I probably reached middle age prematurely…As a surgical attending I condensed this excellent article to four dictums: 1) trust no one 2)assume nothing 3) your own mother would sell you for a price and 4) there are assassins around every corner. Probably wouldn’t last long on faculty these days. No, I don’t own a Grand Torino.
We, as a nation, are protected by the trained and the elite. To think that my life and the lives of my family and every other person in our country teeters on the fulcrum of ne'er-do-wells on one side vs the intensive, sometimes physically and/or mentally tested beyond what they thought their limits on the other side, is scary. Navy Seals, Green Berets, Delta Force, etc. graduate after learning they can perform well beyond their initial thoughts. I want my life protected by the elite.
Lovely article by the incomparable Dr. Sal Mangione, who I had the privilege of training under in IM residency at Jefferson hospital in Philadelphia. I still remember some of his noon lectures to us interns nearly 15 years later!
I used to treat a fair number of people with post-viral syndromes, typically labeled "fibromyalgia" or "chronic fatigue syndrome" - usually with "chronic pain" too. At the height of Purdue's influence (1996-2012) many had been started on large doses of opioids, and/or many other drugs (sometimes up to 6-8 drugs affecting the brain). One universal technique to improve them was to stop as many drugs as possible. I usually found the opioid was the least of the problem (although patients were pharmacologically and perhaps psychologically dependent).
But the most useful thing I did for a few people was to write (literally) and "educational prescription." This applied to women who had dropped out of school or not been able to continue for reasons that most readers will readily imagine. My prescriptions were to community colleges, e.g. "Please help this person to access further education or training that will help her gain better employment." In once case, the prescription was to a building trades union business agent, asking "She has been sexually harrassed at work. Please intervene to protect her and see if some further training can help her improve her economic independence." In that case the union responded more positively than I could have hoped. The patient returned to say she was taking a "math course" and doing "really well" in it.
I think these are examples where a friendly, respectful, and supportive human relationship between clinician and patient goes a long way. I've personally experienced the same from a hotel manager who hailed me after I shattered my clavicle. I was afraid she suspected me of sneaking free coffee (as a non-guest). It turned out she had suffered a similar injury, recognized my sling, and came over to tell me: "Don't worry, honey. It's gonna' be all right!" Most therapeutic intervention I could experience.
Thanks Adam - we are working on objectively quantifying the physician/practitioner dyad with a special focus on how natural language AI in the exam room could potentially augment it!
Adam, you may be too young to have read the classic book by Norman Cousins, The Anatomy of an illness as Perceived by the Patient. It directly examines healing in the context of a positive physician-patient relationship and an intelligent pondering on the therapeutic benefits of the placebo effect. I urge my fellow subscribers to pick this classic up.
Would that there exist a pre-admission evaluation of Stoicism and resilience. An option: admit more medical students and "test" their resilience, better to burn out in earlymedical school than early practice!
I read the second half with interest having suffered from Long Covid myself. I worked with a total of 7 doctors including my GP, a more alternative "functional med" doc, and several specialists.
Here's my take based on my experience.
On one extreme I received an abundance of sympathy but no concrete solutions, suggestions, or a willingness to run a single blood test. On the other extreme was over-promising snake oil. (If you could have a 3rd extreme, I also experienced scolding and shaming for not taking the vaccine early and an arrogant push to take it after the fact which made no sense.) In the middle was a humble and sympathetic attempt to try to help me. Those doctors ran tests within their specialty with no promises but a sincere desire to help if they could.
My favorite doctor was an allergist/immunologist experienced with mast cell activation syndrome. His office was antiquated and poorly run. He didn't actually do or prescribe anything; instead, he helped me rule out many things that the internet told me I had. I do think his general demeanor gave me the confidence to just give it more time and stop trying every supplement that someone said cured them. He predicted I would slowly improve and get better and he was correct.
Regarding the AJM article, there is much debate now about how far to accommodate trainees in their quest for a less harsh training experience. But make it too soft and learning will suffer and they will be shocked to find practice is also stressful. The real solution is to get word out to the premeds that life in medical training and in practice is hard. Bazillions of people are applying to medical school, and some effort should be made to select those for admission who understand it is going to be a difficult road ahead and have the resilience to survive.
1. Many symptoms are caused by abnormal clotting behavior. Taking a nattokinase supplement may help. I and several friends have had relief within two hours, of symptoms that had lasted days to months such as migraines and joint pain.
2. Many symptoms are extremely similar to post-sepsis syndrome.
3. Symptomatic long Covid is strongly correlated with Epstein-Barr virus (mono) reactivation (60% vs 10%).
As a medical student now and 25 years ago... It's so much more onerous nowadays... The micromanaging and surveillance is so intense now... The freedom and flexibility back then is heretical now... So from my perspective, it's a helluva lot harder to be a med student now... With the caveat that you reap what you sow, students have definitely become more inclined to respond to being treated as irresponsible and unable to be trusted by living down to those expectations. So I'm not denying work ethic is compromised in today's students, but I am saying we had it heaps easier back in the day.
Not certain I agree that objectively quantifying the D/P relationship would be helpful. While it is difficult to measure, the inability to do so may be one of the factors that make the D/P bond so important. Trust, empathy, good listening, etc are all unmeasurable. I think I’m OK with that.
Great article, Adam. What a blessing for you to be able to visit these places…talk about carpe diem! I have officially reached middle-age, I suppose; these kids don’t seem as tough. Then again, my mentor called my generation soft! To whit, quotable Rocky Balboa:
"Nobody is gonna hit as hard as life. But it ain’t about how hard you can hit. It’s about how hard you can get hit and keep moving forward."
DELIGHTFUL! As one who revels in the measurable and objective in research, I am also warmed by such views as contained in both references. Long convinced that the best doctors have actually been patients, I'm wondering how requiring same as a part of training might be ethically feasible. Any ideas?
Hard, yes. But when we get it right, it's like magic in the life of the patient and the most gratifying thing in the world to us! Also true outside of our field but rare.
I probably reached middle age prematurely…As a surgical attending I condensed this excellent article to four dictums: 1) trust no one 2)assume nothing 3) your own mother would sell you for a price and 4) there are assassins around every corner. Probably wouldn’t last long on faculty these days. No, I don’t own a Grand Torino.
🤣 re Grand Torino.
We, as a nation, are protected by the trained and the elite. To think that my life and the lives of my family and every other person in our country teeters on the fulcrum of ne'er-do-wells on one side vs the intensive, sometimes physically and/or mentally tested beyond what they thought their limits on the other side, is scary. Navy Seals, Green Berets, Delta Force, etc. graduate after learning they can perform well beyond their initial thoughts. I want my life protected by the elite.
Lovely article by the incomparable Dr. Sal Mangione, who I had the privilege of training under in IM residency at Jefferson hospital in Philadelphia. I still remember some of his noon lectures to us interns nearly 15 years later!
I used to treat a fair number of people with post-viral syndromes, typically labeled "fibromyalgia" or "chronic fatigue syndrome" - usually with "chronic pain" too. At the height of Purdue's influence (1996-2012) many had been started on large doses of opioids, and/or many other drugs (sometimes up to 6-8 drugs affecting the brain). One universal technique to improve them was to stop as many drugs as possible. I usually found the opioid was the least of the problem (although patients were pharmacologically and perhaps psychologically dependent).
But the most useful thing I did for a few people was to write (literally) and "educational prescription." This applied to women who had dropped out of school or not been able to continue for reasons that most readers will readily imagine. My prescriptions were to community colleges, e.g. "Please help this person to access further education or training that will help her gain better employment." In once case, the prescription was to a building trades union business agent, asking "She has been sexually harrassed at work. Please intervene to protect her and see if some further training can help her improve her economic independence." In that case the union responded more positively than I could have hoped. The patient returned to say she was taking a "math course" and doing "really well" in it.
I think these are examples where a friendly, respectful, and supportive human relationship between clinician and patient goes a long way. I've personally experienced the same from a hotel manager who hailed me after I shattered my clavicle. I was afraid she suspected me of sneaking free coffee (as a non-guest). It turned out she had suffered a similar injury, recognized my sling, and came over to tell me: "Don't worry, honey. It's gonna' be all right!" Most therapeutic intervention I could experience.
Thanks Adam - we are working on objectively quantifying the physician/practitioner dyad with a special focus on how natural language AI in the exam room could potentially augment it!
Len
Adam, you may be too young to have read the classic book by Norman Cousins, The Anatomy of an illness as Perceived by the Patient. It directly examines healing in the context of a positive physician-patient relationship and an intelligent pondering on the therapeutic benefits of the placebo effect. I urge my fellow subscribers to pick this classic up.
Would that there exist a pre-admission evaluation of Stoicism and resilience. An option: admit more medical students and "test" their resilience, better to burn out in earlymedical school than early practice!
I read the second half with interest having suffered from Long Covid myself. I worked with a total of 7 doctors including my GP, a more alternative "functional med" doc, and several specialists.
Here's my take based on my experience.
On one extreme I received an abundance of sympathy but no concrete solutions, suggestions, or a willingness to run a single blood test. On the other extreme was over-promising snake oil. (If you could have a 3rd extreme, I also experienced scolding and shaming for not taking the vaccine early and an arrogant push to take it after the fact which made no sense.) In the middle was a humble and sympathetic attempt to try to help me. Those doctors ran tests within their specialty with no promises but a sincere desire to help if they could.
My favorite doctor was an allergist/immunologist experienced with mast cell activation syndrome. His office was antiquated and poorly run. He didn't actually do or prescribe anything; instead, he helped me rule out many things that the internet told me I had. I do think his general demeanor gave me the confidence to just give it more time and stop trying every supplement that someone said cured them. He predicted I would slowly improve and get better and he was correct.
The article in Am J Med was fantastic!!!!!! I agreed 100%. This entitlement on the part of medical students is a crisis.
Regarding the AJM article, there is much debate now about how far to accommodate trainees in their quest for a less harsh training experience. But make it too soft and learning will suffer and they will be shocked to find practice is also stressful. The real solution is to get word out to the premeds that life in medical training and in practice is hard. Bazillions of people are applying to medical school, and some effort should be made to select those for admission who understand it is going to be a difficult road ahead and have the resilience to survive.
Re: long COVID, three points.
1. Many symptoms are caused by abnormal clotting behavior. Taking a nattokinase supplement may help. I and several friends have had relief within two hours, of symptoms that had lasted days to months such as migraines and joint pain.
2. Many symptoms are extremely similar to post-sepsis syndrome.
3. Symptomatic long Covid is strongly correlated with Epstein-Barr virus (mono) reactivation (60% vs 10%).
As a medical student now and 25 years ago... It's so much more onerous nowadays... The micromanaging and surveillance is so intense now... The freedom and flexibility back then is heretical now... So from my perspective, it's a helluva lot harder to be a med student now... With the caveat that you reap what you sow, students have definitely become more inclined to respond to being treated as irresponsible and unable to be trusted by living down to those expectations. So I'm not denying work ethic is compromised in today's students, but I am saying we had it heaps easier back in the day.
Not certain I agree that objectively quantifying the D/P relationship would be helpful. While it is difficult to measure, the inability to do so may be one of the factors that make the D/P bond so important. Trust, empathy, good listening, etc are all unmeasurable. I think I’m OK with that.
Great article, Adam. What a blessing for you to be able to visit these places…talk about carpe diem! I have officially reached middle-age, I suppose; these kids don’t seem as tough. Then again, my mentor called my generation soft! To whit, quotable Rocky Balboa:
"Nobody is gonna hit as hard as life. But it ain’t about how hard you can hit. It’s about how hard you can get hit and keep moving forward."
is that your quote?
DELIGHTFUL! As one who revels in the measurable and objective in research, I am also warmed by such views as contained in both references. Long convinced that the best doctors have actually been patients, I'm wondering how requiring same as a part of training might be ethically feasible. Any ideas?
So hard, right? I wrote this a while back about it...
https://www.sensible-med.com/p/friday-reflection-13-this-empathy
Hard, yes. But when we get it right, it's like magic in the life of the patient and the most gratifying thing in the world to us! Also true outside of our field but rare.