Practicing

Of all the problems we face in clinical medicine, few are more vexing than patient interactions that don’t go well. Dealing with a “difficult patient,” as they’re commonly referred to, can ruin your day and set off a spiraling cascade of thoughts and emotions. Those patient encounters frustrate us and drain us as clinicians. They can leave us feeling at once helpless and self-righteous, empathetic and disdainful. Often, they make us want to run away. Other times, they suck us in, to an uncomfortable degree. I’d say doctors spend as much – if not more – time talking to each other about difficult patients as they do about difficult diagnoses.

Hearing Dr. Autumn Fiester lecture on the difficult patient was one of those rare moments when a phenomenon I thought I had a handle on based on my own experience was completely reframed. Her ideas led me to see the problem from an entirely different angle, and to reinterpret my past experiences as a result.

Autumn Fiester is a philosopher and bioethicist at the University of Pennsylvania, where she is Vice Chair for Education in the Department of Medical Ethics & Health Policy at the Perelman School of Medicine as well as the Faculty Program Director for the Master of Bioethics (MBE) and Master of Science in Medical Ethics (MSME) degrees. She is the Director of the Penn Program in Clinical Conflict Management, which promotes conflict resolution training for clinical providers and clinical ethics consultants. She is the author of over 100 publications in the areas of clinical ethics, clinical conflict management, and more.

I think my conversation with Autumn will really appeal to clinicians who have necessarily had the experience of navigating conflictual or dysfunctional patient relationships. But I also think what Autumn has to say is enlightening for anyone who’s been a patient. As she says, we have all been, or have the potential to be, difficult patients.

An Announcement!
This is the 20th episode of “Practicing,” a milestone I’m not sure I ever thought I’d reach when I started the podcast two years ago. It seems like a good time for me to take a break, regroup and dedicate some time to other projects. Now, this isn’t a farewell, it’s just a “see you later.” I may return with the occasional interview over the coming months, but my hope is to come back with fresh ideas. So stay subscribed! Thanks to all of you for your precious attention, and to those of you who sent feedback, subscribed, shared or rated the show, or helped and supported me in countless other ways. I couldn’t have done it without you. And of course thanks to all my guests – you are what Practicing is all about.

***

Links:
-Autumn's bio

***

Recorded July 11th, 2023
Art: Jeff Landman
Music: Mr. Smith

www.practicingpod.com
Twitter: @practicingpod
Instagram/Threads: practicingpod
LinkedIn: Practicing Podcast

A little over two years ago, two good friends of mine, whose daughter Fera was born just a few weeks before my daughter, came to me with concerns about their baby. Fera was about 9 months old and at a routine check-up her doctor had found that her weight gain had slowed. 

When her mother, Vanessa, reached out to me about this, I wasn’t too worried – so often in pediatrics health concerns turn out to be nothing, or small hiccups that get better on their own. Not to mention the fact that I hated to imagine that my friends’ baby could be sick. But once I saw Fera’s growth curve and heard all the details of her symptoms, including the fact that she was fussy and always thirsty, constantly soaking her diapers, and preferred water to her mother’s milk, I was alarmed. So I arranged to have Fera seen by a colleague and tested at the clinic where I work. 

Within a few weeks, it emerged that something was very wrong with Fera. She was losing everything through her kidneys: water, electrolytes, sugars, proteins. Once that was clear, Fera was hospitalized, and as you’ll hear from her parents, Vanessa Bonneau and Sylvan Lanken, she was diagnosed with cystinosis, a rare genetic disease that causes the amino acid cystine to build up in every cell of a person’s body over time. 

Fera’s diagnosis was devastating: cystinosis is degenerative and though it can be managed and treated with a tremendous amount of work, there is no cure. 

Over the last three years, I’ve seen Fera and her parents struggle, but I’ve also seen her grow up, stabilize, and play with my daughter like any other child. 

I wanted to speak to Vanessa and Sylvan about their experience, about their interactions with the health system and the cataclysm of Fera’s diagnosis. My intuition was that many people – including me – would benefit from hearing their story, and after recording our conversation I’m more convinced of that than ever.

In addition to being Fera’s parents, Vanessa Bonneau is a writer and editor, and Sylvan Lanken is a musician who also works in higher education.

The following interview isn’t easy to listen to at times and it deals with very difficult themes. So please be warned. But I do encourage you to listen if you can – Vanessa and Sylvan brought all of their humanity and openness to this interview, and as a result it is a gift.

***

Links:
-Cystinosis Research Foundation
-Basic information on cystinosis (NIH)

***

Recorded June 29th, 2023
Art: Jeff Landman
Music: Mr. Smith

www.practicingpod.com
Twitter: @practicingpod
Instagram/Threads: practicingpod
LinkedIn: Practicing Podcast

The phrase “evidence-based medicine” is uttered so often in the medical world that it can lose its meaning. So what does it mean? We use the phrase to highlight the ways that medical knowledge and practice are based on scientific data, systematic studies that allow us to determine what really works, to distinguish cause and effect from random associations. And modern medicine has been built around that notion of scientific objectivity. 

But I also like to think of the many gaps in that evidence, the known unknowns but also the unknown unknowns. We can only use the evidence we’ve first sought to gather, after all. We can only seek answers to the questions we think – or allow ourselves – to ask.

My next guest, Olivier Drouin, is trying to ask questions that might expand our notion of evidence-based medicine. With his focus on behavioral science, Olivier seeks to better understand the ways we behave and make decisions, the influences that shape and distort our thoughts and actions. As you’ll hear, Olivier sees this as an untapped evidence base, one that scholars in psychology, economics, political science and law are familiar with, but that medicine has tended to ignore. 

Olivier Drouin is a pediatrician and health services researcher in the Division of General Pediatrics at Sainte-Justine university health center, a pediatric research hospital in Montreal. He trained as a Research Fellow at Harvard, where he also obtained a Master’s of Public Health. Before that, he completed his clinical training at Sainte-Justine and at the Montreal Children's Hospital, where we were fellow residents. He conducts fundamental and applied research in the fields of behavioral economics, public health, global health, and health policy. He’s often called upon to comment on topics related to child health in local and national media. 

Olivier and I first met in pediatric training at the Montreal Children’s Hospital, when he was my chief resident and one of my earliest clinical teachers. We’ve been friends, and occasional collaborators on writing projects, ever since. One thing I’ve always appreciated about Olivier is his commitment to research that has concrete, practical applications, and his broad intellectual range, which allows him to make connections across disciplines.

A NOTE:  we use the terms “obesity” and “overweight” in this conversation, because they are typical medical terms. However, I realized after recording that they can be hurtful and stigmatizing. I apologize for that, and I intend to use more inclusive and respectful language from now on, but I did choose to keep the discussion on the tape, as I do believe it’s valuable.

***
Links:
Olivier's website
Daniel Kahneman: "Thinking, Fast and Slow"
Richard H. Thaler and Cass R. Sunstein: "Nudge"
Daniel Kahneman, Olivier Sibony, Cass R. Sunstein: "Noise"

***
Recorded May 2nd, 2023
Art: Jeff Landman
Music: Mr. Smith

www.practicingpod.com
Twitter: @practicingpod
Instagram: practicingpod
LinkedIn: Practicing Podcast

When I first started reading Lisa Rosenbaum’s work in the New England Journal of Medicine a few years ago, I felt I had discovered the voice I’d been searching for since starting my medical career. At once evidence-based and deeply human, Lisa’s reportage on topics such as vaccine hesitancy, the war on science, or the Covid pandemic provided something I craved, which was to see the medical world explained and exposed in a way that questioned and transcended the assumptions and dogma that so often govern it. 

Lisa isn’t just a critic though. She has a deep love of medicine and as you’ll hear she believes in its potential for good. She is, however, lucid about its shortcomings, and her skill as a writer allows her to approach even the most controversial topics with nuance, sensitivity, and intelligence. She is, to my mind, one of the very best physician-writers working today. 

In addition to her regular written contributions, Lisa recently launched a podcast with the Journal called Not Otherwise Specified, in which she interviews leading thinkers in medicine about their work. 

Dr. Lisa Rosenbaum is a national correspondent for the New England Journal of Medicine, assistant professor of medicine at Harvard Medical School and practicing cardiologist at Brigham and Women’s Hospital in Boston.

Lisa completed medical school at the University of California, San Francisco, did an Internal Medicine residency at Massachusetts General Hospital and a Cardiology fellowship at New York Presbyterian Hospital Weill-Cornell. She spent a third year of fellowship at the New England Journal of Medicine and was also a Robert Wood Johnson Foundation Clinical Scholar.

Lisa and I spoke about her dual career as a writer and physician, the longstanding, in some ways inherited importance of writing and storytelling in her life, the state of US healthcare and the future of medical work. 

This was a special conversation for me – an opportunity to speak with one of my role models – and I hope you enjoy it as much as I did. 

***
Links:
Not Otherwise Specified Podcast
Lisa's Writing @ NEJM

***
Recorded March 29th, 2023
Music: Mr. Smith
Art: Jeff Landman

www.practicingpod.com
Twitter: @practicingpod
Instagram: practicingpod
LinkedIn: Practicing Podcast

In the clinical work I do in urgent care pediatrics, most of the kids I see come in with an injury or an infection – a fever, cough, runny nose, GI symptoms. That means that – as is the case for many pediatricians – so much of what I do revolves around diagnosing infections and counseling families about them. It’s often routine work, but it has its challenges. The most difficult thing, I think, is seeing parents who are desperate for relief, exhausted from a few sleepless nights with a sick, crying child, and having to tell them that their child isn’t in danger, that nothing more needs to be done, and that this too, shall pass on its own. That disconnect between the distress – which I too have felt as a parent – and the routine nature of these illnesses, is tricky to navigate.

In the last few months, and in particular this past Fall, it seems all of society and much of the news cycle in Canada and the US turned its attention to childhood infections. With an extraordinary wave of RSV and then influenza, pediatric emergency rooms and hospitals were overwhelmed with sick patients. Coming in the midst of the Covid pandemic, this wave of viral infections had health systems reeling. In Canada, shortages of medications like common antibiotics and pediatric formulations of ibuprofen and acetaminophen compounded the sense of chaos and of a breakdown in health services. 

All that has now passed, but I wanted to revisit those events and talk a little about what happened. My next guest is someone I’ve come to trust on this subject for his abilities as a communicator. 

Alasdair Munro is a senior clinical research fellow in pediatric infectious diseases at the UK National Institute for Health and Care Research (NIHR) in Southampton, England and a medical doctor. He’s currently a senior trainee in pediatrics working in pediatric emergency medicine. During the pandemic he led the live evidence review of COVID-19 in children with the Royal College of Paediatrics and Child Health while running a number of different COVID-19 vaccine clinical trials. He also sat on The Lancet commission on COVID-19 (safe work, travel and schools) as well as the NIHR working group for the study of transmission of COVID-19 in schools. 

Alasdair’s gained a large Twitter following, and his substack newsletter, the Munro Report, is widely shared. Whenever I read Alasdair, I feel he captures the way I and most pediatricians I know think, about covid, other infections, and pediatrics more broadly. We cover all of that in our conversation, and I hope you enjoy it as much as I did. 

Although I never provide medical advice on this show, since this episode is about my area of clinical expertise, I wanted to make it extra clear that nothing in the following discussion should be construed as direct medical advice to you or a child you know. For those questions, you should see a health care provider yourself. 

And now, here’s my conversation with Alasdair Munro.


***
Links:
Alasdair's newsletter
Alasdair's Twitter: @apsmunro
Don't Forget the Bubbles (pediatric evidence review site)

***
Recorded February 9th, 2022
Music: Mr. Smith
Art: Jeff Landman
***

www.practicingpod.com
Twitter: @practicingpod
Instagram: practicingpod
LinkedIn: Practicing Podcast

“I’m twenty-nine years old, writing in my journal in a sloppy felt-tip pen (no ballpoints are allowed), trying to understand how I went from being a newly minted physician in a psychiatry residency program at Columbia University to a psychiatric patient at Bellevue, the city’s notorious public hospital.”

That’s a quote from the first page of Carl Erik Fisher’s The Urge: Our History of Addiction (Penguin Random House, 2022). As he reckons with what has brought him to that point and enters recovery, Carl revisits his own history of alcohol and drug use and comes to pose broader questions. “Why was there a totally separate system for addiction treatment? Why do we treat addiction differently from any other mental disorder? If everyone seems to know that the system is broken, why isn’t anyone changing it?” he writes. 

“The Urge” explores these and other questions, offering a history of addiction and medicine and society’s response to it through the ages. Drawing on sociology, anthropology, and theology along with psychology, neuroscience, and of course medicine, Carl’s book is part memoir, part work of popular science. But it’s also something more. That’s why I was so eager to explore it with him.

Carl Erik Fisher is an addiction physician, bioethicist, and person in recovery. He is an assistant professor of clinical psychiatry at Columbia University and maintains a private psychiatry practice focused on complementary and integrative approaches to addiction and recovery.  His writing has appeared in The New York Times, The Guardian, Slate, and elsewhere. The Urge was named one of the best books of 2022 by The New Yorker and The Boston Globe. He also is the host of the Flourishing After Addiction podcast, which I highly recommend.

Carl’s work is so compelling to me because it combines his scholarly curiosity with his clinical experience and personal past. It’s one thing to write a history of addiction; it’s quite another to do so while also working with patients who struggle with addiction and who are in recovery while being in recovery yourself. The result is work that I’d describe as integrated, a rich whole that combines the general and the specific, the scientific and the experiential, the analytic and the critical. It’s no exaggeration to say that The Urge helped me see the world around me – both current events and medicine’s particular role in them – as I hadn’t seen it before. 

***

Links:
Carl's website
Carl's podcast
The Urge website

***
Recorded December 13, 2022
Music: Mr Smith  
Art: Jeff Landman
Photo of Carl: copyright Beowulf Sheehan

www.practicingpod.com
Twitter: @practicingpod
Instagram: practicingpod
LinkedIn: Practicing Podcast

The summer I turned thirteen my family moved to Berlin from Canada. Although we were an essentially secular Jewish family, I had a basic Jewish education and quite a developed awareness of the history of World War II and the Holocaust. Like many young readers, I had been captivated by “The Diary of Anne Frank”. I’d also been to museums and seen plays, movies, and read many stories about the period and the plight of Europe’s Jews under the Nazis.

So although I was well aware of Germany’s brutal history, I wasn’t prepared for its omnipresence in everyday life in Berlin. Subtle, almost banal traces of the Nazi past were everywhere: in discreet memorial plaques on buildings, in the names of subway stops, or even on the ground beneath one’s feet, where the names of deported Nazi victims were engraved on special brass cobblestones in the sidewalks in front of the victims’ former homes.

But for Harvard anatomist Sabine Hildebrandt, growing up in postwar Germany meant being surrounded by a lack of evidence of her country’s dark past. Absent Jewish neighbors, abandoned synagogues, and uncomfortable silences: that was her experience. From the silence a curiosity emerged, a need to know that was the impetus for her ongoing quest to excavate the past, to understand it and to memorialize it. And that’s what she does in her book, “The Anatomy of Murder: Ethical Transgressions and Anatomical Science during the Third Reich”, the first systematic study of anatomy under National Socialism. 

Sabine Hildebrandt is an associate professor of pediatrics at Boston Children’s Hospital, and a lecturer on Global Health and Social Medicine at Harvard Medical School. She also teaches anatomy and history of anatomy at Harvard. 

I knew I wanted to speak to Sabine when I saw her name mentioned in not one, but two stories in the New York Times related to German anatomy’s Nazi past; one about the notorious Pernkopf anatomical atlas,  and the other related to her work as a member of the Historical Commission on the University of Strasbourg, which was taken over by the Nazis during the war and was the site of some harrowing abuses. I’ve linked to both articles below.

Speaking to Sabine was interesting on many levels. The history she has systematically laid out in her work is horrific, but unquestionably fascinating and valuable in its own right. But what is so special about her work, I think, is the way it prompts us to reflect on medicine’s relationship to power, and the discipline’s intrinsic potential not only for good, but also for evil.

On that note, a brief warning. My conversation with Sabine includes the discussion and description of medical violence and outright crimes in a context of tremendous brutality and disregard for human life. So please listen with caution and care. 

***

Links:
Sabine's bio
New York Times article on Pernkopf Atlas
New York Times article on Strasbourg University
Sam's review of "The Anatomy of Murder"

***
Recorded October 12, 2022
Music: Mr Smith  
Art: Jeff Landman

www.practicingpod.com
Twitter: @practicingpod
Instagram: practicingpod
LinkedIn: Practicing Podcast

One of the reasons I never tire of making this podcast is that each conversation brings with it a sense of surprise, an encounter with the unexpected. When I heard about Q Hammouri and the advocacy group they founded, Pride Ortho, I was eager to hear about their efforts to break the taboo of queerness in the straight, male-dominated field of orthopedics and to hear Q’s own story. Although we were able to speak at length about that advocacy work and the field of orthopedics, our conversation took us in many other directions, about the nature of identity, the fundamentals of medical thinking, and the ways something as simple as looking and seeing can transform our relationship to the world.

Q Hammouri is a pediatric orthopedist and spine surgeon. They are also an artist, immigrant, proud American, Buddhist, Muslim, Arab, and non-binary. They obtained their medical degree at the University of Jordan and immigrated to the US to pursue further medical training. They received their orthopaedic training at Yale, then completed a fellowship in spine surgery at New York University and a fellowship in pediatric orthopaedics at Columbia University. In 2013, they joined Northwell health to found the Pediatric Orthopaedic Department at Staten Island University Hospital, where they practiced until recently, performing the first pediatric spinal surgeries in the New York City borough of Staten Island. Q is the founding president of Pride Ortho, an LGBTQ+ advocacy group in orthopedics, and sits on the Diversity task forces of Pediatric Orthopaedic Society of North America and Scoliosis Research Society. In 2021, they were chosen as an Atlantic Health fellow for Health Equity for their work on LGBTQ access and advocacy. 

What struck me most about Q’s observations and experience is the way their identity, their many identities in fact, are woven into their professional self, and the way they are as a physician and surgeon. I couldn’t help but see a connection between their attention to detail, their focus on observation as a surgeon and as a visual artist, and their sensitivity to their own appearance, to the ways their patients may feel perceived, seen or not seen, because of their medical condition, their sexual and gender identity, or both. Far from making them a less focused or engaged professional, Q’s different pursuits reinforce their sense of purpose and their grounding in what remains – even in our high tech, hyperspecialized age –  medicine’s essence: tending to the suffering of other human beings.


***
Links:
Pride Ortho
Q's art: Earl of Bushwick
The Whitest Specialty, by Usha Lee McFarling, Stat News, December 13, 2021

***
Recorded October 18, 2022
Music: Mr Smith  
Art: Jeff Landman

www.practicingpod.com
Twitter: @practicingpod
Instagram: practicingpod
LinkedIn: Practicing Podcast

So many forces that seem to be about other aspects of human life – economics, geography, identity, politics – are in fact also intimately connected to health. That connection isn’t just incidental, it’s fundamental: once you begin to see it, it’s everywhere, and it comes through in concrete, important ways, ways that impact human wellbeing.  

Transportation - how we choose to get around - is one such aspect of daily life. We usually talk about it as traffic patterns, transit fares, bus schedules, and commute times. For some, it’s a fascinating subject, for others, it’s simply background noise: there, but hardly worth remarking upon. 

And yet getting from one place to another is something we nearly all have to do, most often on a daily basis. I started riding a bicycle to get around my city about 15 years ago, and I’ve loved it ever since. I can’t get everywhere I need to go by bike, but it’s long been my preferred means of transportation. More recently, I’ve become interested in the greater benefits of cycling, the factors that influence people’s decisions to choose one mode of transportation over another, and how better transit makes for better lives, and even a better world.

At the same time, I’ve seen more and more news of rising rates of car crashes, pedestrian deaths, and cars becoming less safe instead of safer, over the past few years. That’s news I’ve found it difficult to ignore.

As I’ve learned more about these issues, the cascading implications of something as basic as how you get to work, drop your children off at school, or run your errands have revealed themselves to me. Of course there’s traffic and noise and air pollution, but there’s also your individual health, your risk of injury – of death even –  the look of the built environment and your feeling of connection to it. I really believe - and there’s evidence to support this - that how you get around even impacts your mood. 

To explore the health and safety dynamics surrounding urban transit, I was fortunate to be able to speak to Kay Teschke, Professor Emeritus of the University of British Columbia's School of Population and Public Health, and a leading academic in the field. After beginning a career focused on occupational exposure risks, Kay started a new research program in 2004 called “Cycling in Cities”. That research focused on the interaction between factors like the type of bike route available to riders, and the risk of injury or the decision to ride a bike. It has contributed scientific evidence for building routes that welcome cycling in North American cities, and Kay has been involved in provincial, national, and international policy making related to cycling. Even after her retirement, “Cycling in Cities” continues to be a thriving research initiative. 

Talking to Kay helped me better understand the facts around cycling and urban transit, and to more clearly see how, as a society, the way we get around isn’t pure happenstance: it’s the result of deliberate decisions and clear choices – and we live with the consequences of those choices every day. 

***
Links:

Kay's research and Twitter
Cycling in Cities and its successor, CHATR
"The Deadliest Road in America",  by Marin Cogan, Vox

***

www.practicingpod.com
Twitter: @practicingpod
Instagram: practicingpod
LinkedIn: Practicing Podcast

Mental health as a phrase is so broad and far-reaching as to drift into cliché, or elude meaning altogether. 

The many facets and complexities that “mental health” encompasses each merit their own conversation: the role of diagnosis and medication; our approaches to care; addiction and substance abuse; the apparent increase in struggles among our youth; the impacts of the Covid pandemic; the changing workplace; the effect of technology; the role of economic inequality, systemic racism, homophobia and transphobia, and other forms of discrimination; mass incarceration, and the list goes on. 

But there is no question that the theme of mental health, the wellbeing of our mind and spirit, our sense of belonging in the world, is an urgent one, which, it seems to me, has been garnering ever-greater degrees of attention in public discourse. I’ve wanted to figure out how to approach this vast topic and pick out avenues for further reflection and examination. 

That’s why I jumped at the opportunity to speak to my next guest, someone who’s been immersed in mental health work for over twenty years, and has approached it from several angles. 

Benjamin F. Miller is the former president of Well Being Trust and chair of the advisory board of Inseparable, two mental health organizations. Over the last two decades, he has worked to promote and prioritize mental health in policies, programs, and investments in his native United States. 

Trained in clinical psychology at Spalding University, the University of Colorado and the University of Massachusetts, Ben started his career as a clinician and then spent 8 years as an Associate Professor in the Department of Family Medicine at the University of Colorado School of Medicine where he was the founding Director of the Eugene S. Farley, Jr. Health Policy Center. He subsequently joined Well Being Trust, a nonprofit dedicated to mental health, as Chief Strategy Officer and then, until recently, as President.

Ben has testified before state and federal government committees in the United States, is active as a keynote speaker, and has been featured in a wide range of major media outlets, including the New York Times, USA Today, CNN and NPR. He is also the author of “Mental,” a substack newsletter on topics related to mental health. 

I’ll confess speaking to Ben left me with more questions than answers, given the enormity of the topic, but our exchange allowed me to focus my thoughts and his insights provided material for further contemplation. I hope it does something similar for you. 

Just a warning that we do discuss topics of suicide, addiction, and other forms of distress during the episode. If you’re in need of help, please reach out to someone you trust or a healthcare provider. If you’re a healthcare worker, your employer or professional association may also provide support.  And you can always call Talk Suicide Canada, 988 in the United States, or a suicide prevention or crisis hotline wherever you are. 

***
Links:

Ben's newsletter
"The Mystifying Rise of Child Suicide," by Andrew Solomon, The New Yorker
"'It's Life or Death': The Mental Health Crisis Among US Teens," by Matt Richtel, The New York Times


***

www.practicingpod.com
Twitter: @practicingpod
Instagram: practicingpod
LinkedIn: Practicing Podcast