painting of the Tuesday afternoon lessons at the Salpȇtrière in Paris in the 19th century. In Pierre Aristide André Brouillet’s painting, one can clearly see the great professor, Jean-Martin Charcot, holding forth while the patient, Blanche Whitman, is being supported by a tall young man, Joseph Jules Francois Felix Babinski, the Chef de Clinique (the chief resident) and allegedly the favorite to succeed Charcot. He never did as he was failed repeatedly on the exam necessary to become a faculty member at the university by a jealous, xenophobic, anti-immigrant rival, Charles Bouchard. Babinski was born in France and served in the army twice, but his name was Polish as his parents had emigrated to France to escape bias in Poland (sound familiar?). Ironically almost no one remembers Bouchard (his only contribution being the Charcot-Bouchard aneurysm which may be the cause of some intracerebral hemorrhages), but there is no doctor on earth who does not know Babinski’s name. This is one of many reasons why Babinski is my neurological hero.
A family of mice begins to store away food and supplies for the long winter ahead. Most are practical and gather corn, grains, and straw. One of the mice, Frederick, instead collects rays of sun, colors of the rainbow, and words to remember. When winter arrives the family begins to use up their practical supplies. They become irritable and angry and don’t have anything to talk about. In other words, they become burned out. Frederick shares his stores of sun rays, colors, and a poem which enlivens their spirits and saves their lives.
Ever since reading this story to my own children I have used Frederick as a verb. When a wonderful event occurs, I try to remember to Frederick it…….and save it for a tough day.
About a month ago, a 20 year old woman, previously completely healthy, began to experience twitching of her left hand. Over several days this involuntary jerking worsened and spread to involve the left side of the face as well. Her parents told us that her personality had dramatically changed in that she lost her usual ebullient nature and became almost inert and unreactive. She came to us where it appeared that she was suffering from epilepsia partialis continua (continuous partial seizures).
The MRI was very abnormal in that it showed a very bright signal on T2 weighted images in the basal ganglia bilaterally. An EEG was abnormal in that it was quite slow, but there were no definite cortical correlates to the jerking. Continue reading…
I have some strategies for preventing “physician burnout.” I am a little over 70 years old and am not experiencing any of the symptoms of “physician burnout.” I do not state this out of any sense of pride, but I have tried to be introspective about this so as to offer some advice as to how to avoid this problem.
My approach is fourfold. I shall begin by reviewing the definition of burnout, and, in particular, physician burnout. Much has been written about this recently, but in order to address the individual issues, it is important that we are using the same definitions. Secondly, I shall review some facts about the reality of American medicine. Third, I shall articulate a paradox between what seems to be an epidemic of physician burnout in the context of the reality of American medicine. Finally, I will offer a nine point set of suggestions, which are meant to help to avoid the symptoms and signs of this syndrome.
Job burnout is not a new idea, and it is not specific to medicine. It has been in the psychology/psychiatry literature for quite a long time. It may be defined as a feeling of emotional exhaustion characterized by cynicism, depersonalization and perceived ineffectiveness.
In recent years, many have argued that “burnout” is extremely prevalent; not only in society as a whole but in particular in medicine. It has been said that 50% of physicians have at least one of the three cardinal features: exhaustion, depersonalization and inefficacy. The problem with these kinds of data is that are no adequate controls. It is probably quite common for many people, at some point or another, to experience one or more of these cardinal features. The real question is whether this is more than in a control population and whether they are persistent, rather than transient, symptoms. That information is not available. For these reasons, it is likely that the problem of “burnout” is being exaggerated. Nonetheless the problem undoubtedly does exist in an unknown proportion of physicians.
The eminent physicians Martin Samuels and Nortin Hadler have piled onto the patient safety movement, wielding a deft verbal knife along with a questionable command of the facts.
They are the defenders of the “nobility” of medicine against the algorithm-driven “fellow travelers” of the safety movement. On the one side, apparatchiks; on the other, Captain America.
They are the fierce guardians of physician autonomy, albeit mostly against imaginary initiatives to turn doctors into automatons. By sounding a shrill alarm about straw men, however, they duck any need to define appropriate physician accountability.
Finally, as befits nobility, they condescend to their inferiors. How else to explain the tone of their response to the former chief executive officer of Beth Israel Deaconess Medical Center, Paul Levy? As for patients, Samuels and Hadler defend our “humanity.” How…noble.
To me, healing the sick is an act of holiness, not noblesse oblige. Fortunately, we Jews cherish a long tradition of arguing even with God Himself. A famous Talmudic story ends with God acknowledging that even Divine opinion isn’t enough to override the rule of law. Let’s take a closer look at Samuels’s and Hadler’s opinions in relation to the rules of medical evidence.Continue reading…
This week I attended an all day “training” session in a new medical record system. I thought it was interesting that the experience was called “training,” which prompted me to remind myself of a few useful definitions.
Education, from the Latin root meaning a drawing forth, implies not so much the communication of knowledge as the discipline of the intellect; an intra-cerebral process aimed in large part at creating principles upon which new knowledge may be elaborated. Instruction is that part of education that furnishes the mind with knowledge. Teaching is often applied to practice as in “teaching a dog to do tricks.”
Training is an element of education in which the chief characteristic is exercise or practice for the purpose of imparting facility, as in “training for the marathon.” Breeding relates to manners and outward conduct as in “standing when elders enter a room is a sign of good breeding.” Regimentation is the prescription of a particular way of life or thinking usually involving the imposition of discipline. The term, arising from military regiment, is related to the medical usage of regimen, as in “the patient keeps his prescription medications in separate compartments of a plastic container in order to accurately adhere to his regimen.” Propaganda is the systematic propagation of a doctrine, cause or information reflecting the views and interests of those advocating such a doctrine or cause, as in “ACCME is propagating the view that elaborate re-certification maneuvers will improve the lives of patients.”
A cheerful instructor started the session by asking each of us to introduce ourselves and reveal a “secret guilty pleasure.” Mine is to create elaborate cocktails. If only I had had one of my famous Marty’s Beerjitos with me the whole experience could have been much more pleasant. In addition to the instructor, there were several “super-users” in the room to facilitate the process. It was immediately obvious to me that the super-users hovered behind my chair. These friendly young people had correctly identified me a “super-loser.” Had I been litigious I would have reported the experience to our ombudsperson as blatant ageism.
But, alas, they were correct. I was hopeless. Besides, I don’t believe in ombudspeople. I believe one should speak for oneself.
I work at the Brigham and Women’s Hospital in Boston. We call it The Brigham. A month ago we were subjected to a tragic murder of one of our doctors. The winter has been brutal and unrelenting. Then, as I was walking to work the other day I was struck by a ray of light.
It was 7:30 AM and the morning light shone directly into what was the original main operating room of the Peter Bent Brigham Hospital, one of the parent institutions of what we now know as The Brigham. Peter Bent Brigham was a restaurateur who left an endowment for a hospital for the poor. It was decided to site the Peter Bent Brigham in the Longwood area just behind the Harvard Medical School which had moved to this location in 1904.
After a national search, Harvey Cushing was selected to be the founding Surgeon-in-Chief. Cushing, a native of Cleveland and graduate of Yale College and Harvard Medical School, had trained in surgery at the The Johns Hopkins Hospital and was in the process of creating the modern field of neurosurgery. Between 1910 and 1913, Cushing worked with the architects of the new hospital and sited the operating room such that the morning sun would shine into its large window, thereby allowing the surgeons to see well with natural light.
I am a doctor today because of Dr. J.W. Epstein, my pediatrician in Cleveland in the 1950s. An immigrant from the Nazi terror in Europe, he had trained in Vienna and spoke English with a Germanic accent. His house calls are etched permanently in my memory. His visits were heralded by a fury of activity, led by my mother. “The doctor is coming! Put on clean underwear. Clean the house.” Water would be set to boil on the stove, in case the doctor should need to sterilize a needle for an injection. Up would drive his broken-down jalopy, which he would park directly in front of the house. No need to worry about getting a ticket. The police knew his car and would never issue a citation to The Doctor. No one – not the mayor, not the governor, not even Al Rosen, the venerated third baseman for the Indians – would have received such a royal welcome.
In he would come, wearing a suit and hat, carrying a worn black doctor’s bag. “Mudder, ver is da boy?” ”He’s in his room upstairs with a rash and sore throat.” He would put down his bag, sit on my bed, and ask me if the teacher had sent home the homework. He wouldn’t want me falling behind in my school work.
That might interfere with my becoming a doctor. Then came the ritual of the examination. Say aah; schtick out your tongue; take some deep breaths. “Gut… gut…zounds normal” as he listened with his stethoscope, feeling gently on my belly and then finally tap on some reflexes with his tomahawk hammer. “Mudder, it’s da measles, plenty of fluids, back to school in a few days.” “Veel zee you in da office next fall for da usual checkup.” “Mudder; don’t vorry, it isn’t polio.” No time for a cup of tea today; too many other house calls for this afternoon and off he would go. The enormous feeling of relief, transmitted from my mother to me, had me on the mend in no time.
This is what I wanted to do: be the agent of relief, the repository of medical knowledge, the most respected figure in the community. Some years later, as a teenager, I was waiting in Dr. Epstein’s office for my annual checkup before school started in September. I was surrounded by little babies and I realized that I might be growing out of Dr. Epstein. As he was tapping on my back in the usual reassuring fashion, I said to him, “How long can you see me as a patient?” “ Until you’re a doctor.” How could I fail him?