What I Read Last Week

One of the ways I am dealing with empty nest syndrome is by accepting invitations to visit other medical centers. These visits have been absolute pleasures. Giving talks is enjoyable and a bit of an ego boost. Getting to visit the local museums and see old friends who live in the area is a treat. The real highlight, though, is sitting and talking in person to colleagues who have previously only been virtual. Because of my dedication to “making is count twice,” many of these visits have led to Sensible Medicine posts.

Last week I visited The Cleveland Clinic. Here are two of the articles people shared with me.

Aequanimitas for Our Time

The American Journal of Medicine has a reputation for publishing thought provoking (even controversial) commentaries.¹ This piece by Salvatore Mangione and Charles Lockwood argues that because practicing medicine is hard, making training easy is counter to what is necessary to produce excellent and resilient doctors. I can’t say I agree with everything in this article. There are parts that make me picture the proverbial curmudgeon screaming, “Get off my lawn!” Yet, there is a lot I do agree with, and I don’t think I have ever read an article in the medical literature littered with such great quotations. You should read the whole article but here is a generous sampling.

As the saying goes, you know you've reached middle age when you stop complaining about the older generation and start complaining about the younger one.

…resilience might even be the metaphorical load-bearing wall of medical education, because we are tasked with preparing problem-solvers that will bend but not break. Yet, many of today's students seem unready for the harsh reality of their chosen profession. This may actually contribute to the record levels of burnout and depression being observed among early career doctors.

Learning occurs at the point of discomfort, and over time, this process produces wisdom.

And last, from Hemingway:

The world breaks everyone and afterward many are strong at the broken places. But those that will not break it kills. It kills the very good and the very gentle and the very brave impartially. If you are none of these, you can be sure it will kill you too but there will be no special hurry.²

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Long COVID-19 and the Role of the Patient–Clinician Interaction in Symptom Management

This article by Leonard Calabrese and Luana Colloca acknowledges the challenge of long COVID; admitting that the disease remains prevalent and “largely medically unexplained.” For many patients, especially those without objective abnormalities (like postural orthostatic tachycardia syndrome -- POTS) to treat, there is no readily available medical therapy. The authors argue, though, that clinicians:

…do indeed have a potent neurobiological therapeutic in hand that can positively or negatively affect daily clinical outcomes. We assert that the very nature of the clinical encounter and the biopsychosocial factors surrounding the patient–clinician interaction can have meaningful effects on clinical outcomes including quality of life and symptom improvements.

My read on long COVID has been that it is nothing new. We have always seen post inflammatory syndromes of, often debilitating, non-specific symptoms. I was optimistic (in a strange sort of way) that we would make progress with these syndromes because we are seeing so many people suffering with them all at once. Instead of a smattering of people suffering after a sporadic EBV, mycoplasma, or pneumococcal infection, we were seeing thousands of people suffering after a COVID infection. I am still hopeful.

Drs. Calabrese and Colloca go a step further and argue that this period presents an opportunity to study how the patient/doctor relationship can provide meaningful, physiologic benefit to patients. The authors are very careful in how they present their argument. I especially like this statement:

…it is vitally important to emphasize that our advocacy for applying the principles of placebo science mediated by the patient–clinician relationship does not in any way diminish or invalidate the suffering of patients so afflicted by Long COVID but rather opens up new areas to explore neurobiologically based emerging science.

My favorite part of the Hippocratic oath pertains to this: “I will remember that there is art to medicine as well as science, and that warmth, sympathy, and understanding may outweigh the surgeon's knife or the chemist's drug.”

I certainly would like a better understanding of the neurobiologic benefits of clinical excellence and a robust patient/doctor relationship — a measurable response to the art of medicine. Maybe if we could quantify the benefit, more value would be placed on teaching the skill and recognizing its importance.

1. For example, AJM published our The Case for Being a Medical Conservative back in 2019.

2. This quotation is so damn laughably HEMINGWAY. It’s like you asked an AI bot to write in the voice of Papa.