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There was a book that was published several years ago entitled The American Way of Death that focused on the funeral industry and how it was changed by consumerism. Americans were shocked. New York Magazine offers an update on the process of going from vibrant alive person to the funeral home, found here, that is worth a read. In this sad tale, the author follows his mother’s journey through the health care system. It is a tale of progressive disability (the mother), a well intentioned but naive belief in the rightness of the advice given to them (the family), and either ignorance or profiteering (the doctors). Worth the read.

For those of you that have not been to medical school, the clinical years can be a little stressful. Waking up at 4 am to see patients (and waking them up at 5 am with a cheerful “How are you doing this morning?” only to get a “What time is it???”), spending quality time in an operating room, and learning how to “see patients” through very different eyes all contribute to us becoming “doctors.” My 3rd year was spent predominately at Charity Hospital in New Orleans, where the patient base was mostly poor and African-American, in contrast to the Tulane medical students.

Part of this year was spent with one of the fathers of modern cardiology, Dr George Burch.  Dr Burch, who was in his 80s, would appear twice a week and help the team work through problem patients. He would then take the student part of the team up to his lab, where his lab techs (themselves in their 60s) would serve us tea and cookies as he instructed us on the nuances of medicine. We students couldn’t help but notice the three-dimensional vector EKGs inhabiting the room. These were like minimalist sculptures of hearts, and there were many hundreds lining the walls. Finally one of us got up the courage to ask about them.

“Oh, those,” Dr Burch replied. “I’ve been collecting those for years. When the patient died that I’ve done a vector EKG on  I collect the hearts as well. I have 1500 of them. Some day I am going to dissect the hearts and correlate the anatomy with the physiology.”

He died about 5 years later and I suspect never got around to completing this task. I am afraid that the frozen human hearts did not survive Katrina.

I read the Immortal Life of Henrietta Lacks this weekend. The extremely abridged version of the story is that Ms. Lacks, a poor woman who lived in Baltimore at the time, was going to Johns Hopkins for a complaint related to her “womb.” In the course of the diagnostic and therapeutic interventions, some of her tumor was collected and was the first human cell line to be able to grow independently. The HeLa cell was used to develop and test the polio vaccine,  develop techniques used for IVF and creating other cell lines, used to create the building blocks for the human genome project, and is used to test drugs that affect cell growth to this day. Although Hopkins got no money for developing this directly, their reputation was certainly enhanced greatly (5 Nobel prizes can be directly linked to HeLa). Many companies have made a lot of money using this commercially available descendent of Ms Lacks. The Lacks family, on the other hand, struggled for years with lack of access to basic education and health care as well as being treated as research subjects rather than fellow human beings.

Most medical training in New Orleans in my time was (and likely still is)  accomplished while caring for the poor of New Orleans. My choice of Tulane, in part, was because of a reputation for academic excellence and innovation by such folks as George Burch (founder of American Heart Association), Louis Ignarro (Nobel for work on nitric oxide), Michael deBakey (inventor of heart-lung machine key component), and Andrew Shalley (Nobel for discovery of pituitary hormones). I suspect ALL of these folks would have had much less success without their own Henrietta Lacks at Charity Hospital. I suspect Dr. Burch, for example, did not get solid permission for the donation of the hearts, though I could be wrong.

Modern medicine and modern society have moved beyond (I hope) the concept of poor people existing in the health care world so doctors can practice for their well-heeled private clientele. Much of the Henrietta Lacks story is one of objectification of tissue, families, and the entire African-American culture. The ethics of access to modern medical discoveries are difficult. It is when the very people upon whose backs the discoveries are made seem to be denied access systematically that we need to step in. Although not perfect, the Affordable Care Act is a start, and its promise of access beginning in 2014 is a down payment on correcting these disparities.

From a piece by Ken Murray entitled “How Doctors Die

To administer medical care that makes people suffer is anguishing. Physicians are trained to gather information without revealing any of their own feelings, but in private, among fellow doctors, they’ll vent. “How can anyone do that to their family members?” they’ll ask. I suspect it’s one reason physicians have higher rates of alcohol abuse and depression than professionals in most other fields. I know it’s one reason I stopped participating in hospital care for the last 10 years of my practice.

From my friend Josh Freeman’s post “How People Die and How Should We

I have cared for many people who were dying but whose families wanted more done. People who already had advanced dementia and whose physical bodies falling apart. People whose heart and kidneys and lungs were failing, who couldn’t swallow and might choke on even a small amount of food, but whose families believed that if we didn’t do a surgical procedure to poke a hole directly into their stomach we would be starving them; who thought that if we didn’t plan to do cardiac resuscitation or given antibiotics for a possible pneumonia, that we would be killing them. Sometimes I am able to point out that death happens to everyone, and that having your heart just stop, or having pneumonia, or not being fed, are relatively easy, painless, and natural ways to die. Sometimes I am believed and sometimes not.

I made a home visit to a patient last week. She is over 90 years old and though bed bound is as sharp as a tack. I showed up at her apartment armed with a print-out of her health record and an agenda. I had noticed in her health records that we have no “Advanced Directives” in our file. This is important because she has outlived her husband and her children and has no one to make difficult decisions for her, should she become incapacitated. I showed up and apparently she was double booked, as a member of the clergy was there as well (I could tell from the Roman collar, which served the same purpose as my stethoscope). He was going to excuse himself but I asked him to stay. I went the expected routines of my visit (as I’m sure the minister did when he arrived). I then took a deep breath and said “I see from your medical record that we have not spoken about what should happen when your heart stops beating.” She went to reach for the burial information. I said:

“No, I mean in between the time your heart stops and the funeral happens. You see, we have to do everything unless you say not to do so in advance. The chances of us restarting your heart is very small (it’s over 90 years old, you know) so my advice is to let nature take its course. This fellow here (motioning to the minister) is the man to talk about what happens between now and then.”

We all had a nice, if brief, discussion and in the end she elected to sign a paper documenting her wishes.

To me, one of the great lessons of the Easter story is how it came to be when it is. It is a story of people fighting to get their ideas across, for no other reason than because they are convinced they are correct and the salvation of humanity was in the balance. I agree with Josh that stories of physicians fighting to do things to people because “they can’t come up with a reason not to” are representative of medicine (and by extension, humanity) at its worse. We as physicians may not know what the right answer is, but we can surely enlist the help of the patient, the family, and others such as the patient’s minister to get as close to right as we can.

When I applied to medical school, I was 21 years old and had done well enough in school that I knew I would get in “unless I blew the interview.” No one knew what blowing the interview entailed, but my pre-med friends and I had been immersed in chemistry, physics, and biology for the previous 3 years. We didn’t think the interviewer would ask us to draw out a biochemical pathway. This left us with limited background for conversations with folks who either taught or practiced at the medical school and, we presumed, wanted vague assurances that we would be good doctors. Now, thirty five years later and a veteran of over 1000 interviews, I know that “blowing the interview” is difficult, partly because we expect little in the way of life-lessons learned from a 21-year-old who has been immersed in making very high grades for the past 6 years.

I told you all of that to tell you this: what I expect from applicants to medical school is compassion. Compassion can be assessed in several ways, including prior to the interview. The first pass is through actions. Going out to the home to work with wayward children on a regular basis reassures us that you are not just looking to medicine for an easy salary. The second is in answer to the questions “Why do you want to be a doctor?” Please say “I know it sounds corny but I want to help people,” and say it with conviction.

For me, the third measure of compassion is in answer to a question about health system reform.The question is “Have you been following the changes in health care?” The response needs to be “yes” because “no” would imply denial  that you are applying to a professional school that leads to the practice of medicine. It is the next question that gives many applicants pause: “What do you think of the changes brought about by the new law?”

You have likely been exposed to physicians at some point in the pre-med process. These physicians have likely expressed a variety of opinions regarding the changes, ranging from “too socialist” to “not socialist enough.” After I ask this question I can see the wheels turning in the applicant’s head as he or she asks, “Which way does  Perkins fall?”

If you are a reader of my writing, you can likely tell where I stand. That, actually, is not important.Where your need to stand is principally for the patient in his or her access to healthcare for an illness. I am willing to entertain the 21-year-old version of “Personal responsibility is necessary,” although I suspect you have had many advantages that my patients have not had. On the other hand,, if you say to me “I think people should have to earn everything we give them” I am going to flash back to this video and suggest that serious illness might make it difficult to “earn” access to health care. If you start talking to me about “income redistribution,” I will think of patients who due to their underlying illness never were able to generate income.

In short, make compassion the lodestar of your medical moral compass. The rest you will get over time.

The clinical term is “air hunger.” This is not as descriptive as “drowning on the inside”which is what folks say it feels like after they have been made symptom-free. When you see folks initially, they are wide eyed, gasping for breath, with a panic in their face that must be the reflection of Death.

The human body is marvelously designed, but when things go wrong, things go very wrong. Having a failing heart is one of those “very wrong” experiences. Pumping about 5 liters (1 1/2 gallons) out into the body every minute, the heart must collect 5 liters from the body, pump 5 liters into the lungs, and then collect 5 liters from the lungs every minute. If you only collect 4 liters from the lungs, after about 5 minutes your lungs will be filled up with a gallon of water. The clinical term is heart failure but the sensation is very similar to drowning.

The heart is fed by 2 main arteries, one of which splits into about 3 more. Heart failure is a disease that occurs not all at once but generally following the blockage of several of those arteries over time. Most people already know that  heavy smoking contributes to heart failure. Not dying of your heart attack all at once is also helpful, as it gives the heart failure time to take hold. The 911 system, which works best for heart attack victims, may actually have contributed to the increase in heart failure in the US.

This brings us to Vice President Cheney. As you may or may not be aware, he had a heart transplant yesterday. We were all made aware of his long history of heart disease, beginning at age 37 and fueled by family history and a 3 pack-per-day cigarette habit. After his initial blockage, he had multiple interventions (some of which have been proven to do more harm than good) culminating in the use of a Left Ventricular Assist Device as a bridge for these 20 months until a donor heart was located. The bill for the transplant is likely to come in at just under $1,000,000, likely putting the former Vice President in the top 1% of health care utilizers for the third year in a row.

Although this procedure is covered by Medicare, it is unusual for older Medicare recipients to get one. The outcomes are no different in 60-year-olds than they are in 70-year-olds, but some feel that hearts taken from accident victims and such (a scarce resource) should be reserved for younger people. Some, such as the Arizona legislature, are against public funding for certain organ transplants, at least for the poor.

Almost 300,000 die of congestive heart failure annually, many of whom are Medicare eligible. It is my hope that this starts a conversation around the wise use of resources. Can we and should we use public resources more wisely? In discussing a related issue involving heart failure, the AMA Journal of Ethics had this to say:

We implanted almost 200,000 cardiac defibrillators (ICDs) at $40,000 each with the intention of preventing fatal cardiac arrhythmias. Does it matter that 81 percent of them never fired over a 5-year period, at which time a battery would have to be replaced for $20,000 [9]? Does that represent a wasteful use of health resources? We have a test that can identify with 98.7 percent accuracy who among these potential ICD recipients will not have a fatal arrhythmia over the next 2 years. We could save $2 billion per year by using that test. But getting it wrong 1.3 percent of the time represents 800 lives that would be lost each year. How should we assess that outcome, morally speaking? Does that represent a morally objectionable “pricing of human life”?

Perhaps Vice President Cheney had a rare medical condition that made him one of the 300 people to qualify for a Medicare-funded transplant after the age of 70. Perhaps he elected to spend several million dollars of his own money after opting out of Medicare and he was able to use a heart unfit for a younger man.  I hope he will be forthcoming about the details of this process. If so, when I counsel my older patients who have intractable heart failure,  we might be able to frame the conversation as follows:  “What would Dick Do?”

I spent the last several days engaged in a discussion over immigration policy enforcement in Alabama. I had worked to get the national meeting of the Association of Departments of Family Medicine to schedule their 2013 meeting in Mobile. Upon announcing Mobile as a site, the group was immediately made aware of the passage, enactment, and subsequent enforcement of HB 56. Living and working in downtown Mobile, I had always thought of us as described by the Downtown Mobile Alliance:

Mobile is the most cosmopolitan city in the state of Alabama, home to several international corporations that have enjoyed wonderful relationships with the city and its citizens. The Downtown Mobile Alliance actively seeks to create an atmosphere where diverse cultural, ethnic and demographic groups are welcome and encouraged to enjoy our 300 years of hospitality.

Instead, I had to admit that the reality is:

H.B. 56 requires schools to check and report the immigration status of their students. It instructs police to demand proof of immigration status from anyone they suspect of being in the country illegally (if stopped for another reason), even on a routine traffic stop or roadblock. It also invalidates any contract knowingly entered into with an illegal alien, including routine agreements such as a rent contract, and makes it a felony for an unauthorized immigrant to enter into a contract with a government entity.

 In addition, there were some really hateful provisions written in but enjoined as non-enforceable at this time (but liable to be enforced in the future):

It is a crime to harbor or transport unauthorized immigrants; unauthorized immigrants cannot enroll in or attend public universities; it is  a crime for unauthorized immigrants to apply for, solicit, or perform work; it requires that schools check and report on the legal status of their students and their students’ parents; and lastly, it is a crime to be without status in the United States.

In short, if you “look illegal” in Alabama, the police will have the right (if this law is upheld) to detain you until you can prove you belong in America. This concerned ALL of our Latino members, who felt they could not be assured safe passage.

These are not idle concerns. The most recent issue of Mother Jones magazine details some of the consequences of the law, including:

As of this writing, under the new guidelines of the law, Tuscaloosa police have arrested 141 people for driving without proper identification: 97 blacks, 34 Latinos, and 10 whites. Twenty-eight people were handed over to ICE, though officials could not confirm how many, if any, have been deported

Among the arrested was a German executive from Merecedes Benz, so I guess it isn’t all about brown people. The organization elected to move the meeting from Alabama, at a significant loss to the organization and to the city. This prompted a reader of the local coverage to post the following comment about undocumented workers:

Don’t tell me that they pay taxes, I know, they pay taxes on purchases but not on income. So, as you say, and I am a Christian, whatever you do to the least of these, you also do unto me. That knife cuts both ways.

In the book Educating Physicians, which is being used as a template for medical school reform, the importance of physician advocacy on behalf of patients is emphasized. Examples of this advocacy included volunteering time at local school events, volunteering on local boards which further the health of the community, as well as collective action to produce better policy. The authors feel that through these collective actions the professional values and identity of the professional group is continually refined. The organizational logo of ADFM includes the statement “Vision, Voice, Leadership.” The actions of the organization in this case speak even louder.

I was sent an article in the lay press which was followed by the scientific article referenced within the lay article for the “Beyond the Medical Headlines” weekly column that I do for our health system. The article in the lay press had an intriguing title involving “Zombie cells.” The scientific article was a little more subdued (Clearance of p16[Ink4a]-positive senescent cells delays aging associated disorders) and can be found in the journal Nature. The zombie fixated lay writer started with a fairly circumspect quote from on of the investigators:

“By attacking these cells and what they produce, one day we may be able to break the link between aging mechanisms and predisposition to diseases like heart disease, stroke, cancers and dementia,”

but finished it off with a quote that was a little over the top:

“There is potential for a fundamental change in the way we provide treatment for chronic diseases in older people.”

I would be the first to agree that there is potential for fundamental change in healthcare…I have trouble believing that rat doctors will lead the charge in the immediate future

The study was done with mice that are genetically altered to become old quicker than normal rats (who get old pretty quick anyway). They then used a proposed marker for cell aging (p16[Ink4a) and developed a method of removing these “old” cells. The mice were compared to untreated mice at 10 months. The treated mice looked much more ready for a close-up and ran faster on the treadmill than the untreated mice. It is a long way from 10 month old rats to 70 year old people who have smoked for 60 of those years, spent a total of 30 years in the sun, have a sedentary lifestyle and are double the weight that they should be.

If you are interested in how the rats live prior to their untimely demise in the name of research, here is a good article. Here is someone else’s take on translating rat medicine to humans. The bottom line:

The current approach to studying arrhythmia and many other diseases goes back to a three-step protocol worked out by the German scientist Rudolf Virchow, Efimov says. The first step is to identify the clinical signs and symptoms of the disease; the second is to recreate those symptoms and identify a therapy in an animal model; and the third evaluate the safety and efficacy of the therapy in clinical trials. “The problem is that at least in the cardiac arrhythmia field, this paradigm has had very few successes,” Efimov says. “It has resulted in the discovery of almost no successful drugs. Clinical trial after clinical trial has ended in failure.” Mice are the most popular animal model in physiology, but the mouse is not a very good model for cardiac physiology. “A mouse’s heart beats about 600 times per minute, so you can imagine it is a little different from humans, whose hearts beat on average 72 times per minute,” Efimov says. “You can mutate in mice the gene thought to cause heart failure in humans and you don’t get the same disease, because the mouse is so different,” Efimov says. “So, unfortunately, even with the help of transgenic mice, very few results made it from the animal model to the clinic.” The answer, Efimov says, is to insert an additional step in the three-step research protocol. After a therapy has been tested in an animal model, it should be tested in human hearts before moving to clinical trials. “Since we’ve begun to work with human hearts,” he says, “we’re finally starting to catch up with animal physiology.”

We have a rather odd tradition in Mobile known as the “Street Party.” There are certain blocks of certain streets that have a collaborative party on a set date. To accomplish this, all of the houses on that street have to come together to agree on a date, a band, and either cough up the money to participate or find a way to gracefully bow out. The dates for certain streets have become a tradition, so much so that other events are scheduled around the “Fill-in-the-blank Street Party.” Having done this in our block once, I can attest to the strength of will it takes to accomplish this when, let’s face it, geographic proximity is most of what holds the group together.

The party last night, on a single block of South Georgia Avenue, is one of the oldest in the city. Begun by Dr Sam Eichold and his neighbors, the idea was to encourage gentrification of the neighborhood, which had fallen on hard times, by inviting folks who had fled from downtown to revisit in a comfortably large group.  It is my understanding that, at the time of the inaugural party, at least one house on the block was functioning as a “house of ill repute.” Shrouded in the mists of time is the level of participation of this establishment in either the party or the afterparty.

When going to these parties, discussing medical topics is somewhat of an occupational hazard. (Less for me than my friend John (Is it gonna rain?) Nodar, the weather man, but a very real concern.)  Dealing with it is something we are not taught in medical school. We were warned, in fact, not to socialize with patients. As a primary care physician in a town of 200,000, this would be tough to accomplish. For example, yesterday I was with about 500 people. I ran into the parents of one of my patients (a newborn that I care for) out on a date, the baby having been left with its grandmother for the first time; several people whom I see as patients and also run into socially often; and several people who I don’t see as patients but answer random medical questions for on occasion.

I have developed my own set of boundaries for these situations that I will share. If you are a physician feel free to  measure yours against mine and let me know how they compare:

1) Never bring up your MD unless asked – Although many of my neighbors know my dirty secret, I suspect they are more likely to keep it because I don’t go publicizing it myself. The converse of this attitude occurred when my wife and I were at a restaurant and we met a gentleman who was very proud of his MD, so much so that when he caressed my wife’s leg under some pretense or another, he actually said “Don’t worry, I’m a doctor.” As I am salaried I’m not trying to build a practice through personal contacts but I have come to the conclusion that contacts built over cheap wine are often problematic.

2) If someone is already a patient, be careful sharing information unless you happen to have the chart with you – I have a patient that I take care of who is one of the hosts and I happened to take care of his son as well. Several years back, I mentioned his labs looked really good on the most recent blood draw. He said: “That’s funny, I haven’t had it done yet.” Turned out to be his son, who unbeknownst to me was a junior.

3) Learn to be non-committal – Last night, as the evening was winding down (and as I was on call I had had much less cheap wine than everyone else on the street) I was introduced to one of the guests. The conversation got around to his ailment (under the care of a physician who is not me) and my profession.  This stranger shared with me details of his illness. This I am used to and have learned to say “uh, huh” to almost anything.

4) Every now and then you have to break your rules – The fellow mentioned above  then asked whether he should comply with his physician’s diagnostic strategy. I have to admit at that point I moved from non-committal to putting on my doctor ears. I then put on my doctor brain and explained why his physician was ordering these specific tests and why he should follow through with this plan, which I think he will do.

I guess the point is that although I don’t consider myself to be  doctor all the time, sometimes I have to be a doctor whether I want to or not.

I received “Pulse: Voices from the Heart of Medicine” this Friday and was an struck by an essay entitled The End of Nice. In this essay, the author remembers an experience that occurred 20 years ago when she was in training and working in the Emergency Department. The beginning of the essay is as follows:

“Mouse bite, one year ago” read the Chief Complaint entry on the chart I picked up from the “nonurgent” pile.

I was a second-year medical resident, on an eight-week stint in the Temple University Hospital emergency room. It was 3:50 am, the beginning of the end of the night shift. All hell could still break loose before my shift ended, but for now we were in a lull, and the less serious cases got our attention.

I looked at the time of triage for the mouse-bite patient. Five o’clock the previous afternoon.

“Mouse bite one year ago! And the patient’s been here eleven hours!” I exclaimed aloud to no one in particular. “What the fuck? What idiot sits here all night for that?”

“Nice potty-mouth, Kaplan,” commented Dave, the other resident on duty, as he wrote in a chart. “And where’s your compassion? Remember, that’s a suffering person you’re talking about.”

The author, Rosilind Kaplan, goes on to describe the gradual loss of compassion that occurred over the 6 years of medical training but culminating in this Emergency Department experience where people arrived with knives stuck in their chest with the explanation “I slipped and fell on it” as well as people cursing her for saving their life. She points out in narrative form what we know all too well. Many who seek care in the Emergency Department have limited capacity and often suffer from mental as well as physical illness. They are difficult folks to care for and the care providers often suffer from burnout.

In the case of the mice bite it turns out that  the patient was excessively worried (even obsessing)  about possible damage to her body festering unseen and so came at 4:15 in the morning:

“Sometimes I just worry. I start thinking about something and it gets bigger and bigger in my head, you know?” She spoke quietly, looking down.

I did know. But I wasn’t going there at 4:15 am.

“I started thinking about this yesterday and how it might have been a rat and I could have rabies. I never went to a doctor, and what if I die from this because I was stupid? So I came.”

I, too, remember some very similar experiences from my training. When I was a second year medical student at Tulane, I was working in the Emergency Department at 3:30 one night and was given a patient to evaluate who had been waiting to have a cyst evaluated for 4 hours. Being a 24 year old with not much life experience and no experience draining cysts (so he would have to wait for a real doctor anyway) I asked him what had made him seek care in this setting at this time.

He said ” My wife and I had a fight, my kids are out of control, and I felt that the Charity Hospital Emergency Department was as good a place as any to think through my problems. Oh yeah, and I can get a cyst taken care of in the mean time as well.”

While rounding in the hospital this weekend, I encountered a patient who suffers from somatization disorder. I was struck not by her lack of insight into her illness (multiple symptoms with no physiologic explanation), nor by the damage that had been done to her by the medical system (multiple surgeries for pain type symptoms with no clear pathology identified). I was struck by the certainty that she has rejected multiple opportunities to develop a trusting relationship with a doctor. She described for me multiple visits to    faceless Emergency Physicians who she felt could certainly be able to fix her wiring and stop her persistent though transient pain and weakness.  As we discharged her, making her an appointment in our office that I knew she wouldn’t keep, I thought back to my days as a student and attending in the Emergency Department.  I hope someone talks to her before ordering another MRI and neurosurgical consult.

20 years away from these experiences offers perspective. Practicing primary care, we use relationships to ferret out the real cause of our patient’s symptoms. In concluding her essay, Dr Kaplan says, and I concur, that while “real disease” may be causing the symptom, situational anxiety and depression are never far down our differential. Our patients, though, seek out our brand of care. I chose to work in this setting because I want to know who is in the exam room before I knock on the door. Health care reform offers opportunities to move some of these difficult to reach patients into primary care as well, as described here by Atul Gwande. Are we ready for them?

What kind of bed side manner do you want your doctor to have? I have to teach a class tomorrow in “doctor” attitudes to 1st year medical students, so all I should  have to do is poll my family, friends and neighbors, put together a list of do’s and don’ts on a handout, project it on a slide show, and walk away to applause. Would that it were that easy.

Empathy, the ability to see and understand another person’s point-of-view and share the associated feelings, is an important trait for doctors to have. Teaching this is hard work. I was struck by an interview between Krista Tipett and Frances Kissling on the program On Being this morning while coming back from rounding in the hospital. Ms Kissling, a Catholic pro-choice advocate,  was asked why she thought homosexuality was being rapidly accepted in our society while the abortion fight was continuing. She answered that, in part, many people had trouble developing empathy for a person seeking to terminate a pregnancy:

In the case of abortion, you are dealing always with the destruction of life. It may not be life that is personal; it may not be of the highest value. It doesn’t, in my opinion, have rights, but I think particularly as time has passed, we are all striving to create a world, where most of us are striving to create a world in which life in all its forms is fostered and nurtured. And abortion in some ways goes against that. So if you have a kind of absolutism, you know, if you don’t contextualize it and you just look at it even if you’re not looking at it as murder or killing, you know, in the grossest terms, but simply as the interruption of life processes that we would prefer under other circumstances go forward, it always has a dimension of loss to it. …I would say is the other difference is that abortion is something that enters a person’s life at a specific moment and leaves it very quickly. … And for most people, most of us don’t want to think about abortion, and even women who have abortions don’t want to think about abortion all of the time. They don’t make — they don’t want to make abortion, for the most part, a defining part of who they are and their identity.

What I would like is to have our medical students able to demonstrate empathy with a patient who is seeking their counsel and guidance, even though they may not personally approve of the choices at hand. Why is this hard? Training for health professionals occurs at times of stress for both the learner and the patient. We have traditionally learned how to enter into such a relationship by being placed in clinical situations and reacting. Here is a description of one learner’s experience:

At the end of his third year, Chatterjee describes what he witnessed:

“I have seen a 24-hour-old child die. I saw that same child at 12 hours and had the audacity to tell her parents that she was beautiful and healthy. Apparently, at the sight of his child — blue, limp, quiet — her father vomited on the spot. I say `apparently’ because I was at home, sleeping under my own covers, when she coded.

“I have seen entirely too many people naked. I have seen 350 pounds of flesh, dead: dried red blood streaked across nude adipose, gauze, and useless EKG paper strips.

“I have met someone for the second time and seen them anesthetized, splayed, and filleted across an OR table within 10 minutes.

“I have seen, in the corner of my vision, an anesthesiologist present his middle finger to an anesthetized patient who was `taking too long to wake up.’ I have said nothing about that incident.

“I have delivered a baby. Alone. I have sawed off a man’s leg and dropped it into a metal bucket. I have seen three patients die from cancer in one night.

“I have seen and never want to see again a medical code in a CT scanner. He was 7 years old. It was elective surgery.”

Medical students very quickly develop a “us against them” mentality. Rather than a nuanced world view where suffering is placed in context and healing takes into account the whole person, the “extraordinary becomes the mundane”

They distance themselves from their own feelings and from their patients through intellectual engrossment in the biomedical challenges of diagnosis and treatment, and through participation in highly structured, in-group forms of medical humor

It is now believed that preparing students for this experience leads to less depersonalization and more empathy than the traditional training methods. Empathetic care givers should lead to exchanges between doctors and patients based on mutual understanding. There is even a recent study proving this.

In the study, groups of established physician-teachers from five different academic medical centers met at least twice a month. During the meetings, the doctors either practiced skills designed to enhance compassion, or reflected on their own work through discussion and narrative writing.

After 18 months, residents and medical students at each of the medical centers evaluated the physician-teachers, as well as a “control group” of faculty, on such matters as listening carefully and connecting with others, teaching communication and relationship-building skills, and inspiring the adoption of caring attitudes toward patients.

At all five sites, those physician-teachers who participated in the program consistently outscored the controls.

We are just beginning on this journey here at South Alabama. The exercise I do tomorrow will use the movie The Doctor to demonstrate empathy. Over the two years we work with the class to get them to understand what they are going to see as they move into their clinical experience and give them some tools to cope. Even more helpful would be formal groups that meet during the clinical years (known as Balint Groups) to help learners understand they are not alone and to guide them as they develop their own nuanced viewpoints, but I’m afraid that would be asking too much.