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I N S I D E T H E M I N D S

Inside The Minds:

The Art & Science of
Being a Doctor
Leading Doctors Reveal the Secrets to Professional
and Personal Success as a Doctor
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First Printing, 2002

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Copyright © 2002 by Aspatore Books, Inc. All rights reserved. Printed in the United
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permission of the publisher.

ISBN 1-58762-119-3

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understanding that neither any of the authors or the publisher is engaged in rendering
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This book is printed on acid free paper.

A special thanks to all the individuals that made this book possible.

Special thanks to: Kirsten Catanzano, Melissa Conradi, Molly Logan, Justin Hallberg

The views expressed by the individuals in this book do not necessarily reflect the views
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 Inside the Minds:
The Art & Science of
Being a Doctor
CONTENTS

W. Randolph Chitwood, Jr., M.D. 9

PRACTICING TO A HIGHER
STANDARD: PATIENT FIRST

Laura Fisher, M.D. 37

THE GOOD SOUL: COPING WITH
CHALLENGES FACING DOCTORS
TODAY AND TOMORROW

Michael J. Baime, M.D. 55

RECAPTURING THE CALLING
OF MEDICINE

Leo Galland, M.D. 77

THE PATIENT, PLEASE, NOT
THE DISEASE

Rosalind Kaplan, M.D. 99

IT’S ABOUT THE HUMAN BEING
Marianne J. Legato, M.D. 121
WHAT IS A “GOOD DOCTOR”?

Marc Borenstein, M.D. 133

THE INCREDIBLE VALUE OF BEING
WITH YOUR PATIENTS

Arturo Constantiner, M.D. 163

THE COMPASSIONATE PHYSICIAN:
STAYING ALIVE IN TODAY’S
BUSINESS OF MEDICINE

Martha S. Grayson, M.D. 177

A RELATIONSHIP THAT WORKS:
THE DOCTOR-PATIENT PARTNERSHIP

Nicholas A. DiNubile, M.D. 191

MEDICINE: EMERGENCY ROOM, LOCKER
ROOM, BOARDROOM

Dedications & Acknowledgements 231

 The Art & Science of Being a Doctor

PRACTICING TO A HIGHER
STANDARD: PATIENT FIRST

W. RANDOLPH CHITWOOD, JR., M.D.

East Carolina University
Brody School of Medicine

Department of Surgery
Professor and Chairman

9
 Inside The Minds

The Art, the Science, and the Physician’s Path

The essence of medicine can best be understood by considering

it a true profession, encompassing both art and science. It is this
unity and the unique application of these disciplines that make a
good physician. Adding unswerving commitment and ethical
behavior makes a great doctor. The intertwining of these
qualities makes medicine a challenge with many rewards, but
also many demands. This profession, more than any other,
affects both the physical nature and the emotional behavior of
not only the patient, but also the family. This alone is why the
three learned professions were considered to be medicine, law,
and the clergy. They all affect the true being of a person – how
one feels about oneself. A special, continuing trust and bonding
relationship can evolve from a positive physician encounter
during stressful times, and this bond is usually amplified and
preserved, especially when a patient’s health is restored. The art
and science of medicine have been inextricably interrelated for
centuries, albeit with less advanced technology than today.

The art of medicine, first practiced by Galen and the early Greek
physicians, preceded by centuries the science and technology of
medicine as they are known today. On a superficial level,
without a true understanding of the significance of doctor-patient
communications, some might think the art is simply a good
bedside manner. The ability to listen to patients, recognize and
understand their needs, and show compassionate feelings for
them and their families has a therapeutic benefit for the patient.
Such encounters often relieve much of the anxiety of families,
while giving the physician the opportunity to truly observe his or

10
 The Art & Science of Being a Doctor

her patients in a more comfortable, natural milieu. The

complexity of biological systems, as well as the interdependence
of the mind and body, demands that the profession incorporate
every aspect of the patient in the care provided.

Physicians practicing the art of medicine optimally develop a

sixth sense – an uncanny ability to use deductive reasoning,
often without having much hard data – in approaching the
patient’s illness. This sixth sense generally evolves to an
instinctive skill, which allows the doctor to piece together a
myriad of symptoms and laboratory results to complete the
diagnostic puzzle. This important ingredient develops only with
experience, observation, scientific knowledge, and dedication to
medicine. Doctors of the past often relied on this innate
understanding more than on diagnostic testing. Unfortunately,
many physicians today have reversed this trend and rely less on
complete understanding of a patient’s history, physical findings,
and emotional complement.

The science of medicine is distinct from the art of medicine,

although each is dependent on the other. The doctor who
understands the art of medicine generally understands the
science, which in turn perpetually enhances the art of the
profession. The science of medicine requires a database of
knowledge acquired over years through reading, research,
observation, and experience. The basis of medical scientific
education, both clinical and natural science, is initially obtained
in college and medical school. The more formal curriculum
concludes with a residency program and may last up to 10 years
following medical school. During this period doctors learn to

11
 Inside The Minds

apply what they have learned and make constant improvements

by an iterative process and observation of their results.
Appropriate senior supervision guides the resident’s hand toward
the right decisions for patient care. This period does not preserve
the classical “walls” present in most educations, but subtends a
broader environment of the clinics and hospital wards.

Following this closely mentored training and study, the doctor is

ready to begin a new learning experience in his or her practice.
This is a special time, as it signifies the beginning of a more
introspective personal education for the young doctor. It is a time
during which many of us learn as much about ourselves as we
learn about our patients.

One of the first obligations of physicians, both young and

mature, is to keep abreast of new scientific information. The
complexity and speed with which knowledge is generated and
communicated today make it imperative to stay current, not only
on the advances in global medicine and one’s specialty, but with
regard to the general advances made in science and technology.
Each of these may relate indirectly to medicine and new medical
developments. Today Internet communication and rapid
worldwide data transfer have enhanced our ability to keep up-to-
date scientifically.

Surgical specialties also demand the development of adroit

physical abilities that include fine spatial manual dexterity, often
embracing ambidexterity. Moreover, these talents must be linked
to an in-depth understanding of anatomy and physiology. Many
of these skills can be acquired through practice and observation,

12
 The Art & Science of Being a Doctor

while others remain individual and innate. Daily, surgeons apply

base knowledge through manual dexterity to effect a cure for
their patients, often without the benefit of a long analysis. The
distinction between cognitive skills and technical applications
here becomes blurred in most situations, as they are interlinked.

Combining the Art and Science to Benefit the Patient

The individual seeking and accepting the role of physician takes

on a unique responsibility to each patient, as well as to the
public. The lifestyle of a good doctor should remain apart from
the herd. As physicians are observed more often and more
closely than others, they should remain responsible at all times.
Being a doctor becomes part of a person’s being with an almost
continuous consciousness of this responsibility. The expectation
of the community generally is that physicians should be held in
high esteem and respected. However, the character of the person
who is called “Doctor” defines this realization. These
responsibilities and expectations should influence all of the
physician’s interactions within the profession and community.
Daily foibles, such as unbridled anger, lack of verbal etiquette,
and loss of control can impair an otherwise superb physician and
rob him or her of public respect. The stresses of the day have
impaired many excellent doctors through substance abuse,
emotional instability, and lack of control. The preeminent
physician Sir William Osler (1849-1919) once said physicians
must “educate your nerve centers” and act with imperturbability
– displaying “coolness and presence of mind under all
circumstances.” He considered this latter quality that most

13
 Inside The Minds

appreciated by the laity. These maxims hold as true today as they

did on the day he wrote them early in the last century.

One of the most essential qualities in a doctor is honesty, which

includes all professional practice, with colleagues, in the
hospital, with patients, and in personal life. Most important, the
doctor must maintain self-honesty, which allows one to assess
personal actions and review medical outcomes. The true doctor
is one who can be introspective personally and professionally.

I believe doctors have the obligation to conduct themselves

according to high moral standards, much as Boy Scouts are to
follow a moral code of behavior. It is important for doctors to set
ethical standards for themselves, for both their personal life and
their medical practice. Accepting the responsibility for patients’
illnesses, and in many cases their lives, requires the physician to
live by a high ethical standard; this is essential for the best
treatment and care of the patient.

The physician needs to be an intelligent person with an almost

insatiable desire to keep learning. Driven by intellectual curiosity
and the need to satisfy self-imposed standards of medical
learning and practice, doctors should pursue knowledge, even in
time spent on non-medical matters. They must enjoy the pursuit
of lifelong learning. This continuous learning allows the best
application of the right treatment and best medical care within
the scope of resources available to the patient. The term
“holistic” has become a cliché for an understanding of the patient
as a whole person with the inseparable workings of the mind and
body. Treating patients thus requires the doctor to be a person

14
 The Art & Science of Being a Doctor

who understands this concept and brings it to the bedside.

Patients are affected by many things – not only their physical
ailments – and the best doctors truly hear what patients are
saying and fully understand the impact of emotions on illness, as
well as prospective treatments and outcomes.

Communication skills are quintessential for the effective doctor.

Patients and families must have the best possible understanding
of the illness, treatment options, and prognosis. Again, hearing
what patients and family members are saying not only enhances
the patient’s understanding, but engenders more comfort and
confidence in the doctor entrusted with the care. Communicating
with patients consists of more than just advice; the doctor’s
words may be the patient’s only solace, especially when no
treatment is available or appropriate. The physician needs to
communicate with family members. Beyond their personal need
for understanding, they are the ones who will become extended
caregivers. Osler, an early 20th century ethicist at Johns Hopkins,
said, “It is much more important to know what sort of patient has
the disease than what sort of disease the patient has.” The doctor
needs good communication skills to bring the art and science of
medicine together for the benefit of the patient.

Keeping up-to-date and practicing medicine, with its constant

advances, as well as being a compassionate communicator,
would seem to be enough for any professional person. However,
the demands on the physician extend much further. Physicians
set standards for themselves and also follow practice guidelines.
It is these personal standards that should demand the most from
the physician. Physicians should become involved in hospital

15
 Inside The Minds

medical staff activities and communicate effectively with the

hospital administration. Who other than these frontline
caregivers can better determine the adequacy of the facility or
quality of medical practice in the hospital? It is at the
administrative and board of trustee levels that decisions are made
on the purchasing of medical equipment and staff appointments.
Quality assurance has become synonymous with always being
sure the best possible care is provided and that monitoring
mechanisms are effective. Only involved physicians can know
and influence these activities to create the best hospital practices.
Active hospital participation should include support for in-house
continuing education of peers and staff, as well as the
community. Patients frequently tell their doctors of their
experiences at the hospital, good and bad. Both concerns and
compliments must be passed on to the administrative decision-
makers. The physician needs to be concerned about the
professional activity of the other hospital caregivers and how
they are treating patients. The doctor must always be the
patient’s advocate, both for safety and for support, during the
stressful time of a hospital stay.

There is one additional arena that cannot be ignored: the health

of the people in the community – public health. Many of the
illnesses requiring treatment start years before we first see
patients present with symptoms. Many of their illnesses are
preventable or can be controlled. Education and early detection
are essential components of public health. Physicians who
support community public health, practice preventive medicine
in their offices, and make their voices heard in community
forums supplement their effectiveness.

16
 The Art & Science of Being a Doctor

Prevailing through medical school, internship, and residency

requires long hours and hard work. It is the tenacity to see an
undertaking to completion that initially distinguishes young
doctors and gains the respect of others. However,
notwithstanding this respect, the doctor must maintain this pace
and commitment. The penchant for hard work must be an
essential characteristic of the practicing physician. Today
lifestyle alterations are becoming more important than the
professional life for many doctors. Also, the unbridled pursuit of
economic goals by practitioners can disconnect them from the
respect they have worked so hard to earn. When either of these
latter issues becomes the primary nucleus of a doctor’s life, then
it is appropriate for the public to remove this doctor from the list
of those regarded as “professional.”

The Personal-Professional Balance

Many of us find it impossible to disconnect from patient

responsibilities at the end of the day or workweek. It is difficult
to gain respite from all responsibilities; however, periodic
vacations are a must for the sake of personal health and family
happiness. Achieving a balance between personal and
professional life requires each doctor to do what is right for
himself or herself. I find this balance easily, as I have many
hobbies that meld very nicely with my professional life. Each
hobby has a synergistic effect on the other and forms a
continuum with my work. Two examples of how hobbies and
medicine work together for me are my serious interest in
photography and my past interest in ham radio.

17
 Inside The Minds

My knowledge of radio communications has given me an

appreciation and understanding of technology that translates to
an understanding of many of the newer types of equipment we
use in the hospital, such as those controlled by computers. My
experience with photography has been extremely useful in
diagnostic imaging and in the use of the three-dimensional
screen of the Da Vinci® robot in the operating room.

Balance between personal and professional life will be achieved

when the doctor can feel that the system he or she works in is
delivering the care he or she wants to deliver to patients. When a
doctor is dissatisfied with the work environment, it may not be
possible to maintain a balance in life.

In addition, I believe that achieving satisfaction in life requires

the doctor to have some protected time or personal time to enjoy
the pleasures of family or to pursue the hobbies that offer the
opportunity to relax and recover energy spent in the practice of
medicine. This balance will afford the doctor the time to keep
fresh within the profession and to satisfy natural curiosities.

The Physician and Goal-setting

Success in any profession depends on planning, whether one is

in the training period to enter a profession or is already a
functioning professional. Primary to any planning, I believe, is
the setting of a goal. Having a goal sets a pathway to one’s
objective and facilitates the development of strategies to meet
that goal.

18
 The Art & Science of Being a Doctor

As a physician with serious concern for patients and their

illnesses, I find goals can take the form of developing the
ultimate treatment or setting a clinical pathway for treatment.
The development of new technologies or the refinement of
present equipment can also be valuable goals. The best way to
pursue goals of this nature, or those relating to a daily practice, is
through continuing education by the doctor. Going forward or
being on the cutting edge in the practice of medicine requires the
doctor to be current on all medical research and new
technologies.

Goals will need to be reset as they are reached or as experience

dictates. It is important to remember that achieving goals will
frequently depend on allowing other individuals or an institution
to give their support to the endeavor.

My strategy for setting goals includes establishing a timeline for

the execution of the various phases of the plan. The financial
portion of the plan must have a detailed listing of resources
needed and resources available. In addition, planning for other
sources of financial support is critical.

Planning must also consider obstructions that could arise, along

with legal or regulatory obstacles that exist or may develop.
Ethical issues must be considered from the point of view of
personal values and from the point of view of the institution, the
practice of medicine, and the patient.

All physicians need to develop planning and evaluation

techniques to function smoothly in their practices and to

19
 Inside The Minds

experience the success of their work. Goal-setting is an ongoing

process that can allow the doctor to take alternate pathways in
the treatment of disease and in reaching personal goals.

Not infrequently, setting goals to achieve high levels of patient

care or development of some innovative equipment or treatment
can lead to frustration. However, in many cases the physician
trained in goal-setting and planning will turn the frustration into
a drive to do something new for the patient and for medicine.

The Challenging Aspects of Being a Doctor

I find medicine a continuous challenge, including all aspects of

practice. The advances made every day in medicine make it
imperative that physicians keep abreast of new developments.
More new information has arisen in the past 10 years than in the
past 100 years. The ever-increasing patient disease and
psychosocial complexities increase this challenge. Rarely do we
see patients with a single disease entity or uncomplicated social
situation. Moreover, the aging population has placed both
volume and complexity demands on physicians, as well as on the
ever-changing healthcare delivery system. Guidelines,
assessments, and limitations are imposed increasingly on the
practice of medicine that do not seem to be linked to patient care.
Moreover, the economic situation in healthcare has become more
limiting and in the future may preclude access to healthcare for
many people. Clearly, many of these converging problems will
challenge our young doctors and their successors even more.

20
 The Art & Science of Being a Doctor

Perhaps one of the greatest challenges for the physician is

working with other physicians in a team approach to affect the
best patient outcomes. Working together will ensure maximal
combined expertise and minimize any potential for error. The
patient benefits most from a cohesive, coordinated effort, and
each physician can benefit from added insight, knowledge, and
collegiality. Working together will reinforce future efforts and
improve patient care. Unfortunately, today economic alliances
can preclude the best doctors in the community from coming
together as a cohesive force. This is regrettable for both the
patient and physician professionalism. I believe this
cohesiveness must be reestablished. Fortunately, in areas of less
competition and incomplete managed care penetration, cohesive
relations exist among individual groups and solo practitioners.

As mentioned, the aging population is challenging modern

medical practice more than ever. This group brings complex,
chronic diseases along with demands for the latest in medical
treatments. In addition, many present combinations of co-
morbidities, making treatment difficult at best. Treating each
illness, while avoiding conflicts between treatments and drugs
and meeting the demands of a population seeking an active and
productive life, is a challenge for every doctor today. It is
interesting that in the past physicians had less to offer in terms of
therapy, and to a healthier population, but more time to spend
with each patient. Oddly, this ratio has reversed because of the
increasing number of complex patients.

For example, the aging population experiences frequent

medication complications, often because of their inability to

21
 Inside The Minds

follow treatment recommendations. For those with later, even

subtle, mental changes, the challenges also include safety and
caregiver concerns. An elderly caregiver may become the person
needing the greatest attention. Although the science of medicine
in making a diagnosis and prescribing the best treatment may be
foremost in the physician’s mind, the art of working with
patients of all ages and their families is a great challenge and is
becoming an even greater one. Often elderly patients want to live
independently, but when they become debilitated, the family
response is neglect because of work arrangements, lack of family
cohesion, inadequate means, or any combination thereof. The
physician often becomes the intermediary, brokering care
through extended living arrangements, more frequent doctor
visits, or family counseling. This is a role that many physicians
had little involvement in 25 years ago, as family structures were
different, and “elderly patients” were a younger set than those
seen today.

The doctor’s efforts to save lives and alleviate patient suffering

are not always successful. As an experienced cardiac surgeon I
often operate on very ill patients, some with few options. Many
of these patients are elderly, with multiple medical conditions
that make them high-risk. In many instances, it is appropriate to
perform a complex heart operation despite the risks. Even
knowing these risks does not help the family or the surgeon
become conditioned when the patient does not survive. Even
more perplexing are circumstances that are worse than mortality.
For example, the surgeon may get the patient through surgery,
but when a stroke or respiratory insufficiency occurs, the patient
is not restored to the lifestyle he or she had hoped for. Clearly,

22
 The Art & Science of Being a Doctor

this is one of the most difficult aspects of being a surgeon. The

same things occur in any physician’s mind when the results
obtained are less than optimal. This is a part of medicine, but the
best doctors never become accustomed to or really accept failure.
Our credo is to restore health to our patients and to do no harm –
this is the essence of our profession.

When apparently at a roadblock in treating one of my patients, I

consider the alternative pathways available. As the patient’s
advocate, I take seriously my responsibility in finding a
treatment that affords the patient an opportunity for a cure or
amelioration of his or her illness or pain, whatever is the best
that can be achieved, considering the situation.

Great resources are available to me in seeking an alternative

treatment if my first choice is not suitable for some reason.
Consulting with other physicians and specialists in the area is
always available to the doctor. Bringing others’ knowledge and
experience to the situation may uncover some approach to the
problem that is satisfactory for my patient. Additionally, I have
medical literature available to search for an alternate
methodology that has been tried and tested by other physicians.

In other situations, searching for new ways to get patients to

treatment may not be centered on the illness, but on the payment
of the treatment and the hospital’s use and care. Here again, I
seek alternative funding so my patient can receive the needed
care.

23
 Inside The Minds

Constant Change: Challenges and Satisfaction

Physicians practicing over the past several decades have seen

marked changes in the healthcare system and in the care of the
hospitalized patient. The passage of Medicare and Medicaid
legislation in the early 1960s first provided greater access to care
for the patients and better reimbursement for the physicians.
However, within the past 10 years these funds have retrenched to
the point that care has become threatened, and access to care will
surely decline for our elderly and less wealthy patients. Not only
have these funds decreased for physician payment, but hospital
reimbursement has also fallen drastically.

These factors effect not only patient care, but also medical
student, postgraduate, and specialty training. Moreover, funds
for basic and clinical research are severely threatened and
dwindling. The academic medical center, once the cornerstone of
innovation and discovery, as well as physician education, is now
threatened more than ever, and many of these institutions are
near closure. The American public expects the best medical care.
This includes new technology, new discoveries, and well-trained
physicians. No doubt in the near future a complete reassessment
of federal, state, private insurance, and managed-care funding
will need to be addressed in the face of decreasing care quality
and access. While physicians must keep abreast of all new
scientific findings, their judgment in the choice of treatment and
clinical activity may be altered by government regulations.
Physicians have lost a great deal of autonomy in treating their
patients.

24
 The Art & Science of Being a Doctor

For example, the federal government’s demand for shorter

hospital stays has influenced, and in some situations determined,
the actions of the doctor who must comply with all regulations.
The hospital often pressures the doctor to discharge patients as
soon as possible. Limits set by private healthcare insurers also
put restrictions on the doctor and the hospital. Clearly, we must
be concerned about the cost of healthcare; however, at the same
time we must continue to advocate the best treatments for our
patients.

Although the requirements imposed by insurance companies

present a challenge, the uninsured also pose a financial problem
for both the doctor and healthcare institutions. Finances are
squeezed from other angles, as well. For example, the filing of
lawsuits by patients and their families puts pressure and expense
on the physician, who must have ample malpractice insurance.
Frequent lawsuits, many without merit, have compelled some
insurers to cancel or totally withdraw from providing malpractice
insurance. This creates another difficulty for the practicing
physician.

But in spite of all of these difficulties, many medical advances

have added to the excitement of practicing medicine. Great
advances in the discovery of drugs and their increased
effectiveness in the treatment of some formerly untreatable
diseases afford the doctor the satisfaction of success in patient
care.

The advances in diagnostic tools have been exciting for the

doctor and have simplified many procedures once thought

25
 Inside The Minds

necessary for an accurate diagnosis. Patients have benefited

greatly from newer imaging technology, avoiding the more
invasive aspects of exploratory surgical procedures for diagnosis.

These advances have led to less invasive techniques for treating

illnesses. Endoscopic techniques in the operating room have
resulted in fewer traumas to the patient needing surgery, less
discomfort for the patient, and shortened hospital stays.
Although the advances in technology already allow surgeons to
perform surgery with fewer traumas to the patient, the future
holds promise of even greater advances in this area.

In the future, medicine will be driven even more by technology.

The operating room is in a revolution of advances, as evidenced
by robotic surgery, the ultimate in less invasive surgery. It is
practiced in many locations around the world. Medical school
settings are preparing the best of surgeons to perform surgery
with this advanced equipment.

Nanotechnology, making equipment smaller, will be another

advance in medical practice that will contribute to smaller
implants and smaller equipment used in less invasive techniques.

Telemedicine will also benefit the home healthcare patient by

adding visual images to the communications between the doctor
and the caregivers in the home setting. Telemedicine will also
increase the ability of practitioner-teachers to share patient
experiences with other physicians without having to leave home
base.

26
 The Art & Science of Being a Doctor

Research findings relating to the genome – along with the

application of these findings in understanding the basis of
disease, the treatment of disease, and hopefully its prevention –
can only challenge the scientific minds of physicians and their
desire to bring the latest to their patients. This increased
knowledge will bring the doctor to a better understanding of the
true basis of disease.

Increasing medical records’ use of the computer will provide the

physician with easy access to all patient data, assisting in and
ensuring a more accurate diagnosis and comprehensive care. The
computer and Internet give the physician and the public access to
medical information, and as this area matures, it will provide a
stronger database of current research and up-to-date medical
thinking for the doctor.

Members of the general public already use the Internet to search

for an understanding of their illnesses, and this research will
make them more active participants in their own care, which can
enhance the communications between doctor and patient.

These advances in technology and information, I believe, will

contribute to the emergence of the specialist in medical practice,
such as the cardiovascular surgeon. The generalist will be the
entry level of medicine.

I believe, as do others, that the future will see a continuation in

the speed of change in medicine, and that the changes will be
both a challenge and a source of satisfaction for us all. The

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advances promise much to both the ill person and the practicing
physician.

When asked what I would do if I could create any new drug in

the world or cure any disease, I would respond without
hesitation: I would like to create a new drug that would cure viral
illnesses. Through the use of this drug many infectious diseases
and many malignancies could be cured or stopped. Such a drug
could have a tremendous impact on the world’s health and social
well-being. An endeavor of such magnitude would require the
development of an initiative, collaboration with pharmaceutical
companies and the National Institutes of Health, and the
involvement of many different scientists with various types of
expertise.

Doctors as Leaders

Personal success begins early, when a doctor receives a good

basic training in medicine, which is then continuously fed by his
or her intellectual curiosity. This curiosity is a force that will
need the continuous nourishment of current scientific and
updated medical information.

To satisfy their curious minds, doctors must read the scientific

and medical literature. In addition, attendance at medical
conferences exposes doctors to the latest information and enables
the exchange of ideas between active minds. These activities will
add to the continuous growth of the doctors in the profession and
prepare them to teach courses for colleagues and the support

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staff at the hospital. Teaching courses will enable physicians to

synthesize their experiences and knowledge into a
comprehensive understanding, gain opportunities to contribute to
the profession, and increase leadership skills. These activities
will prepare doctors for certification and recertification in
medical specialties.

If the profession is to move forward in technology and the giving

of care, it is essential for all doctors to continue learning and
sharing knowledge. I find that personal studies, teaching, and
writing will add to a physician’s growth, as will learning from
other physicians’ skills and behaviors.

Pursuing an understanding of technology and its advances,

especially as they are applied to medical practice, is fundamental
for physicians if they are to be used to their fullest advantage. I
see the physician as not only understanding and using
technology, but also applying the knowledge gained to meet the
needs of the future. Innovations in technology by the physician
will enhance medical practice for the benefit of patients.

An example of such an innovation I am presently working with

and training surgeons to apply to their patients is robotic surgery.
This less invasive advance in surgery will benefit the patient by
reducing the trauma and discomfort of surgery and shortening
the hospital stay. Bringing technology to the future and even
creating the future of medicine is a measure of personal and
professional success.

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The physician also has a role as a team member or team leader

within the clinical area. Initially it is essential that the doctor
know the objectives of the group’s efforts and share the same
goals with the other team members. Dedication and commitment
to meeting those goals require good communication skills with
all team members, and most important, a high ethical and moral
approach to the problem at hand.

Team membership may require that the physician develop some

increased technical skills when appropriate to help meet the
team’s objective. Included among these skills may be surgical,
data coordination, profusion, and robotic surgery skills.

While working with other doctors, I observe and respect the

many skills they bring to medicine. It is their ability to treat
patients effectively, sometimes with limited resources, that
reminds me that most physicians are in the profession for the
right reasons. Although we are all faced with the changing times
and perhaps negative influences on the conscientious practice of
medicine, many continue to preserve their personal and
professional standards. The physician who has that extra caring
will study the ethical issues facing medicine today and
incorporate this thinking into his or her daily practice.

Being a good clinician is the basic quality of a leader in

medicine. Early in my medical career, I learned that hard work is
essential to be a good clinician. I soon realized that it is part of
every aspect of being a doctor, especially a leader in the
profession. Working as a physician got me involved with many

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local issues and activities, and I see this as inevitable for the
doctor working within the community.

Another quality I see as necessary in a leader is the ability to

think globally about issues that extend beyond the field of
medicine. Tenacity to see a problem through to some conclusion
is a characteristic I’d expect to see in a leader in medicine.
Imperturbability in working with others in the profession is
necessary for smooth working relationships within the clinical
area, as is the ability to work with a group and be able to foster a
single group opinion. An important quality for personal and
professional growth is the ability to take criticism and learn from
mistakes.

Leadership in medicine can take many forms. Some doctors

bring their expertise in medicine and their management of
personnel and communication skills to the organization and
administration of a healthcare system and a hospital. Their
leadership in ensuring the best care for patients in a pleasant
environment that is fiscally sound is a great contribution to the
profession and healthcare in general.

Professional organizations can benefit from the leadership skills

of a physician who will strive for the protection of the highest
standards of the profession. Other physicians become leaders in
the public health arena, working to ensure the health and safety
of the broader community, both nationally and internationally.
Their efforts protect our nation’s health while having an impact
on others worldwide. Similarly, physicians can provide their
leadership on the local level of their community or their state.

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They can lend assistance to the local public health personnel by

gaining community support for necessary health protection
actions. They can also assist local and state legislatures in
understanding health-related issues of legislation.

Researchers in clinical medicine, whether at university settings

or pharmaceutical companies, provide leadership in the
development of new techniques, drugs, and medical equipment.
Their leadership skills are the force behind the innovation in
medical practice and patient care that moves the profession of
medicine forward.

All of these leadership positions in medicine ensure quality in

the treatment of patients and the working efficiency of our
healthcare institutions. Physicians cannot practice medicine
without being leaders. Their role as patient advocates demands
leadership.

A Legacy of Excellence

Considering the best advice I ever received reminds me of how

lucky I was to grow up with two physicians in the family. My
father and grandfather, both doctors, set standards for me by
their example. My grandfather visited his patients on horseback,
assuring them the care and attention they required. My father
told me doctors work on Saturdays, which I initially didn’t think
necessary. But I soon learned in medical school and in my
practice that keeping abreast of the latest in medicine and being
available for patients more often than not requires working on

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Saturdays. I did have to acknowledge to my dad that he was

right: Doctors work on Saturdays.

With these examples of great doctors in my family, and my own

efforts in working to be a great doctor, I find medicine is my life.
It is not only an intellectually stimulating but also a demanding
profession that requires continuous study and research. Working
to be a great doctor requires the practitioner to want to contribute
to the art and science of medicine and actually be a part of its
future.

While these thoughts and endeavors are motivating forces in my

life and in the lives of many physicians, the practice of medicine
is a humbling experience. Our patients’ well-being depends on
our knowledge, skill, and caring. It is the seriousness of this
responsibility that in turn motivates me to work toward
excellence. It is the circle of intellectual stimulation, motivation,
and humility that brings life to the practice of medicine.

Both my father and grandfather believed and practiced medicine

based on the standard that the patient always came first. They
told me how putting myself in the patient’s place would help me
work and live by the standards I had set for myself. “Work to be
excellent” was their advice to me. Their standards, their lives,
and their practice of medicine are the best advice I could have
received from anyone. I believe their example is a model for all
physicians in the practice of medicine.

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Good Doctor Versus Great Doctor

A doctor who gives a limited number of patients (according to

his or her abilities) good care is a valuable asset to the
community and the profession, but more is required to be a great
doctor. A great doctor is one who influences the pathways of
medicine, contributing alternative and innovative ways for better
treatment of patients. A great doctor is a steadfast worker and an
overall renaissance person who seeks solutions to the many
challenges of medicine and healthcare in general.

A great doctor will have an impact on medical education and on

the training of interns and residents he or she comes into contact
with. A great doctor will keep up-to-date on medical
information, attend continuing education programs, and know
when to consult. A great doctor will have an effect on the health
of the community, sharing experience and knowledge with
community leaders. This ability to effect policy change will also
be felt at the administrative and board levels of the hospital.

The nature of medicine and its responsibilities sets the physician

apart from other professionals. The golden rules for the
physician as a person and professional are those of the highest
moral and ethical standards. The physician must be ever mindful
of the vow to “Do no harm.” I pass on to all doctors the advice I
received from my grandfather and father: Put the patient first,
and put yourself in the patient’s place for better understanding.

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Doctors face many challenges today, but medical practice

remains a rewarding life for the curious, the innovative, the
compassionate, and the dedicated.

Dr. W. Randolph Chitwood, Jr., is from Wytheville, Virginia. He

completed his undergraduate studies at Hampden-Sydney
College and received his M.D. degree from the University of
Virginia. He did his residency in general surgery and his
cardiothoracic training at Duke University. He became a full
professor and Chief of Cardiothoracic Surgery at East Carolina
University immediately upon completion of his surgical training.
He was named Chairman of Surgery at East Carolina University
in 1996.

Dr. Chitwood is a Fellow of the American College of Surgeons

and a member of the Society of Thoracic Surgeons and the
American Association of Thoracic Surgery. He is currently
President of the International Society for Minimally Invasive
Cardiac Surgery and President-Elect of the Society for Heart
Valve Disease. Dr. Chitwood specializes in minimally invasive
mitral valve surgery and performed the first total mitral valve
repair with a surgical robot in the United States.

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THE GOOD SOUL:

COPING WITH CHALLENGES
FACING DOCTORS TODAY
AND TOMOROW

LAURA FISHER, M.D.

The New York Hospital
Internal Medicine & Infectious Disease

Attending Physician

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 Inside The Minds

Art, Science, and Obsession

The science of medicine refers to an immense and ever-growing

fund of knowledge that describes the normal and abnormal
function of the human body. However, medicine is not a pure
science, such as physics or mathematics, because no two patients
are alike in how they experience (feel the symptoms of) or
manifest (show the signs of) an illness. I like to view the
individual patient as the canvas and the interacting elements of
his or her physical and mental wellness and pathology as the
pigments of paint on that canvas. The art of medicine is evident
when the individual doctor uses his or her personal experience,
intuition, skill, and knowledge to diagnose and improve the
physical and mental health of that individual patient.

A medical student must first take basic science courses (such as

anatomy, histology, embryology, physiology, and molecular
biology) to establish the groundwork for more advanced clinical
courses. The rigor of medical studies also trains the student of
medicine to think in a logical, deliberate, and systematic manner.
The student must have a solid understanding of the mechanisms
of wellness and disease before he or she can memorize and use
long lists of signs, symptoms, and differential diagnoses. The
clinician’s responsibility is to further master the science or
building blocks of medicine (e.g., cardiology, hematology,
dermatology, allergy and immunology, rheumatology, infectious
diseases, pulmonary medicine, gastrointestinal disease,
oncology, psychiatry, nephrology, neurology, endocrinology) to
diagnose and treat the patient correctly. The art of medicine lies
in knowing how to retrieve and integrate a seemingly infinite

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number of possibly relevant facts when encountering a particular

patient. This art is demonstrated by the ability to obtain a
relevant medical, family, and social history and to perform an
accurate and thorough physical exam to make a rapid and proper
diagnosis and to devise an appropriate treatment plan.

A doctor must know which questions to ask and how to ask them
of a patient in a respectful and non-threatening way. He or she
must also know how to interpret a patient’s subjective
complaints and concerns in light of that patient’s social,
physiological, psychological, and cultural make-up.

Different patients might have the same underlying disease

process, such as angina, yet present with very different
complaints, such as chest pain, lightheadedness, shortness of
breath, or gastrointestinal upset. Other patients might present
with the same complaint – a cough, for instance – yet have
different causative illnesses, such as asthma, infection,
pulmonary embolism, cancer, or gastrointestinal reflux. A
complaint of headache could indicate meningitis, migraine,
sinusitis, temperomandibular joint syndrome, temporal arteritis,
subarachnoid hemorrhage, or a simple tension headache.
Appreciating these varying presentations in different patients
relies on the diagnostic art within medicine.

The job of a good internist overlaps with that of a psychiatrist. A

clinician must appreciate the interaction of the psyche and the
body. He or she must be able to recognize and diagnose
psychiatric illness. Many internists feel comfortable prescribing
medications for uncomplicated depression and/or anxiety. For

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example, a new patient presented to me with complaints of

headaches, memory loss, shortness of breath, paresthesias,
migratory body aches, fatigue, and lightheadedness. She had
already been evaluated by several other physicians and had
undergone extensive and expensive diagnostic testing; yet no
diagnosis had been made and no therapy offered. After a long
conversation with the patient, we were able to identify her sense
of being overwhelmed by a recent move to New York because of
her husband’s job change, the recent birth of her first child, and
some marital strain. She was actually relieved by the diagnosis
of depression and somatization and responded quickly to
appropriate antidepressant medication and behavioral therapy.

The art of medicine can also be demonstrated in the effective

handling of a patient’s phone question. Even without examining
the patient, a working diagnosis can often be entertained if one
knows which initial and subsequent questions to ask and if one
not only listens to, but successfully understands the patient’s
replies. Recently a patient telephoned because of a rash. By
questioning the patient about the color, size, pattern, and location
of the rash and of associated paresthesias, I suspected the patient
had Varicella Zoster. The patient came in to my office, and
appropriate antiviral therapy was initiated. Similarly, a patient
might page a doctor at night with the complaint of chest pain.
Only a good doctor could relatively accurately distinguish
musculoskeletal pain (which could be treated with anti-
inflammatory medication and evaluated the next day) from more
serious processes, such as pulmonary embolism or ischemia
(which would require immediate emergency room evaluation).

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Basic or clinical researchers are both scientists and artists, as

well. They must have an overwhelming personal passion and
vision to ask the proper question and to formulate their
hypothesis. An AIDS researcher must first master all of the
available scientific facts relevant to HIV infection to then create
a new model or laboratory technique or antiretroviral compound.
The physician-researcher must be obsessed with a dream – to
prevent or cure diabetes, breast cancer, lung cancer,
cardiovascular disease, Alzheimer’s Disease, epilepsy, or
autoimmune disease, for example. His obsession is not unlike
that of the greatest artists or poets.

A Good Soul

Good doctors have to be intelligent, diligent, well read, and

caring. The main drive for doctors should be that they truly want
to help others achieve mental and physical health. Kindness is a
prerequisite for good doctoring. Physicians must know how to
deal well with people of all ages and of different cultural, ethnic,
socioeconomic, and religious backgrounds. As already
mentioned, they have to know which questions to ask of which
patients and the proper manner in which to ask them. They must
be able to listen to and interpret the patient’s answers. Physicians
must be able to deal with subtleties in physical findings and in
patient’s complaints. Different patients have different
perceptions of pain, shortness of breath, pruritus, and so on. So
intelligence, compassion, a strong fund of knowledge, and good
detective work (knowing how to put symptoms and signs and

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risk factors together to find the right diagnosis) are all critical
factors in a doctor’s success.

Only when a doctor-patient relationship is based on respect,

caring, trust, and understanding is the art of medicine clearly
demonstrable. A doctor’s bedside manner is of the utmost
importance in his being an excellent physician, because it invites
the patient’s necessary participation in the medical process.

I believe the ability to achieve personal and professional success

is something most of us begin to establish in childhood.
Someone who is happy and well-adjusted in childhood and the
teen years will probably remain content, well-rounded, capable,
and optimistic in later life. Professional and personal successes
usually go hand in hand. If one is personally successful –
meaning that one is content with oneself, happy with his or her
life circumstances, interested in what he or she is doing, and has
strong significant relationships with a husband, wife, family
members, or friends – it will be easier to be a good doctor. A
doctor’s patients, colleagues, and staff will respond to his or her
charisma, warmth, and self-confidence. Patients will find it
easier to confide in and trust that kind of doctor. Optimism and
good will are contagious. Likewise, if the doctor is successful at
work – meaning she feels good about her interaction with
patients and staff, her ability to help her patients, and her
reputation among colleagues and patients, she will take this
feeling of contentment home at the end of the day. Family and
friends will share and benefit from these good feelings.
Conversely, love for family and friends can overflow and
manifest as good will toward her patients.

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Organizational skills are very important, as well. It is not easy to

maintain a stable and happy home life and to have a thriving
practice. To succeed at home and at work, one must have
excellent organizational and time management skills. Many of
the best doctors are married, in a significant relationship, or
enjoy significant friendships. They have to multitask. They have
to learn how to juggle their personal and professional lives. I am
a mother of three young daughters. I have a lot to manage each
day between spending precious time with my husband and
daughters, supervising a busy household, and running a very
busy full-time private practice. My typical day starts around 5:30
in the morning, when our middle daughter awakens. After
spending several hours with my husband and daughters, I spend
a full and hectic day at the office. I find it beneficial to exercise
daily at the gym before returning home. I find that my hour on
the stationary bike allows me time to unwind, clear my head,
read my beloved novels, and catch up on reading medical
journals. I then enjoy spending the evening with family or
friends.

There is not much free time available to sleep, catch my breath,

or just think. Luckily, I have always had a lot of energy, a sense
of can-do, good organizational skills, discipline, and the ability
to enjoy almost anything I choose to do. Despite the lack of
enough hours in a day, it is important to challenge and reward
oneself in extracurricular areas, be they music, art, literature,
travel, the theater, or sports.

Countless seminars offer advice on how to be kinder to patients,

how to comfort patients, how to respect their confidentiality, and

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 Inside The Minds

how to give a patient bad news (such as in imparting a cancer or

an AIDS diagnosis). However, if one is a good, honest, and kind
person, these skills should come naturally. I believe a good soul
will manifest itself both at home and in the office.

Face-to-Face is Best With Patients

My strategy for dealing with patients is relatively old-fashioned.

I prefer face-to-face contact whenever possible. When a patient
calls with a complicated question or problem I ask him or her to
come into my office to talk in person. The physician-patient
encounter is very important and subject to nuances of a facial
expression, a pause or hesitation in conversation, and changing
body language. Subtle messages or clues to the patient’s
psychological state might be lost with a phone conversation,
e-mail correspondence, or messages relayed by a nurse, a
secretary, or an answering service. Avoidable mistakes are often
made when a physician tries to make too many diagnoses or to
prescribe therapy over the phone. I have seen cases of
appendicitis misdiagnosed as gastroenteritis and cases of
pneumonia misdiagnosed as the common cold. Some issues can
be handled over the phone if the patient cannot come in for an
appointment, but direct, face-to-face time is important whenever
possible.

Personally, I have not gone the route of e-mail. I have an e-mail

address but do not typically share it with patients. I have found it
to be useful on the few occasions when a patient lives in another
time zone (making it difficult for phone consultations during

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office hours) or when consultants have sent me digital

photographs of patients’ rashes. Just this week I received very
helpful photographs of a patient’s skin lesions from a referring
doctor. One photograph was of the erythema migrans lesion of
early Lyme disease, and the other was of recurrent erythema
multiforme of unknown etiology. Unfortunately, a lot is lost in
translation when people are typing answers and questions back
and forth.

Just as you might sip a new wine and know instinctively that it is
a good vintage, there are some innate characteristics of a good
physician. His or her intelligence and enthusiasm are readily
apparent. The best doctors are usually bright, quick-thinking,
perceptive, and directed. As I have pointed out, they know how
to ask the right questions and can integrate information very
quickly and accurately. Typically, they can make the proper
diagnosis with fewer tests and procedures and can select the
therapy with the most efficacy and the fewest unwanted side
effects.

Greatest Challenges Facing Today’s Physicians

For the individual clinician, the most basic and common daily
challenge is in establishing and maintaining a good patient-
doctor relationship. This rapport can be especially difficult to
establish with certain patients who might be angry, hostile,
frustrated, or frightened. This challenge would be true of any
interaction between strangers meeting for the first time.

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There are rare occasions when upon first meeting a new potential
patient, I am struck by the instinctive realization that the patient
is extremely antagonistic or hostile or convinced he or she has an
illness that he or she clearly does not have. On these occasions I
believe I cannot in good faith take on that patient’s care. I have
found it is better to explain to that patient that the two of us will,
for whatever reason, not be able to establish a therapeutic
relationship, and to terminate the intake interview without billing
the patient. It is important to explain that this action is in the
patient’s best interest.

The typical first doctor-patient encounters will bear fruit,

however. Trust has to be established and solidified over time.
The patient has to be willing to confide in the doctor and has to
be willing to answer the doctor’s questions honestly. The
physician cannot make a diagnosis or determine the correct
treatment if he or she does not know the right questions to ask or
if the patient does not feel comfortable giving honest and
complete answers. A patient must feel at ease in discussing prior
or current drug or alcohol use, sexual practices, lifestyle aspects,
contraception, dietary preferences, bowel habits, etc. This trust
takes time and effort to establish.

On a more macro scale, there are unfortunately countless

bureaucratic challenges a doctor encounters. Managed care limits
a doctor’s autonomy in ordering diagnostic tests, prescribing
medication or other types of therapy, and referring patients to
outside consultants. Frequently a patient wants to have a
mammogram done by an in-network radiologist, while the best
mammographers might be out of network. A patient might ask to

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be referred to a participating surgeon, while the better surgeon

might be out of network, as well. Unfortunately, the third-party
role of insurance companies can threaten the trust and respect
and rapport between patient and physician.

Physicians are often challenged by the allocation of limited

resources. Many patients cannot afford the best medications for
their conditions. There are frequent shortages of many vaccines.
This past year witnessed temporary shortages of diphtheria-
tetanus vaccine, Hepatitis B vaccine, influenza vaccine, and
Varicella vaccine.

Waitlists for organ transplants continue to lengthen. A just and

pragmatic way of distributing these resources must be found.
Other ethical issues, such as when it is proper to withhold or
discontinue potential life-supporting care, continue to challenge
us.

We are witnessing new diseases that must be addressed

aggressively and quickly. AIDS was only recognized in the early
1980s and continues to be a major health issue worldwide.
Significant work is being carried on regarding prevention and
treatment, but an effective vaccine or cure is nowhere in sight.
Newer challenges include the crisis with bio-terrorism. What we
once thought was merely a theoretical threat was proved a reality
when anthrax-infected letters were sent through the United States
mail system. We are concerned about the risk of broader bio-
terrorism, including smallpox, plague, and the hemorrhagic
viruses. Most of us didn’t envision such a scenario before the
events of September 11th and subsequent weeks.

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A doctor must have a consistent and successful approach when

encountering a diagnostic roadblock. Interns, residents, and
fellows are expected to avail themselves of text books when they
are challenged and to seek the advice of more senior physicians
at the hospital when the approach they have embarked upon
fails. As an internist I prefer having a copy of important
reference books both in the office and at home in case of
nighttime or weekend calls from patients. When I have difficulty
with a particular case, I go back to the beginning and sometimes
find clues I missed on first perusal. At this point in my career I
am very fortunate to have a terrific list of specialists in other
fields whom I respect and whom I can call on for advice when
necessary. Sometimes a phone call will answer the question, but
it is often necessary to refer my patient for a consultation. I
believe the best doctors are those who recognize their strengths,
but also acknowledge their limitations. It is important to admit
when one doesn’t know the answer and to seek that answer
elsewhere.

Some doctors use the Internet to get information when they hit a
roadblock. From my limited experience, in terms of useful
medical information, the Internet offers more breadth than depth.
That is fine for physicians at an early stage of training who want
to find a wide differential diagnosis or symptom complex list.
Unfortunately, I have been disappointed thus far in my efforts to
find detailed information on esoteric medical subjects. I prefer
referring to the standard medical periodicals, such as New
England Journal of Medicine, Annals of Internal Medicine,
Journal of the American Medical Association, The Medical
Letter, and Morbidity and Mortality Weekly Report.

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The Future of Medical Practice

One of the biggest changes in medicine has already set in, and
that is managed care. Individual doctors have already accepted
its reality and have decided they either will or will not participate
with managed care companies. Although there may be policy
changes regarding physician referrals and coverage of diagnostic
tests, therapeutic procedures, and prescription medications, I do
not believe that managed care will ever disappear.

Electronic information will continue to have an impact on the

practice of medicine. A small percentage of physicians are
already communicating with their patients online. Again, I am
fairly averse to that practice and am not thrilled so far with the
communications going on between doctors and patients online.
The idea of patients seeking information online before coming to
a physician is theoretically good, but thus far I have mostly seen
undesirable ramifications. Many a patient has done his or her
own computer research and made an incorrect diagnosis. I have
seen too many patients who have convinced themselves that they
have sero-negative Lyme disease despite the lack of any risk
factors or physical findings of Lyme disease. For the physician,
it is often difficult to dissuade a patient from an erroneous
diagnosis that he or she has made based on online searches. On
the other hand, it is often useful for the physician to refer his or
her patient who has a definite medical diagnosis to specific
physician-approved online sites for in-depth information or
advice. Excellent online sites already exist for patients with
diabetes, obesity, migraine headaches, epilepsy, sleep apnea,
lupus, rheumatoid arthritis, coronary disease, cancer, asthma,

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hypertension, and countless other illnesses. In the future more

electronic medical information will be available to patients. I
hope it will be more accurate and accessible and less of a
stumbling block when it comes to patients seeking appropriate
diagnostic and therapeutic information.

New information regarding disease processes, therapy,

epidemiology, risk factor modification, and medical technology
is constantly being published. The physician is faced with new
diagnostic tests, such as electron beam CAT scans for cardiac
calcium scores, whole-body CAT scans for the diagnosis of
cancer, PET scans, SPECT scans, thin-prep PAP tests, new
breast imaging modalities, blood tests for genetic predisposition
to certain cancers (such as BRCA1 and 2), and blood tests for
ovarian, breast, prostate, and colon cancers. He or she must be
familiar with the ever-growing number of antibiotics,
antihypertensive medications, antidepressants, and lipid-
lowering agents. A good doctor must read voraciously to keep
abreast of this new information. It is important to read journals in
general medicine and in one’s particular subspecialty as they are
released. Much important and useful medical and health-related
material can also be gleaned from lay publications, such as The
New York Times or The Wall Street Journal. Doctors must make
every effort to attend conferences offered at their hospitals or
offered by state and national medical organizations.

Unfortunately, ours is a very litigious society, and countless

inappropriate and frivolous malpractice cases are being brought
against good physicians and hospitals. So many of these lawsuits
are brought by angry or unhappy people looking to lay blame

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where it does not exist. Certainly there have been valid claims of
negligence and medical malpractice, but too many innocent
physicians are sued because of misplaced anger,
misunderstanding, and greed. Our society must recognize that
bad things can happen to good people, and that many bad health
outcomes are not preventable. I believe our fear of death and our
unrealistic expectations of near-immortality are partly
responsible for people failing to understand that not all disease
and death can be prevented. Our society often sees promises in
medicine where these promises do not and cannot exist. Another
atrocity that must be addressed and corrected is the utterly
fantastic settlement amounts that juries often determine. I
question our current jury system’s ability to fairly adjudicate
malpractice cases and to determine settlement amounts. I believe
a panel of respected physicians and judges would be more able
to make decisions in malpractice cases than a lay jury.

Highest Standards

To be a good doctor, one must be kind, hardworking,

compassionate, intelligent, and ethical. My six siblings and I
learned this lesson from our father, who was and is a great
physician of the old school. Each of us chose to become a
physician in turn. Our mother is brilliant and talented and would
have chosen to enter the medical profession herself had her
parents supported her desire at the time and not been convinced
that a woman’s place was not in medicine. (Thank goodness
women are now welcome in medicine.) She obtained her Ph.D.
in biophysics and enjoyed a rewarding career in teaching. Both

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of our parents emphasized the overriding importance of

knowledge. We were encouraged to help others in whatever
ways we were most capable. In our family the combination of
academic excellence and concern for others led to the pursuit of
careers in medicine.

Good doctors must be humble, yet confident. They must respect

their patients, their staff, and themselves. They have to trust their
knowledge base, understanding of and rapport with patients,
diagnostic and therapeutic ability, and instincts. They must feel
comfortable in making decisions and then take responsibility for
these decisions. They must be able to recognize and admit their
mistakes and act to remedy these mistakes. They must be open-
minded and creative in making an initial differential diagnosis,
but insightful and deliberate in honing that differential to a single
diagnosis.

Physicians must abide by the golden rule, which is to “love thy

neighbor as thyself.” The reason we pursue a career in medicine
is not for money, fame, or pride, but to help others. Maimonides
was a 12th century physician, rabbi, and philosopher whose
Prayer for the Physician I like to quote:

Before I begin the holy work of healing the

creations of your hands, I place my entreaty
before the throne of your glory that you grant me
strength of spirit and fortitude to faithfully
execute my work. Let not desire for wealth or
benefit blind me from seeing truth. Deem me
worthy of seeing in the sufferer who seeks my
advice – neither rich nor poor. Friend or foe,
good man or bad, of a man in distress, show me

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only the man. If doctors wiser than me seek to

help me understand, grant me the desire to learn
from them, for the knowledge of healing is
boundless.

Dr. Laura Fisher received BA degrees in biology and biomedical

ethics from Brown University in 1981. She received her medical
degree from Brown Medical School in 1984. She was a medical
resident at The New York Hospital (Cornell Medical College’s
teaching hospital) before doing her Infectious Disease fellowship
at The Massachusetts General Hospital in Boston. Dr. Fisher
returned to be Chief Medical Resident at The New York Hospital
in 1989 and has been an attending physician in the Internal
Medicine and Infectious Disease divisions there since. She has a
private medical practice on the Upper East Side of Manhattan.

Dr. Fisher has been consulted frequently as a medical expert on

television (ABC, NBC, CBS, FOX, CNN, and CNBC), on the
radio, in newspapers (The New York Times and other regional
papers), and in journals (Redbook, Elle, and others).

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RECAPTURING THE CALLING

OF MEDICINE

MICHAEL J. BAIME, M.D.

University of Pennsylvania School of
Medicine
Penn Program for Stress Management

Director

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 Inside The Minds

Art and Science: Defining the Differences

Being a successful doctor involves practicing a discipline that

is both an art and a science. The first aspect of that discipline is
the discipline of the science of medicine – that is, the ability to
skillfully apply medical science and technology to enhance
health. This is what we usually think of as the practice of
medicine. This aspect truly is a science, as it involves knowing
how to change the biology and physiology of the body, and, in
particular, how to carefully alter biology to restore health when
disease has interrupted and affected it. But there is more to the
practice of medicine. The other essential component of being a
doctor is the art of healing people – the skill with which the
healer can use his or her presence and relationship with
someone to make a difference. Although physicians spend most
of their time and energy working to master the science of
medicine, it is the art of medical practice that provides the
deepest satisfactions.

I aspire to combine this art and science as seamlessly as

possible. The technical expertise – the science of medicine – is
relatively straightforward, even though the amount of
information is overwhelming. After all, information is just
information. It is objective and concrete, and you can always
look it up again if you forget. You remember what you can, and
you learn to find the rest when you need it. This has become
easier as computer and information technology have made
medical information more accessible. Fifteen years ago I spent
hours each week keeping a file of journal articles up-to-date.
Now I log on to my institution’s online library. I have a lot

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more room in the file drawers in my office. Soon I expect to

have access to that information from a wireless digital
computer I will carry in my pocket. I already carry a medical
textbook and a database of drugs in my pocket organizer. So,
although we will always respect the physician who seems to
have mastered the immense fund of medical knowledge by
remembering the most information, the actual memorization of
this knowledge seems to be progressively less meaningful. This
is an exciting development, and the use of information
technology will continue to reshape the future of medicine in
unpredictable and startling ways.

Despite this fabulous technology, however, physicians still

need to work very hard to remain abreast of the science of
medicine. There is an increasing emphasis on “evidence-based”
medicine, which is the practice of medicine based on research
and objective data, rather than opinion or belief about how
something should be done. One would hope that this is how
medicine has always been practiced, but when we actually look
closely, we find our beliefs and prejudices may distort our
perception of what we actually know. Medical science is
working to derive objective guidelines and principles to direct
the technical practice of medicine. Getting expertise in that,
again, is quite straightforward. But all of the information in the
world will not help us be better doctors unless we can take its
content, understand how that information applies to each
individual patient, and use it effectively. Truth, or at least the
truth of medical knowledge, does not stand still. There may,
somewhere, be an absolute truth, but in the practice of
medicine, all truths are relative. Our knowledge about how to

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help bodies heal and how to prevent disease is always

provisional and in constant flux, just like everything else in the
21st century. People who practice medicine are required to keep
up with that constantly changing science. Technology does help
by providing access to information, but that information still
needs to be processed, evaluated, interpreted, and used to attain
a goal.

There is really no easy or practical way to keep up with this

constantly rising flood of information. I make an effort to read
at least one new article pertaining to my field of internal
medicine each day. Doing so allows me to keep pace with the
flow of science. Of course, the actual reading of a medical
report is not difficult and can be done very quickly. But it can
take hours of contemplation and study to actually understand
what that article means, to see its strengths and weaknesses,
and to appreciate how it applies to one’s clinical practice and
individual patients. I would like to claim that I always complete
this task, but I do not. I am lucky enough to be in a large
teaching institution with a teaching practice that has students,
interns, and residents working beside the faculty each day. That
environment gives me a tremendous number of opportunities
for learning, right at my fingertips. Then I do my best, and at
the end of each day, I hope my best was good enough. It is a
humbling experience to perform a task that so dramatically
affects the life of another human being, and to acknowledge
that one’s mastery of that task will always be incomplete.

The biggest challenge of medicine, however, is not mastery of

the information that comes from books. It is mastering the more

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human aspect of healing, and merging that healing role with the
scientific and technical expertise. Physicians need to do this
deliberately and proactively. Often we take that part of medical
practice for granted, thinking the wisdom of our accumulated
experience is enough. Sadly, it often is not. And although the
over-emphasis on the science of medicine at the cost of the
practice of its art deprives our patients of something they want
desperately, the greatest loss is our own. That is because the
greatest rewards of medical practice are found in its most
human interactions.

We must deliberately cultivate the interpersonal part of healing

alongside the technical expertise. It is hard to say exactly how
to do this for a particular physician. It is very personal. It is
much easier to prescribe a daily medical journal article. I like to
think I make both of those aspects a priority and value both
equally. It is very difficult to maintain that balance, and it
sometimes seems that people who practice medicine tend to be
biased one way or the other. It is very common to find that the
real technical expert in a field, or the person who is most
widely known or most knowledgeable about a particular
problem, is the least skillful at the interpersonal art of healing.
A cynic might conclude that once they know that they are a real
expert, they believe they no longer need to work so hard at
caring and feeling. More likely, they are just too busy. In any
case, their patients feel their absence, although if most people
had to choose, they would choose the doctor with the technical
expertise and hope they will get the time and the caring from
someone else.

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Encouraging Mindfulness

The role of the doctor is to apply technology skillfully and to

cultivate his or her inner resources and those of the patient.
This is a powerful way to promote wellness and to help the
patient heal. It is also very challenging. Part of the difficulty
comes from the intense time pressure and stress of current
medical practice. We will have to do something to make the
practice of medicine less pressured for both ourselves and our
patients if we are to continue to provide optimum care.

One way I try to work toward this goal is to teach patients and
healthcare providers mindfulness and meditation practices. I
run a mindfulness meditation-based stress management
program at the University of Pennsylvania, where I teach both
patients and doctors to use the concept of “mindfulness” as a
tool for healing. This mindfulness is defined as a moment-by-
moment awareness of what is happening right now, in each
moment. Mindfulness mediation is a technique that teaches one
to bring awareness to the present moment and let it remain and
rest there. When we remain in the present moment, we find we
can relax fully and deeply in that moment. We do not need to
worry about what has happened and is already finished or about
what is still off in the future and may never occur.

When we begin to notice what our minds are actually doing as

we go about our business, it is shocking to find that we are
seldom paying attention to what we are doing right now. What
doctors usually do when they are with a patient is to carry on
numerous different conversations in their heads at the same

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time. We are always talking to ourselves, and it is sometimes

shocking to see how many different simultaneous conversations
we carry on. We tend to do this automatically, on “automatic
pilot.” This is similar to what happens when we drive home and
do not really notice what we are doing, where we’ve been, what
we’ve seen. When we arrive and get out of the car, sometimes
it seems that someone else must have done the driving. We
were not paying attention to where we were going at all and
don’t remember how we got home.

This automatic pilot is not a problem if we are doing something

that doesn’t matter. It is fine to drive your car on automatic
pilot, at least when the ride is uneventful. It is not, however,
such a good way to practice medicine, even if we perform the
technical aspect of our practice perfectly.

Our absence in the encounter with a patient deprives them of

our presence. It is this presence that actually provides a bridge
between healer and patient. That one-on-one presence of a
doctor, the healer, in the room making an active, living
connection with the patient is what gives that patient a link to
themselves, to their own being, to their own heart, and to their
own sources of strength and healing. The actual felt presence of
that other person is what lets the patient know that someone is
there.

Mindfulness also provides a powerful set of tools for stress

management The ability to rest in the present moment helps
people undo their anxiety and face their challenges with
balance and confidence. Mindfulness is about learning how to

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connect with one’s own inner resources. My public program at

the University of Pennsylvania Health System has trained more
than 2,000 people to use meditation as a tool for healing. I also
teach classes at the University of Pennsylvania School of
Medicine for students and trainees, as well as doctors in
practice, to help them use these techniques in their own
professional lives and to enhance healing.

Meditation may or may not become more popular, but

something that accomplishes these goals is absolutely
necessary. It is absolutely necessary for us to come to our
senses and reassess the role of our own presence in the art of
healing. Without it, a part of what is most important about
medicine will remain lost to us and our patients.

The economics of healthcare have painted us into a very small

corner. The time pressure that everyone in healthcare feels has
made the delivery of healthcare mostly a technological
exercise. The act of being a doctor can be reduced to the act of
writing a prescription and ordering tests. That is partly because
there just isn’t enough time to do anything else. We are afraid
to start a conversation with our patients because we might open
Pandora’s box and invite a flood of feeling we cannot manage
in our cramped schedule. But it doesn’t take hours of relating to
a patient to actually let them know they are cared for or to feel
the healing presence of someone who cares for them. Instead, it
just requires a healer whose mind is stable and steady and
present in that moment with that patient. It happens in an
instant, and it is felt right in that instant. You don’t need to do
anything. Just be there.

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I believe it is possible to train yourself to return to the

simplicity of that presence with another person by using
mindfulness techniques or something like them. If we don’t do
it, the profession of medicine will become increasingly focused
on the concrete interaction. Medical care will be something like
plumbing or electrical engineering. This mechanical aspect of
healing does provide the appropriate technological intervention,
but it doesn’t provide what people are longing for in their
hearts. That is why the medical profession is denigrated in our
culture right now. The modern practice of medicine disappoints
patients, and it disappoints the people who provide the care, as
well. The doctors who care most about this kind of caring for
people are the most discouraged and are the most likely to
leave medicine. We must correct the overemphasis on
technology. This does not mean we should use less technology,
but rather that healing needs an interpersonal – as well as a
scientific – aspect.

The most challenging part about being a doctor is dealing with

the increasing time pressure and constraints that are put on
physicians. It was different when I began practicing medicine,
and it will be different again. When I started, I spent 20
minutes with each patient and had a much more spacious
interaction with them. That has changed, and it will change
more in the future.

I now have 15 minutes with each patient. Many practitioners

have less. Three or four times an hour, someone walks in the
door. I have to hear their story, examine their body, make a
decision about what is happening to them, explain it to them,

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tell them what I think they should do, speak to their fears, and
allay their concerns. Even just telling someone I must change
their blood pressure medication conjures up a very complicated
set of feelings, including questions such as: Will they live?
With they have a stroke? Will they be able to have sex? And
this densely felt interaction occurs four times an hour. For the
physician, it’s like playing a 60-minute symphony in 15
minutes. Even if you hit all the notes, it doesn’t sound right. It
is hard to do it well. It seems impossible to do it well 20 times a
day. Many of the best doctors feel they are past their limit and
can’t manage their practices properly. Every day I hear
someone say that they just can’t do this much and do it well. I
see no signs of this pressure abating anytime in the foreseeable
future.

Could we just practice medicine without doctors? Could we

dispense technology with a machine that would interview the
patient, and plug your body into a computer, as you plug your
car into the analyzer at the auto repair shop? Sometimes it
seems as if doctors are being asked to fulfill that function. It is
very unsatisfying. As the time pressure and the demand
increase, you are being asked to perform that function more and
more quickly. The result is that you get less and less personal
satisfaction, and actually perform your job less well.

Our entire culture is changing in the same way that the practice
of medicine is changing. There is no reason to think anything
will halt the progression to more speed and increasing demand.
As our speed increases, and we find ever more efficient ways to
do more things at the same time, it will become even more

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difficult to practice healing in any real and meaningful way.

We will become lost to ourselves, adrift in a sea of multitasking
and overwhelming demands. Our culture must be cured of its
speed, its tendency toward violence, and its materialism. Our
culture is a trap set to catch itself. We are on a path that fosters
incredible productivity at the expense of the people inside. This
will become increasingly obvious.

Unfortunately, you cannot change the direction of a culture by

getting on a soapbox and preaching. This kind of change must
come from within, from the people whose lives are affected by
the speed and tension of their daily lives. We have to take a
look at ourselves, at how we live, and ask if this really works
for us. We need to ask if our lives are helping us fulfill our
deepest needs. People themselves must recognize that they are
part of a larger system and that by moving at this pace, they are
lost to themselves. Until we come back to ourselves we can’t
do anything.

The only way to really make effective change happen is to

begin with ourselves. We need to take a good, honest look at
ourselves and think about what we want and what we can
realistically accomplish. In the face of these challenges, first of
all, I have developed a tremendous amount of humility. I do the
best I can and accept that it is a process of constant growth and
learning. Each time I fail, the failure is actually pointing out
something I could learn to do better. Second, I cultivate my
own presence and my own being in my own practice,
deliberately and intentionally, in an ongoing way. I never want
to view my practice in a percentage/product way. I am always

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working to learn about how to be with people and how to care

for these people in their own way, in the way that works for
them, as best I can. Fortunately, in the practice of medicine we
have the potential to provide a tremendous benefit for others. I
believe if we just start with the concrete details of our own
medical practice, we can affect others in ways that can really
make a difference. Then the larger changes will be more likely
to happen. Change happens with one person at a time.

Finding Ways to Change

It is not as difficult to make these changes as it might sound. In

my own practice I make a very deliberate attempt to pay
attention to the whole person. As doctors, our tendency is to
focus on the disease. In this mindset the blood pressure is the
problem, and the goal of the visit is to make that blood pressure
number what is should be. Although that is one goal, it makes
the whole practice narrow and limiting if that is the only thing
that happens during a visit. To prevent this narrow and
mechanical type of medical practice, I use meditation-based
techniques in my practice. They allow me to slow down enough
to actually feel or experience what is happening with a patient.

You do not have to learn to meditate to use mindfulness as a

tool to enhance medical practice. Doctors don’t have to shave
their heads or wear funny robes instead of a white coat to use
these techniques. Mindfulness in clinical medicine is the simple
practice of coming back to your personal presence and
experience while you are with a patient. It is not all that

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difficult to do, although if you are not in the habit, it might be

very hard to remember to try.

You can experiment with this kind of approach in your own

medical practice or job. For instance, as a doctor, you might
stop at the doorway of the examining room before each clinical
encounter, take a deep breath, feel that breath settle into your
body, and rest briefly in the present moment. This will give you
a moment of transition, allowing your mind to let go of the
thoughts and activity of the last encounter. You might or might
not consider this kind of break in the flow of work
“meditation,” and I don’t think it matters. If you practice
formal meditation, the major benefit will be that when you have
a few seconds to rest in stillness, you are more effective at
actually resting. You are less likely to react to the tension and
speed of what has come before.

Then, when you enter the door to see the next patient, you can
let that moment of mindfulness continue. You can focus all of
your attention on the patient for the first 30 seconds of that visit
– say, for the duration of three slow breaths. You might ask the
patient a simple question, such as, “How are you?” and then
simply rest and watch and feel while the patient responds.
Usually, the first few moments of the visit contain transitional
small talk, devoid of any real content. I ask doctors to use that
time to fully place themselves in the moment. Your only goal
during these 30 seconds is to have a full and direct experience
of the patient, to be completely aware of what is happening to
the patient in the largest sense possible. Feel and notice the
patient. By doing this, you will be able to actually see the

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person who is there, instead of continually processing people in

an inattentive, automatic way. If you see four people an hour,
eight hours a day, for 10 to 20 years, you begin to do it
automatically. You are not a bad or uncaring person; you are
just a human being. We begin to pay less attention to events
that happen over and over. It takes an active process, an effort,
to change this.

The experience of the patient is strikingly different when the

physician starts a visit like this. The patient notices something
is ... different ... about the doctor today. Of course, nothing is
really different except that the doctor is actually in the room
with them. But patients feel that something special and
meaningful has happened. Often they comment on it or ask
about it. Surprisingly, the visit is likely to be shorter than usual,
possibly because the patient has received what they really
wanted right at the start of the visit. Then they can relax,
because they feel more confident that they will be cared for.

We live our lives scanning our environment for the things we

fear or want. We are always looking at the past or looking
toward the future. It is very easy to miss the moment we are
actually in. This is a loss in all sorts of ways. Personally, we
can be asleep at the wheel of our own lives. We can coast along
in the same direction without ever really taking stock of where
we are and where we truly want to go. Professionally, it affects
how our patients experience our care. The patient is so present
and so exposed in so many different ways.

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There are many reasons to fear a simple visit to the doctor. First
of all, the reason for the visit is usually something frightening.
People don’t take medicine or visit doctors because they like to.
They participate in medical care because they do not want to
suffer disability, pain, or death. These are very reasonable
motivators, but frightening ones. Then, of course, they are
about to have their body examined in a way that transgresses
the social boundaries that protect them in everyday life. They
may experience guilt or shame or anxiety. Meanwhile, the
doctor is also anxious, probably about whether he can get out
of the room quickly enough. There is no blame in that, either; it
is very difficult to practice medicine on a schedule, on any
schedule. People and their problems do not fit neatly into 15-
minute blocks. Then the patients who are in the waiting room
will be angry if their wait is too long. But because of all of the
distractions, it is easy to overlook the very anxious, half-
dressed human being who is lying on the examining table,
hoping someone will care. It is so easy to disappoint that
person. I have done it thousands of times myself.

Everyone is uncomfortable when that happens, and no one gets

what they want. My goal is to undo that unhappy event with
meditative techniques that help doctors to stop and be present.
When you do actually find yourself there, in the moment, what
you tend to find is not a disease state or a blood pressure
problem that needs to be fixed, but another person. While this
statement seems insignificant, it makes a qualitative but very
important difference in what is happening in the room. Patients
feel the difference. They feel the attention. Doctors feel the
difference, too. A day filled with empty, meaningless drudgery

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can become a day filled with people the doctor cares for and
cherishes. It is the same day, but the awareness or attention is
focused in a different direction. Doctors can recapture the
calling of medicine. And most surprisingly, it doesn’t take any
more time to practice this way. The doctor and the patient are
both already there. It was just the attention, the human contact,
that was missing.

Just as in every aspect of our culture, in medicine, the concrete,

material aspect has overshadowed the experiential, felt aspect.
Re-exposing this felt aspect is essential. It is a constant process
of maintaining a complete awareness of all domains in that
interaction. The doctor must be completely aware of the
physical and cognitive aspects of a patient and have the ability
to decide where the patient needs the most help. I give this
same advice to my staff, as well. Pay attention. Observe as
much as possible. Notice. If you are taking a patient into an
examining room to take blood pressure, take the opportunity to
acknowledge the patient as a person, rather than an object. It
sounds exhausting, but in reality it is not. It isn’t physical
exercise. It is a mental event. It is relaxation into the present
moment with the patient. It is a learned art.

Finding Your Own Path

There is no prescription for success. The interesting thing about

practicing medicine is that it gives you so many ways to find
your way as a professional. As with anything that matters, it is
important to have clear and explicit goals. However, at the same

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time, it is important to have some flexibility with those goals. If

your goal is to help people, there are numerous ways you can
make this happen. Most important, however, is that you follow
your own inner voice. You must find a way to make your own
way of being fit with what you do. In some cases that might be
to relate to people on a very personal level. This is what has
sustained me throughout my career. Others will find different
ways. I believe the journey toward success in medicine has more
to do with finding your own voice and your own path than it
does with anything else. It is a deeply personal process. For me,
as a clinician, success as a healer or a physician is the ability to
simultaneously practice this interpersonal art and to apply the
science of medicine.

You must find your own way and live it and trust yourself. My
practice is a primary care practice. I used to be the physicians’
administrator of a practice. I was the section chief of a division
of general internal medicine. I was a leader, and that has its
obvious satisfactions and stresses. In my current practice,
however, I am just another clinician. Most of my time and
energy go toward developing the meditation-based stress
management program. I used to practice the meditation on the
side, in my own time, and at times it looked as though the
program based on those techniques would never be successful in
any external way. But it had its own rewards for me personally,
so I trusted that and stayed with it. As a result it has become
successful in an external way. I now am part of a large university
health system. And while I am not leading a practice, that was
not what held the personal rewards for me. Speaking with my
own genuine voice in my own way makes the difference. I

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believe, then, that if you have a passion for something and

follow that passion, you will end up speaking with a genuine,
authentic voice that others can feel and hear. Your passion might
be for research or for some other particular aspect of medicine. It
might be outside of medicine. It doesn’t matter. If you trust it,
you will find your own brand of success. Maybe no one else will
notice. If you have really listened deeply to yourself, you will
not care.

The practice of medicine is one of the most rewarding and

powerful things a person can do. It is an incredible and
compelling privilege to touch people physically, spiritually, and
psychologically. The capacity to actually decrease patients’
physical suffering while helping them find their way through life
is incredibly powerful. By cultivating my ability to do this, I feel
a deep sense of reward. I enjoy the lives I have touched and the
people who have been able to benefit. And in return, as they
allow me to share their lives with them, I benefit.

For me, the practice itself has become a way to nurture and
cultivate my own life. I feel I have learned something precious
and mysterious about life through the practice of medicine. I
know what it feels like to be a very old person living alone in
despair, or to be a new mother filled with hope. From intimate
experiences of so many lives, I feel I have learned something
essential about what it means to be a human being, alive, in a
body that has the energy of the world coursing through it, a
fragile body that cannot live forever. I have learned to be afraid
and to have the courage to face my fear, and to be afraid and to
not have the courage to face my fear. I have learned so much

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about what life means through my practice. It is such an

incredible path. I would never advise anyone to become a doctor
for any of the material rewards the profession offers. They are
not worth the struggle and loss they cost. But the spiritual
rewards are priceless. In our modern technological medical
profession, it is almost suspect to talk about the spiritual rewards
of practice. But medicine is a calling, and a calling is always a
summons from something higher. It is up to you to decide who
or what is calling and how you should answer.

Facing the Challenges

The worst part of being a doctor is disappointing people. Often

the system takes us away from the real calling of medicine for
financial reasons. Practicing in primary care, you develop an
immense amount of humility. When I reach a technical
roadblock, things are much simpler: I ask for help. It is easy to
become overconfident or to feel that you should be able to do
something you can’t, but that is really a trap.

The harder situation is to be with someone you really can’t help.

This is the person who has just heard that he or she has cancer
that isn’t curable. Doctors must deal with some of the saddest
and most bitter experiences of human life. There are structured
ways of dealing with these situations as a doctor, in terms of how
to present the information to the patient, and so on. However, for
myself, I find the most important thing is to not turn away. The
temptation is to turn away when we run out of technology to
apply. As a doctor, if you accept the premise that you are simply

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applying the science and technology of healing, then when you

are done with administering treatment, you have nothing else to
do, and you leave. Instead, you must be present with the patient,
no matter how hard it is for you as a doctor. Staying there, not
leaving, is the real challenge.

While doctors, for the most part, come into medicine with a
tremendous sense of altruism, it is often hard to see this from the
outside. Part of the problem is that the doctors are so
disappointed in the system that a kind of bitterness gets in the
way. There is a tremendous drive to not care so much. Actually,
people often view that as a positive thing. They feel opening
themselves up too much and caring too much will damage them.
I actually don’t see anyone who has been damaged by caring too
much. I believe it is exactly this caring that allows the profession
to renew itself. If we don’t have that caring, we have nothing.
The caring is the most fundamental basis of healing. If we don’t
practice it, then we might as well be replaced by a machine that
dispenses the right prescription.

I respect doctors who can keep their hearts open and never stop
caring. Doing this is tough, but important and necessary. It
makes it easier for you, as a doctor, to take a larger view of life.
We must all face hopeless situations in our own time and in our
own ways. It is just built into our being to experience suffering
and sadness and loss. Sometimes it is bitterer than others, but
there is something about it that is truly a very human experience.
It is really important for me to understand this as I try to get
through the process of loss while I do what I must for my patient.

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Appreciating this process of loss and the fact that death is

inevitable for all of us is actually what gives us the deepest
appreciation for the life we have right now. We realize life is
fleeting and precious. If anything really matters, it is to live the
moment as fully as possible, right now. There is absolutely no
guarantee we will get another. Having this deeper sense of the
fragility of life leads to the deepest rewards of being a physician.
It leads us to find depth and meaning in our work. It teaches us
how fragile and precious is this human existence. It transforms
the practice of medicine into a path toward a deeper
understanding of life itself.

Dr. Michael J. Baime, director of the Penn Program for Stress

Management, received his B.A. from Haverford College and his
M.D. from the University of Pennsylvania School of Medicine.
He completed his residency training in internal medicine at the
Graduate Hospital, after which he served as Chief Medical
Resident at the Graduate Hospital.

Before joining the Penn Health System, Dr. Baime held a

number of administrative positions at the Graduate Hospital,
including Assistant Program Director of the Internal Medicine
Residency, Director of Ambulatory Services, and Chief of the
Division of General Internal Medicine. He is a Clinical Assistant
Professor of Medicine at the University of Pennsylvania School
of Medicine and is a Diplomate of the American Board of
Internal Medicine. His special interest is stress management,
and he runs a systemwide program for the University of
Pennsylvania Health System. He has been included in

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Philadelphia magazine’s “Top Doctors” issue for seven

consecutive years, including this year’s “Top Doctors for
Women” issue.

In 1992 Dr. Baime founded the Stress Management Program to

address the growing need for the treatment of stress and
associated health problems without the use of medications. The
program was developed to address the psychological and
physical aspects of stress that are difficult to treat in an
outpatient practice. More than 2,000 individuals have
participated in this public program. In 2001 and 2002 he and his
team created and taught two highly successful stress
management programs designed to address the needs of
healthcare professionals. More than 145 Philadelphia-area
doctors, nurses, and other healthcare professionals attended the
course.

Dr. Baime has lectured and taught stress management

techniques throughout the country, including engagements for
the American Medical Association (AMA) and the American
Occupational Health Conference (AOHC). He has discussed
mindfulness meditation on National Public Radio’s “Fresh Air”
and has been interviewed for a segment of ABC’s “Nightline.”

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THE PATIENT, PLEASE,

NOT THE DISEASE

LEO GALLAND, M.D.

MDheal, Inc.

President

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 Inside The Minds

The Need for Patient-Centered Diagnosis

For the past 20 years I have had a practice that extends beyond
conventional internal medicine. I see people who have chronic
and difficult-to-solve problems. My patients range from children
with autism to adults with cancer or degenerative neurological
diseases. They include people with very well-defined illnesses,
such as inflammatory bowel disease and people with much more
vaguely defined conditions, such as chronic fatigue.

I was trained in the conventional medical model, which basically

holds that people get sick because they get diseases. Each
disease is then viewed as an independent entity that can be given
a diagnostic code and can have appropriate treatments attached
to it. These diseases can be studied in school without reference to
any single patient who has the disease.

Over the past hundred years this tendency within conventional

medicine has only become stronger and stronger. Today if you
are a doctor practicing in the United States and are dependent on
any government regulatory mechanisms or third-party
reimbursement, you cannot treat a patient unless you attach an
ICD (International Classification of Diseases) code to that
patient’s diagnosis. Furthermore, any treatments you do that are
reflected in CPT (Current Procedural Terminology) codes must
be appropriate to that ICD code. Thus, the identity of the patient
as an individual becomes just a footnote to the disease.

Today we also see the prevalence of evidence-based medicine.

This approach to medicine rests on the results of double-blind,

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placebo-controlled trials. In a double-blind, placebo-controlled

trial, researchers treat groups of people with the same disease
and try to control for variability among individuals. A basic tenet
of this method is that one can remove the inter-individual
variability and just look at the treatment for the disease itself.
Evidence-based medicine and conventional medicine in general
rely on a diagnostic process that asks, “What disease does this
patient have?” This is the primary question doctors are first
taught to ask and then to answer. The treatment that follows is
the treatment for the disease, not necessarily the treatment for the
individual. Although medical students hear the adage, “Treat the
patient, not the disease,” the truth is that doctors don’t learn how
to treat patients – they only learn how to treat the disease.

After completing my training in internal medicine, I became

dissatisfied with the limitations of disease-centered medical
practice and began looking for ways to improve the efficacy of
medical treatment. I was especially concerned about the long-
term outcome for people with chronic or recurrent illness. I
called patients I hadn’t seen in some time to ask them how they
were feeling and what they were doing to take care of
themselves. I was constantly impressed by the large degree of
individual differences in response to the same kind of therapies. I
also realized that an individual’s short-term response to
treatment was a poor predictor of how well the person would be
many months later. For most patients, long-term health status
had less to do with the disease or its treatment than with
characteristics of the individual, such as family and social
support, dietary practices, personal habits, or the environments in
which they lived.

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I realized that in the evaluation of patients, doctors must analyze

those individual factors that contribute to the genesis of illness
and to long-term outcomes. I developed a process for organizing
and structuring this analysis, which I called patient-centered
diagnosis. I apply this process to each individual I work with. I
then use this approach to try to generate therapies that are
specifically targeted for that individual – therapies that might be
quite novel for other people suffering from the very same
disease.

Understanding Mediators, Antecedents, and Triggers

The concept of patient-centered diagnosis is as follows. People

become ill because of factors I call mediators, antecedents, and
triggers, or MAT. It is possible to understand these scientifically.
If you can identify the mediators, antecedents, and triggers in
each individual case, you can achieve much better results than if
you only treat the disease. Knowing what the disease is may give
you some idea of what the mediators are, but it often will not tell
you about the other factors you must be also aware of.

Mediators

Mediators are not the causes of diseases; rather, as their name

implies, they are intermediaries. Mediators are those things that
occur to produce the eventual manifestations of disease.
Probably the hottest area of medical research in the 20th century
involved understanding the chemical mediators of disease
underlying both inflammation and coronary heart disease, as

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well as the spread of cancer. The fascinating thing is that such

scientific pursuit revealed that mediators are not disease-specific.
That is, these chemical mediators are each involved in multiple
diseases, and each individual disease involves multiple
mediators. It is possible, then, to understand illness based on
mediators without delving too deeply into specific diseases.

Biochemical mediators are not the only kind. Psychosocial

mediators, for example, interact with the biochemical mediators
in a very direct fashion. Social reinforcement and support, as
well as beliefs and expectations, play important roles in
mediating the entire phenomenon of illness and disease. It is
important, then, for a doctor to look at all of the mediators
involved in any one patient situation.

The second thing we must understand is that mediators do not

cause disease. Instead, they are part of response patterns that
allow organisms to maintain equilibrium in the face of changing
or stressful environments. Most conventional drug treatments are
aimed at suppressing mediators that have run out of control. We
can see this by simply looking at drug category names. We have
beta-blockers and calcium-blockers, antihistamines and ACE
(angiotensin-converting enzyme)-inhibitors. We have developed
an armamentarium of pharmacological substances whose
primary action appears to be suppressing hyperactive chemical
mediators. The side effects of these drugs are a direct extension
of their effects on the body.

Again, mediators are not there to cause disease; they exist

instead to regulate the changing environment, internal or

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external. Numerous factors in a person’s life influence the

activity of these mediators. Diet and nutrition are important areas
I have emphasized in my practice, but there are others. For
example, there are natural rhythms – daily, monthly, or seasonal
– that have an effect on mediator activity, as well. Understanding
how these rhythms affect an individual can be very useful in
designing therapies that help prevent relapses.

Triggers

We are exposed to many things internally and externally that can

act as triggers for the symptoms of illness. The most obvious
example is the person who suffers from allergy and is exposed to
an allergen. That person may then develop a skin rash or
wheezing. There are many diseases that are not ordinarily
considered allergic, in which environmental, dietary, or
psychosocial triggers can be identified if the doctor looks hard
enough. Helping the person eliminate those triggers can produce
improvement, if not a cure.

Triggers must not be overlooked. As an example, let’s take a

disease called Sjogren’s syndrome. This syndrome is an illness
that can have very different manifestations, but the hallmark
symptoms are dry mouth and dry eyes due to inflammation
involving the glands that produce saliva or tears. It appears to be
an autoimmune disease. People with this syndrome can have skin
rashes and joint pains, and they can experience difficulty with
concentration and memory due to inflammation impacting on the
brain. There is basically no conventional treatment, except to
treat the symptoms. Some studies, however, have indicated

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patients with Sjogren’s syndrome have a tendency to produce

antibodies directed against gluten, the protein in wheat. Most of
the patients I have seen with this syndrome have benefited
greatly by eliminating gluten from their diet. Gluten, in some
patients, is basically a trigger for part of the mechanism
provoking the syndrome. This, however, is not a specific disease
association because many different diseases may be triggered or
activated by gluten. Also, gluten sensitivity is not the cause or
the only cause of Sjogren’s syndrome; it is one factor involved in
aggravating it for many individuals.

Antecedents

Antecedents are those things present in the individual, before the

onset of illness, which contributed to the illness. There are
several types of antecedents, and understanding them is very
important in understanding how to proceed with an individual
and in getting a handle on the actual prognosis.

There are basically three types of antecedents. First, there are

genetic factors. Today a great deal of attention in medical
research is being devoted to genetic factors as antecedents in
illnesses. However, I believe most of this research is displaced;
that is, most of the relationship between genes and illnesses has
more to do with the regulation and activation of genes and how
environmental influences alter gene expression than it does with
gene inheritance. Much of the genetic research will help us
understand the chemical mediators of illness better, but – in the
short term, at least – I do not think it will shed much light on the
antecedents of illness. That is not to say that it won’t be able to

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do so in the future, but for now the attention is overly focused on

the notion that genes are the actual cause of the illness. In reality
they are just one part of the background of the illness, as
antecedents, or rather, as influences on the mediators.

Just as important, we must also look at the events and

experiences of the individual patient’s life, as these experiences
can condition and shape the development of the immune system
or the psyche in the direction of illness. Some studies have been
done here, as well, especially looking at patterns of childhood
abuse as they relate to illness patterns involving the
gastrointestinal or reproductive systems in adult women. Again,
however, we cannot overgeneralize these results and apply them
to each particular patient.

The third type of primary antecedent is the precipitating event. A

precipitating event, most simply, is something that happens to a
person. Before this event, the person considers himself or herself
normal; after this event, however, he or she has become a
patient. They now see doctors, and there has been a general
change in health and condition.

I then identify this precipitating event, which I do by first asking

the patient, “When was the last time you felt perfectly well?”
This is a very different question from, “How long have you had
this disease?” The answer to the former will lead me back to the
antecedents of the illness. Some people have been unwell in one
way or another for most of their lives. You must think of these
people differently than you think of those who have been
perfectly well and have suddenly been struck by illness.

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I continue by asking the patient what exactly was going on in his

or her life prior to this illness. What things changed? What
occurred? The things that turn up are amazing in that they lead to
a variety of different and unique approaches to treating the
patient.

For example, a disease called ulcerative colitis (an inflammation

of the large intestine) comes on in late adolescence or late
adulthood. It lasts for life and can be incredibly severe. The
symptoms are generally diarrhea, blood in the bowel movements,
abdominal pain, fever, and weight loss. Those who suffer from
this disease have an increased risk of colon cancer. What amazes
me most is that, of the patients that I have seen with a diagnosis
of ulcerative colitis, a good 20 percent of them actually have
infections as the cause of their colitis.

One way to figure out who is likely to have an infectious colitis

and who is not is to look at the origins of the illness. Often
people who have traveled extensively to third-world countries
have developed an acute diarrheal illness upon their return. The
diagnosis of an infectious cause was not considered in these
people because the antecedents of the disease were not
considered. Instead, the gastroenterologist simply performed a
colonoscopy, found what appeared to be ulcerative colitis, and
started treating them for ulcerative colitis. This happens less and
less these days, but even so, the mere occurrence of it is yet
another manifestation of the tendency to look for the disease and
make the disease diagnosis, and not look at the actual
background of the illness, which often can lead to a different
explanation.

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Making a Patient-centered Approach Work

The appeal of a disease-centered approach is that it can be

adapted into a kind of cookbook, in readily and rapidly applied
format. That is: Here are the criteria; you meet the criteria; and
these are the treatments that go with the criteria. There is little
problem solving, little thinking, and limited data gathering.
Advances in healthcare technology may help this system work in
some cases, but there is a very large gap between medicine’s
scientific potential and its actual performance.

Ignoring the role of the individual patient in healthcare

undermines the effectiveness of the system. Seventy-two percent
of chronic disease and premature death in the United States
could be prevented if available medical knowledge were
thoroughly applied, but successful application requires an
understanding of the individual characteristics of patients, their
nutritional habits and lifestyles, and their attitudes and sources of
social support. Disease resulting from medical errors and the side
effects of prescription drugs has become a serious public health
problem, constituting the fourth leading cause of death in the
United States. Many adverse drug reactions occur because
doctors have neglected the individual characteristics of patients
for whom the drugs were prescribed. The conventional, disease-
centered model of healthcare fails a lot of individuals,
shortchanging the patient, the doctor, and society as a whole.

The first step to a more comprehensive and flexible approach to

treating patients lies in accurate and thorough data gathering. By
deconstructing an illness using the patient-centered approach, I

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can then reconstruct different approaches to therapy. To

accomplish this goal, I must first gather the data necessary to
understand the patient as an individual in relationship to the
illness.

Information technology can be very helpful in this area. Huge

gains have been made in the application of science and
technology to healthcare. The reality is that the way in which
data is gathered from patients has not changed in 150 years, and
the result is that the process is incomplete. This is an important
process because the majority of important information about the
patient is still gathered verbally from the patient. However,
doctors don’t have time to gather all of this data, and even if they
did have the time, they would then have trouble organizing it in a
useful fashion. Furthermore, often, even if they did have the data
organized in a useful way, they might have difficulty deciding
how to actually respond to and apply the data.

Although technology has been blamed for the impersonality of

healthcare, I believe that information technology – properly
applied – can make healthcare more personal and enhance the
relationship and communication between patient and doctor. For
the past several years I have been working on an information
technology approach to patient-centered diagnosis, founding
MDheal Inc., an information technology company, in 1999. The
way the approach works is that the patient, using computer
software, answers a large number of questions, either directly or
indirectly through an interviewer. These are detailed questions
about symptoms and their characteristics, standard medical
questions, family history, diet, lifestyle, social circumstances,

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and environment. The information is then filtered, reformatted

and presented to doctors in a manner in which doctors are trained
to see data. Basically, MDheal is a tool designed to facilitate
doctor-patient communication.

I envision a future in which computer technology enhances

rather than hinders the delivery of personalized healthcare. I
believe more personalized care will lower healthcare costs by
being more effective and by incorporating individually-oriented
strategies for maintaining health and preventing illness. I believe
information technology will help patients be more active in their
own care and that involving patients in this way will yield better
health outcomes. In this vision there is one comprehensive
collection of clinical data filled out by both patient and doctor
and available in digital format and on paper to patients and their
physicians. Doctors will enter detailed observations on a
handheld computing device while examining the patient. All the
data will be automatically transformed into a comprehensive,
structured medical record and Problem List.

Each problem identified will be automatically linked to a

database for additional information. Therapies based on the
recorded characteristics of each individual patient will be
retrieved. An expert guidance system will highlight those
characteristics of each patient that must be addressed for care to
be effectively tailored to the needs of that individual. The system
will integrate nutritional, environmental, and psychosocial
influences with detailed analyses of symptoms, family medical
history, and the patient’s own life history. The doctor will be
given information that enables an integrated approach to

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management of the patient’s health needs. The patient will

receive educational information, instructions for self-managed
care, and motivational encouragement that will be automatically
generated for each patient, enhancing treatment compliance,
patient retention, and treatment outcomes.

Such a program can change the nature of a visit to a doctor. It

can create time for more personalized care and give patients
more information about their health problems. It can make it
possible for patients to receive authoritative advice about new or
innovative therapies from their doctors. It will enable doctors to
address the needs of their patients more thoroughly and
effectively.

We are presently in discussion with some major healthcare

centers that are interested in implementing this system. I target
the providers of healthcare rather than the third parties. The
problem with HMOs and insurance companies is that the way the
system is currently organized, employers frequently change
insurance companies, as they are constantly looking for better
rates. As a result the average person stays with one insurance
company for about three years. Because of this, insurance
companies are not necessarily interested in long-term cost
savings, and instead, they focus on the short-term, bottom-line
savings.

We instead target the providers of healthcare systems that have a

national or international reputation for high-quality healthcare.
We want to start with places that are truly interested in offering
the best care they can offer. Our approach has therefore been to

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go to these providers and explain to them that by using our

approach, they can allow their doctors to be more effective and
can therefore render higher-quality, more comprehensive service
without increasing costs – most likely, with decreasing costs.

In terms of specific demographics we target chronic-care

ambulatory patients, not acute care in the hospital. As we have
worked through the system, we have ended up focusing on
ambulatory patients who are receiving chronic or ongoing care,
who speak English, and who are likely to be computer literate, or
have access to computers at home.

Once we establish the value of this program and approach in

settings where it is easier for it to operate, we will develop
foreign-language versions, as well as versions that use perhaps a
different vernacular for asking questions. What will need to
happen is that health systems will have to allocate space and a
certain amount of resources to allow for patients to come in and
take the computer interview in the actual facilities. One eventual
possibility might be for the entire system to work around a
touchtone screen with verbal questioning via headphones. The
technology is here; we just presently lack the necessary funding.

In the end my goal is to support healthcare by bringing in this

entire dimension that has been squeezed out by technological
advances – that is, the communication between doctor and
patient, and the body of information that the doctor must have to
responsibly and most effectively work with the patient. One
hundred years ago doctors made house calls. Doctors knew what
a patient’s home was like. They knew what kinds of foods they

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were eating. They could see what the interactions were like with
family members. And while this specific interaction almost
never happens anymore, the information gained in this venue is
absolutely important. Many scientific studies tell us of the
importance of this information.

The Healthcare Climate: Two Counteracting Trends

Over the past 30 years I have seen the existence of two distinct
currents that have struggled with one another. On the one hand,
there is a negative current. There has been an increasing
bureaucratization in healthcare. This trend has been based on the
reification of disease entities. That has shaped not only education
and training, but also compensation and hospitalization practices.
As a result it has had an incredibly negative effect on healthcare,
on the morale of physicians, and on the satisfaction of patients.

On the other hand, there has been a secondary trend that has
taken several forms. The first is an increasingly actively
expressed desire on the part of consumers of healthcare not to
play a passive role. Consumers are beginning to ask more and
more questions. They want to be informed. They want to work in
a cooperative fashion with the doctor, not be merely acted upon
by the doctor. And while this shift has taken many different
forms, there has been an undeniable sea change over the past 30
years in the relationship between patients as consumers and
doctors as providers.

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Second, there has been a great deal of scientific research

validating the importance of knowing the patient’s agenda,
psychosocial factors, diet and nutrition, and environmental
influences in the development of illness and the development of
strategies for helping people get better. The kinds of
interventions I bring to healthcare are increasingly supported by
scientific research, which has been quite gratifying to me.

I advocated things 15 or 20 years ago, based on a relatively small

amount of data that made sense to me, that now continuing
research has subsequently shown to be important. These include
the role of the omega-3 essential fatty acids in the development
of illnesses and in the treating of a wide variety of illnesses. I
first started lecturing about those in the early 1980s, and the
research started to appear in the late 1980s, continuing into this
century.

The importance of these fatty acids and the role they play is
highly significant. In my book I report the case of a
schizophrenic adolescent who had an amazing response to
treatment with essential fatty acid therapy. There was a recent
double-blind, placebo-controlled trial looking at various fatty
acid supplements in treating schizophrenics, which was actually
a follow-up to a study done at the National Institutes of Health
on patients with manic-depressive illness. It identified the
component in omega-3 essential fatty acid therapy as something
called EPA (eicosapentaenoic acid), which is beneficial for the
treatment of individuals with schizophrenia and very helpful for
bipolar disorder, or manic-depressive illness. This was not a
substitute for drugs, but it worked so well for manic-depressive

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patients that the study was stopped six months early because it
was clear that one group was doing so much better than the other
group, and the researchers said they couldn’t go on with the
double-blind placebo in good conscience. When they stopped the
study, the researchers found it was actually this particular fish oil
that was making the difference.

Unfortunately, the government has created and generally

continues to foster the first trend. They have encouraged the
development of procedures and tests that they will, for the most
part, pay for quite readily, while discouraging doctors from
spending time finding out what they really need to know about
their patients. I don’t see this changing. Government is almost
never personal, and it is usually pretty stupid. And while there
have been a number of initiatives to educate lawmakers, these
initiatives tend to be small. Lawmakers understand the system as
it is and on its own terms, making the education of these
lawmakers a hard task.

The main effects of these initiatives have been attempts to de-

stigmatize psychological therapies and to bring them into the
mainstream, all of which is helpful. Also, the growing interest in
alternative and complementary therapies may help foster a more
personal interaction between doctor and patient. One of the
reasons people are interested in alternative and complementary
therapies is that they tend to be more personally oriented, rather
than disease oriented. To the extent that the government supports
that, it begins to soften the bureaucracy and increase doctor-
patient interaction. Even so, we have a long way to go.

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However, aside from these bureaucratic challenges, as well as

the inherent difficulty of working with people who have
complex, chronic, multifactorial illnesses, there are still more
challenges to the doctor. The large amount of new information
doctors must understand and apply on a regular basis poses a
challenge to doctors today. In this area, information technology
can be very helpful. At some point it is my vision to take the
kind of patient information gathered by the tools MDheal is
developing, and to use that data to generate automatic searches
of the new literature databases that are available. In this way,
then, with a few mouse clicks a doctor can find relevant
information about potential treatments for a patient that are
based not only on the disease, but also on the individual
characteristics of the patient.

The Science of Caring

In general, doctors who are fresh out of training tend to be at

their most arrogant. In hospital training you see patients for only
a short period of time. You see them in the acute and critical
situations in which the tools that are presently available tend to
be the most effective. Young doctors tend not to have had the
humbling experience of treating patients over a number of years
and seeing those treatments fall apart with relapses of chronic
illness. They have not yet discovered that you can do a fantastic
job of helping pull someone through a crisis, but not being able
to prevent the next crisis.

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A number of residency programs are stressing patient-centered

approaches and comprehensive approaches to interviewing.
However, the studies that have been done have shown no
increase in patient satisfaction resulting from interactions from
doctors who have been trained this way. It is obvious, then, that
things are still being left out.

I believe the reasoning for this is that whenever the educators

begin talking about a patient-centered approach within medical
education or training, what they really mean is a psychosocial
approach. As a result doctors who are trained that way tend to
take a strongly psychological approach to chronic illness. Many
patients are not interested in that, and whether the patient may be
right or wrong, the doctor must certainly have the ability to
understand the patient’s agenda and not just to impose his or her
own agenda.

I have identified a set of necessary skills that I call the Science of

Caring. Each of these skills is fundamental to a helpful and
successful doctor-patient relationship. They involve the
following:

First, the doctor needs to have the ability to actively listen to a

patient to try to elicit the patient’s story and concerns.

Second, the doctor must have the ability to acknowledge and

understand a patient’s agenda. Again, every patient has his or her
own agenda, and often the true agenda is quite different from
what the patient appears to be coming in for. Sometimes these
agendas exist in addition to the disease the doctor is treating, and

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sometimes they are completely distinct. A doctor must be able to

understand that to be effective.

Third, the doctor must have the ability to carefully explain things
to the patient. If the doctor can’t do it, there should be someone
in the doctor’s office who can. Studies have shown the main
thing patients want from doctors is information and explanation.
Most doctors tend to think patients just want drugs and a quick
fix. But in reality this is not true, and it is becoming less true.

Fourth, the doctor must have the ability to understand the context
in which the patient became ill. Here, again, the doctor must look
at things like family and social support, environment, and dietary
factors.

The first three skills are basic human characteristics that most
individuals have the capacity to access if they understand the
importance of accessing them and if they have some training in
doing so. The fourth requires a fair amount of information and
knowledge.

Finally, the doctor must have the ability to show empathy. He or

she must know how to offer reassurance, encouragement, and
hope to the patient without being deceitful and dishonest.

Studies have shown that 80 percent of premature death and

disability result directly from factors related to diet, nutrition,
lifestyle, and other alterable life patterns. The biggest challenge
in medicine – and therefore its greatest promise – lies in helping
patients change those behaviors that cause disease. We need that,

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and will benefit from it far more than continued work on the
genome, for example. I love basic science. I love understanding
the basic foundation for the development of illness, and I am
glad that further work in this area will continue. But that is not
the main thing that is needed now. If the already available
knowledge were applied in a thorough manner, we could alter
the health of individuals in the county and cut costs far more
effectively than any scientific research will help us do, at least in
the foreseeable future. This is the change I look forward to.

Dr. Leo Galland graduated with honors from Harvard

University, earned his medical degree at the New York
University School of Medicine, and completed his training in
internal medicine at the NYU-Bellevue Medical Center. He has
held a research position at Rockefeller University and teaching
positions at the Albert Einstein College of Medicine, the State
University of New York at Stony Brook, and the University of
Connecticut. He has been in private practice in New York City
since 1985. In 1997 he founded the Foundation for Integrated
Medicine to foster the integration of nutritional and
environmental medicine into clinical practice and medical
education. In 1999 he founded MDheal Inc. to develop computer
software that enhances doctor-patient relationships and
enhances the clinical encounter.

Dr. Galland is internationally known as a pioneer in nutritional

medicine and environmental health and as a master educator,
clinician, and medical detective. He has extensive experience in
developing medical innovations and introducing them to the

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medical community. Health practitioners and patients

throughout the United States, Canada, Europe, and Australia
have sought his advice and consultation.

Dr. Galland has appeared as a featured medical expert on ABC,

PBS, CNN, MSNBC, Fox Cable Network, the Christian
Broadcasting Network, the Trinity Broadcasting Network, and
dozens of local affiliates of the major broadcast networks.
Interviews with Dr. Galland and articles about his work have
appeared in Newsweek, Reader’s Digest, Redbook, McCall’s,
Self, Bazaar, Men’s Fitness, Allure, Bottom Line, The New York
Times, the New York Daily News, The Washington Post, and
many other publications. The New York Daily News listed Dr.
Galland among “50 People to Watch in 2000,” citing his
leadership in developing innovative approaches to healing. He is
the author of several dozen scientific publications and two highly
acclaimed books that have a special following among health
professionals: Power Healing (Random House, 1998) and
Superimmunity for Kids (Dell, 1989).

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IT’S ABOUT
THE HUMAN BEING

ROSALIND KAPLAN, M.D., F.A.C.P.

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The Art of Partnering With the Patient

What we learn in medical school and in residency training –

physiology, biology, medications – is basically science. The art,
which schools are gradually beginning to teach students, is the
spirit of healing. I don’t think I was ever really taught that; after
medical school, when I became a resident and actually had
responsibility for patients in the hospital, I realized I knew
nothing about taking care of people. Caring for patients requires
much more than merely knowledge of medicine. To really
practice the art of medicine, you have to know your patient with
a depth that many doctors do not like to get into, because it is
very time-consuming. You need to know the history of a patient
– not just their medical history, but who they are, what they’ve
been through, what their bodies have been through, and what
their minds have been through. Things that happen to us early in
life change the whole way our bodies and minds function and
react to things. The most important thing is to know your patient.

I also think there is a real art to being able to talk to patients and
realize they are human beings. A doctor doesn’t look at a
disease; a doctor examines a human being. You want to look at
the whole person, asking yourself, “How can I help this person
have the best quality of life, given any limitations they may have
and what their needs will be in the future?” When I add medicine
and medical interventions into the art, I ask myself, “How will
this affect this person’s life? How will it make them feel,
emotionally as well as physically?” In many ways, the art lies in
being a partner with the patient.

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The field of medicine keeps growing with new technology. A

doctor needs to keep up with the technology. You need to know
what test will get the appropriate information for you, what the
differential diagnosis is, and what the possibilities are, based on
what the patient describes to you. You need to know what tests
are needed, once you know what is wrong with the patient, what
treatments are available, and which treatments are most effective
for the particular problem. You really do need to know all the
science behind that. It is challenging, these days, to keep on top
of the game. Every day there’s a new medication, and you need
to know everything about it – how it interacts with other drugs,
and so on.

The difference between the art and the science is that for
questions of science, you can look up information in a book –
you can pick up a book, go online, or pick up your Palm Pilot,
and you can find every drug interaction for every drug that’s out
from two months ago back. The science of medicine, although
there’s a tremendous amount of it, is always available if you use
resources. Knowing how to find that information becomes a very
important skill. The art, however, you have to find inside
yourself.

An Alternative Path to Success

My definition of success as a doctor may be different from that

of other doctors. I finally feel successful now because I did
something a little unorthodox a couple of years ago. I left the
group practice I was in, which was part of a health system. The

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practice had fallen into the trap that all primary care medicine
has fallen into now, which is – because of all the discounted
insurance and HMOs – that a practice becomes a mill, where it’s
difficult just to break even in the office, and I don’t think we
ever did. You have to push patients through at a tremendous rate,
and you have to have huge panels of patients. Consequently, I
don’t think our patients were very happy because everything was
very difficult – getting through on the phone, getting
appointments – such that they never got the time they needed.
The doctors were always in a rush and running late.

The dissatisfaction of my patients made me feel terrible; I think

patients should leave an office visit feeling they’ve had their
questions answered. If possible, patients should leave feeling
reassured, and if that’s not possible, they should leave assured
that everything is being done that needs to be done – that if other
doctors need to be spoken to, that will happen, or if a follow-up
is needed, that will happen, and that the lab results will actually
be looked at, and the patient will get a call. The doctor should
also take the time to think through each issue and come up with
the best possible plan, not just the most expedient one. I think
that level of security for the patient has gone by the wayside in
many practices.

As a physician, I was exhausted. I was very unhappy. I didn’t eat

or go to the bathroom some days because I was running from
room to room, and it was a very unsatisfying practice. I work
with a lot of patients who have deep, complicated problems; I
spend a lot of time with eating disorders and other common
mind-body problems. When I was unable to spend an appropriate

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amount of time with a patient, it was truly devastating to the

patient. If I did spend enough time with them, I’d spend the rest
of the day trying to catch up. So if I actually had a chance to
fully deal with a problem, I’d be late for my subsequent
appointments and have more and more people angry with me.
The staff would say, “You’re late! You’re late! You’re late!” For
me, that was not a successful way to be practicing. Some people
would have thought I was a very successful doctor then because
everybody in the area wanted to come to our practice, especially
the women. But in fact I was very unhappy. My kids would tell
me I was not home enough, or that they wanted to talk to me
about something, and I wasn’t there. I also wasn’t taking care of
myself – that was the biggest downside to that lifestyle. If you
can’t take care of yourself, you can’t take care of your patients.
You have to be able to be an example, because if you don’t know
what to do for your own health, then how can you know what to
do for a patient?

Completely unhappy under that system I decided to conduct an

experiment. When I told one of our administrators (with whom
I’d never gotten along well to begin with, because he wanted to
push the patients through, and I would protest), he said, “I’ve
really been thinking about the way you practice, and I think
maybe you should try a psychiatric model.” Under a psychiatric
model, patients pay for time, and most psychiatrists don’t take
HMO and other discounted insurances – people pay out of
pocket. Psychiatrists don’t have a lot of overhead because they
don’t have a lot of staff. I thought it was an interesting concept.
In a way, I do practice a lot of psychiatry. But people need

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medical care, and some of them need the 10-minute visit for the
sore throat.

So instead I ran a mixed model: I rented a very small space,

hired one staff person who had some nursing background and
administrative abilities, and set up three phone lines instead of
10 (one for outgoing calls and two for incoming calls, so people
wouldn’t get a busy signal). I had a person answering the phone
instead of an answering machine that would tell the patients to
push option 1, 2, or 3 and then put them on hold for 20 minutes. I
allowed half an hour for follow-up appointments and an hour for
a physical or if a patient said he or she had a complicated
problem and really needed to talk to the doctor. I started out
charging what I considered a very reasonable fee for that amount
of time. My overhead was low. I didn’t take any of the
discounted insurances. I did accept Medicare – and still do. As
an out-of-network provider, patients could pay up front and then
submit the charges to their insurance companies. If I used good
documentation of diagnoses and the patients filled out their
insurance forms, they would get at least a portion of the costs
returned to them. The only kind of insurance this doesn’t work
for is HMO’s, which require the physicians to follow their
protocols.

When I started my new practice I thought, “Now I’ll just have a

few patients. I’ll have a tiny practice.” Fortunately, I didn’t
worry a lot about my income at that point because I have a
working husband who is also a physician. It turned out that
patients loved it. I thought very few patients would come from
my old practice, but I ended up with people flocking in because

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they needed the TLC and the time, and they were willing to pay
for it. For the few patients who truly couldn’t pay, we worked
things out. We bartered for services a few times – I got back
equal value of something, sort of like the old model of bartering,
where the doctor gets a chicken, and the patient gets medical
care.

Living in an affluent area and having a niche with eating

disorders and psychosomatic problems put me in a fortuitous
situation. The timing was right, and it worked. The practice
grew, and I actually got to the point where I felt too busy. As it
happened, one of my partners from my former practice wanted to
leave that practice to try doing the same thing. So we got a larger
space, and we now share an office with two staff people – one is
a medical assistant, and one is a receptionist/administrative
person – and the four of us run the office. Every phone call gets
answered, and every patient gets a half-hour or an hour to meet
with one of the doctors. I’m happy. I feel successful. I don’t
make a lot of money, but I feel successful because I’m practicing
medicine the way I want to practice medicine.

There was a recent Newsweek article about doctors opening these

small practices, and now many people in Boston are talking
about “concierge practices,” where people pay some amount of
money up front, depending on the services, and they receive
unlimited care from the doctor, including unlimited cell phone
calls any time of day or night. I think that’s a little extreme, and
for me there was an ethical conflict in asking people to pay up
front for services they don’t know they’re ever going to receive.
Unfortunately, I feel an ethical conflict in that some people can’t

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afford to do what I’m doing. But I also see that I don’t have a
multitude of options – if I just worked with the insurance
companies, I’d be back to the old game where I’d be in a hole.
Now I work six sessions in my office a week – a session being a
half-day – and I spend one afternoon a week at an eating
disorders residential center, where I oversee the medical care. I
can be at home the rest of the time. I carry my beeper, and I’m
available for emergencies on days I’m not in the office, and half
of the evenings and weekends.

I’ve found my lifestyle is acceptable now. I have enough time

with my kids, and when I am on call, I no longer get dozens and
dozens of phone calls because my patients are getting their needs
met in the office. During the day, if they need a prescription
they’ll get the receptionist on the line; she’ll take down their
information; and the nurse will call in the prescription within an
hour. It’s going to happen, so they don’t have to call me at eight
o’clock in the evening and say, “My prescription was never
filled.” I also won’t hear, “I was sick, but I couldn’t get through
on the phone,” or “I knew I wouldn’t get an appointment, so I
didn’t even bother calling.”

I rarely get calls that aren’t necessary. My patients don’t want to

call me on Saturday because they know I’m a person and that
I’m out doing what I do. That’s the whole point: We are people
to each other. It’s not me providing a service and them being
pushed through the system. My kids are happier; they feel I’m
more accessible. If they have to reach me during the day, they
can page me, and I can take the five minutes between patients to
call them back without getting backed up.

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I feel blessed to have a career I enjoy. Of course there are

pressures, and there are still days when I’m very stressed, but for
the most part I feel my life is balanced, and I’m able to take care
of myself. I don’t have to wait 10 hours to go to the bathroom
anymore! That’s how I define success, for me. And I think my
patients are happy.

Staying on Top of the Game

I like to use the technology available to keep up with my field.

The Internet is wonderful for getting information; I can do
MedLine searches from my home computer. The convenience is
extraordinary. I don’t have to pick up the Physicians’ Desk
Reference; I can just push a button now and get all the
information I need about drugs. I listen to the drug company
representatives when they come in – with a grain of salt, of
course – because I have to know what new drugs are out, and by
the time I get peer-reviewed medical information, some of these
drugs have been out for a while, and my patients may have
already started taking them. I have to keep up with the news
media because patients often find things out before we do.

I have to go to continuing medical education courses to keep my

accreditation, but I also go for myself, because I want to know
what’s happening. Recently I had to take board recertification.
The American Board of Internal Medicine has required that
physicians who took the exam in 1989 or later recertify 10 years
later, so last year I went through a very long process, reviewing
all the different topics in medicine. I had to complete take-home

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test modules; they give you three months to complete each one.
That involved a lot of review and rereading. Then I had to study
for a daylong sit-down test, which reminded me of my first set of
boards. Anything I had missed, I picked up for that test.

I don’t think board recertification was a waste of time, but I was

not impressed with the way it was administered. It was not a
good educational process. I think that rather than cramming
everything into a year of studying for recertification, it should be
an ongoing, continuing process, and there should be
requirements for everyone to keep up. Right now a lot of people
are “grandfathered” in and will never have to take the test. I do
not think that will ever change, but I think we could use this as
an ongoing process to self-evaluate, as well as for the board to
evaluate us. Recertification does not need to be done all in one
short period of time. Ten years after most people certify for the
first time is usually a time when they are at a crucial period in
their lives, in terms of families. Most of us have children, or we
may be doing a lot of other things, and it’s also a big career-
building time. For me, it was especially difficult because I was
caring for an elderly parent. I was really sandwiched and pushed
during that year; I felt a lot of pressure. Fortunately, I deal fairly
well under pressure, but I think people who don’t would benefit
from having board recertification stretched over a longer period.

I think it’s important to set long-term goals, but I’m not a person
for setting very picky, specific goals. I ask myself, “Do I want to
be working more? Do I want to be working less? Do I want to
know more about specific things?” When I started working with
many patients with mind-body problems, I said, “In theory, I

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really like this work, and I have a lot of ideas about it, but I need
better background.” I was a psychology major in college, but
that’s a pretty vague background. So I looked around for ways I
could learn more about theory and about psychobiology and
psychopharmacology. A psychiatrist at the Philadelphia
Association for Psychoanalysis (an organization mainly for
psychologists, psychiatrists, and other therapists who are
learning analysis) who was very interested in the border between
psychiatry and medicine – mind and body – had started a
fellowship that was free to non-psychiatrists with good ideas
about what they would like to learn about the mind. He had been
one of my teachers when I was a medical student rotating
through psychiatry, and a friend reintroduced us. He encouraged
my participation, so I took some courses there in the evenings,
and did a lot of reading under the supervision of several of the
senior psychiatrists. I undertook this with a lot of thought about
how the information fit into my practice. Now I also look for
conferences on mind-body medicine and psychopharmacology.

Once I think about what I want to know or what I want to learn, I

will go out and look for ways to do it. I think planning for five
years ahead, in terms of structural issues in the practice, is
extremely important, as well. We look over our finances, the
physical structure of the office, and the structure of how the staff
is working. We ask ourselves what we need to have happen, so
that a year from now things will be running just as smoothly, and
a few new things can be implemented. For instance, right now
we are considering a new database, and possibly having a
gynecologist part-time in our space. Then we ask what will need
to happen for us to still be running smoothly and have some

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loftier goals accomplished in five years – perhaps electronic

medical records, for example. I think planning is important, but
it’s more of a gestalt than it is writing down goals one, two, and
three. Also, circumstances and aspirations are always changing,
and goals have to be reassessed frequently.

The Challenges of Being a Doctor

There are times when the responsibility of being a doctor feels

overwhelming. It is particularly difficult when you have a patient
who’s not doing well and you cannot figure out what is wrong or
what to do to make it better. In these situations it is important to
know that you don’t know. I used to always say, “Oh, I should
be able to figure this out,” but, in fact, none of us knows
everything, and even if you know everything, sometimes you’re
too close to a situation – sometimes you look at the details, but
can’t see the whole picture. I will always call colleagues,
sometimes specialists, because my patients often need a
specialist who knows the finer points of certain diagnoses.
Sometimes I need only to consult my partner, or another internist
colleague. It’s important to get past being ashamed of not
knowing, and that was something that, unfortunately, we all
carried with us from training. On rounds as a resident, if you
were asked a question and didn’t know the answer, it was an
embarrassment. The fact is that many times you don’t know, and
you have to be able to say, “I really don’t know what the
situation is. I don’t even know how to evaluate the next step.
What do you think?”

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I can’t say there is a single person or type of person I would

particularly like to emulate, but what I strive to be is a doctor
who is always open to hearing what other people have to say –
whether it’s my patient, my staff, or other doctors. I strive to not
be defensive and to not worry about my image too much because
that impedes learning. I strive to emulate doctors who are
humble, open, and honest. I don’t try to emulate those doctors
who have to say, “Oh, I knew that!” or, “Well, I think what I did
was just as good!”

Another challenge I face is when something goes wrong in the

doctor-patient relationship, and the communication isn’t working
right, and I wonder whether there was a better way to serve the
patient. I think for me that’s the hardest. I’m pretty self-critical,
and I think about those things a lot. I think the best way to
communicate with patients is face-to-face, always. I schedule
regular follow-up visits with any patient who has complicated
problems going on; it’s very important to have regular visits set
up. I’ve found that if we don’t set up the regular visits, and
there’s a lot going on, and they don’t show up again for three
months, things will really start to fall apart for them. If they are
coming to regular visits, they tend to pull it together; there’s
some accountability to me in face-to-face visits. We use the
phone a lot in between visits, for questions and to communicate
information back and forth (to discuss lab values or to talk about
their visits with a consultant, for example). We use e-mail,
although I don’t like to. I’ve always been very resistant to
technology; I was probably the last doctor on earth to get a cell
phone, but once I got used to it, I got to the point where I
couldn’t do without it. I don’t mind if patients e-mail me with

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simple questions or with requests for information; I just

discourage them from using it to put a lot of their private
information forward, because I think there are privacy issues. I
also think that when you can’t hear the person’s tone of voice or
see the other person’s eyes, a lot of miscommunication can
happen.

I would say that for most physicians, the time and financial
pressure are now the hardest challenges to deal with. I feel lucky
to not be quite so pressured with that. It’s an overwhelming
responsibility, and it’s hard when I can’t leave work in the
office, and I bring it home with me in my head. Sometimes I
think it would be nice to be doing something that would allow
me to just walk out of my office and never think about work for
a weekend, but that doesn’t happen. When I go on vacation I call
the office – not because I think they can’t do without me, but
because I want to know how somebody is doing, or I want to
know how something turned out.

One of the largest current issues is malpractice. Malpractice

insurance is prohibitively expensive for some of the
subspecialists – physicians who do invasive surgery, particularly.
Lawmakers have to handle that issue, unfortunately. In the
Philadelphia area, one of the things that are driving the price of
malpractice insurance up is litigation that has yielded a lot of
large awards to patients with malpractice claims. Malpractice
insurers feel this is a very risky area, so they’ve pulled out, or
they’re refusing to insure more doctors. In some cases insurance
has become so expensive that some doctors can’t afford to buy it

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and practice. We can’t practice without malpractice insurance, so

it puts everyone in a terrible bind.

I think the only solution for this problem is tort reform. There
must be some limit on what people can sue for and how drawn-
out these malpractice events will be. There may need to be some
limits on awards, so that the malpractice insurers can actually
insure people. In other countries with nationalized medicine,
there are certainly malpractice suits, but not as many frivolous
ones. I certainly would never want to see a patient who was
harmed by true malpractice not receive what is due him or her. I
often see a lot of “dragging the net,” where a patient is harmed,
and they or their attorneys may feel they have to file suit against
not just the person who actually caused the problem, but also the
drug company or the entire practice. So they drag the net and sue
more people, and a lot of doctors then get involved in a lawsuit.
These suits get drawn out for years, developing huge attorney
fees and lost time. Those kinds of things drain the physicians
emotionally and drain the financial system. Until we reform that
process, we’re going to have a malpractice crisis. If you look at
what’s going on in politics, you can see attempts to start
reforming the process, but it will take a long time.

Figuring It All Out

I wish I could say I’ve received good advice, but I never had
anybody to help me with that. I figured it out on my own – it was
pretty rocky at times – and some of the things that happened to
me along the way were less than ideal. One thing that happened

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that I think is important to point out is that I went through a

serious illness myself. Fortunately, I ended up okay, but being a
patient really showed me a lot about the whole world of
medicine from the patient’s point of view. It also taught me a
great deal about striking a balance – that you just can’t keep
pushing yourself, and that eventually you will break down if you
do that. So I guess much of the knowledge I eventually got was
through trial by fire. I hope that as we see what is happening in
medicine right now – the malpractice crises, the patient
insurance crises, and the unhappy doctor crises – we’ll learn we
need to be teaching our future doctors more about striking the
balance.

Learning the science of medicine comes primarily from

schooling and training. It’s important to go to a solidly good
school, where you know you have top people in the field who are
interested in teaching. One of the real crises right now is finding
good academic physicians. Some medical schools have senior
physicians who are so pressed to do their clinical work or
research that teaching – which is never well compensated – falls
by the wayside. It’s important for young people interested in
medicine to make sure they will interact with people who truly
want to teach medical students, who truly want to instruct
residents. Beyond that, learning the profession requires finding
people to work with whose work you think is good, whom you
admire, and whom you can ask for advice and emulate. I think
it’s very important to have mentors. I never had a mentor, but I
always wished for one. Now I think I’ve found mentors – not
one person who does everything ideally, but a variety of people.
I work with so many psychiatric problems that I seek advice

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from psychiatrists and psychotherapists whose work I admire.

My therapist colleagues can often help me sort out the
psychological from the physiological. I also ask my partner,
whom I trust very much, for help. I can review an unexpected
situation with her, asking, “What do you think of what happened
here?” and get good feedback. She always has up-to-the-minute
drug information at her fingertips, and she approaches
complicated problems in a thoughtful and systematic way. My
husband, who is an academic internist and does a lot of teaching,
is very helpful. He always knows where to find information and
is very good with technology. I’ve learned from him. He also has
always been a good role model with patient interaction – one of
his areas of interest is teaching good patient interaction to
medical students – so I trust his advice in dealing with difficult
interactions. It’s important to have a variety of people around
you who have different talents you can draw on.

Since I changed my career path, I get calls from other doctors

who are unhappy and are looking for other ways to practice
medicine, and I hope I give some good advice. My favorite piece
of advice to give other people is about self-care for doctors,
particularly younger people who are in training now and trying
to decide their future in medicine. I always say you have to take
care of yourself first; you have to find a way to get sleep, eat
reasonably, and exercise; and you have to be able to take care of
your emotional needs. If you don’t do that, you can’t answer to
patients as well.

These recent phone calls from other doctors saying, “How did
you do this, and what do you think I should do?” have in some

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ways put me in a leadership position. If you want to be a leader

in medicine, I think you have to take chances – never with
patients, but with your office and the model of care you provide.
A leader cannot be too focused on security – financial security or
job security – because if that’s what you’re focused on, you’re
not going to be able to think about what it is that you really want
in your career. It sounds a little bit hokey, but I think that if
people would listen to their hearts and ask themselves, “What do
I want to be?” and “What do I want to provide to my patients?”
they would be much more successful. If you answer those
questions and come up with a plan, the patients will come. If
there are good doctors out there, patients will find them. Patients
are desperate for good care. You shouldn’t feel you have to stay
in the system or that you have to practice medicine the way the
majority of people are doing it. Concerns about job security will
prevent you from finding a good way to practice medicine for
yourself.

Stay Open to Future Changes

I think something big is going to happen in the world of

financing medicine. I really don’t know what it will be. I don’t
think our country is headed for socialized or nationalized
medicine because of the very capitalist interest of the country,
and I don’t think the big-money people will let that happen. But
something will happen. I’ve seen too many doctors leave my
area because they cannot afford their malpractice insurance, or
leave medicine because they’re so unhappy. I don’t know exactly
how these issues will resolve themselves. I think some of it

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might swing back to what I’m doing – the “old-fashioned way,”

like when I was a kid and you used to go to the doctor, pay the
doctor, and if you had medical insurance you submitted the
claim and got back what you got. I think that will be at least part
of what will happen – that more and more doctors will start
practicing the way I do, or in some similar form.

In the future I hope patients and doctors will come to more of an

understanding of each other’s position. Patients want and need a
lot of things from their physicians, and right now physicians’
hands are pretty tied. The reason people are angry at some
physicians and at the way the world of medicine is working is
that they’re not getting their needs met. I hope we will eventually
meet in the middle to gain an understanding of each other and
find a way to work things out.

To prepare for these changes I think it’s very important to be

forward-thinking and flexible. In the time I’ve been practicing
medicine things have changed drastically. I have to understand
that they’re going to continue to change, and that I may have to
change my plans. If we did go into a nationalized system, my
whole practice would have to change, and I think I have to be
open to that. You have to say, “OK, whatever will happen will
happen, but I still want to practice medicine, and I will still have
to look for my niche and my place.” I think one of the sad things
that happened to the older physicians is that they didn’t foresee
the system of HMOs coming. When it hit, their practices were so
altered, and they were disappointed and disillusioned. They had
worked so hard, and now all of a sudden they were told they had
to practice a radically different way. We have to be looking

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ahead all the time. Change will happen, and we have to be open
to it.

Seeing the Human Being

A lot of people think the only physician’s oath is the Hippocratic

Oath. The Hippocratic Oath is certainly important, in that it
basically says we’ll practice our art and science ethically. But the
other physician’s oath is the Oath of Maimonides, which says,
“Inspire me with love for my art and for your creatures; in the
sufferer let me only see the human being.”

I would say that if there’s one rule for being a physician, it’s
seeing the human being in the patient. If you do that, it forces
you both to practice ethically and to do your best. I think we also
have to stay humble; practicing medicine is a humbling
experience, and we will all make mistakes. Talking about our
mistakes has been terribly discouraged in the medical world for
as long as I can remember. The concern about malpractice is one
reason not to talk about mistakes, but the other reason is the
shame that you didn’t know or you didn’t do something right.
We need to be humble, realizing that we all make mistakes, that
there’s always a time when someone else could have done it
better, and that there’s always another way that it could have
been done. If you allow yourself to know that you can learn, and
then you’ll really be working in the best interest of the patient.

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Dr. Rosalind Kaplan is a board-certified internist in private

practice in Haverford, Pennsylvania. She earned her M.D.
degree at the University of Pennsylvania School of Medicine and
completed post-graduate training at Temple University Hospital
in Philadelphia. She also completed a two-year clinical
fellowship with the Philadelphia Association for Psychoanalysis,
studying psychosomatics.

After several years in academic medicine, Dr. Kaplan began in

private practice, treating general medical problems, as well as
the medical complications of eating disorders. She serves as a
medical consultant to the Renfrew Center, a residential facility
for eating disorders.

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WHAT IS A
“GOOD DOCTOR”?

MARIANNE J. LEGATO, M.D.

Columbia University College of
Physicians & Surgeons

Partnership for Gender-Specific Medicine

Founder and Director

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The Personal Difference

As she was driving me to my medical school graduation, my

mother said something to me that has informed my whole career.
She said, “I just want you to know that you can’t be a good
doctor without being a good person.” I remember feeling
skeptical at the time: I thought that simply mastering a critical
mass of important knowledge would guarantee I’d be successful.
But I never forgot what she said, and I now think it was the most
provocative piece of advice I’ve ever been given. Through my
vocation, I’ve learned to control my temper and my demand for
immediate results. I’ve learned the importance of patience and of
being completely truthful. I’ve learned not to take advantage of
people who are weak and compromised. I truly believe that if I
have developed at all as a human being, a lot of it has to do with
the demands of my particular profession, which requires a high
standard of personal virtue.

There are no perfect doctors; there are only “good enough”

doctors. Good doctors are dedicated to the welfare of their
patients and try never to harm or exploit them. Good doctors, in
general, admit when they don’t know the answers to questions.
Good doctors have a good enough critical mass of up-to-date
knowledge and information that if people are ill (or think they’re
ill), their doctors can effectively help them. But simply knowing
a lot of facts isn’t enough: A really effective doctor must be a
well-integrated, mature, empathetic, and courteous individual.
Regard and respect for patients is an essential ingredient of
effective treatment. Cultural, social, and economic information
about the patient is important to understanding how best to help

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them. That’s why house calls aren’t a burden, but a wonderful

chance to add essential elements to what we know about the
patient and how to marshal the best resources to cure or palliate
his illness. In short, personal qualities make the difference
between a good doctor and a great doctor.

There are a few giants in medicine: Soma Weiss, the famous

Harvard physician, or Robert Loeb, one of the greatest of the
physicians who taught at Columbia’s College of Physicians &
Surgeons, are two fine examples. Those men seemed to know
everything about illness, and they were impeccably gifted at
diagnosis. While I remember them as great scholars, the doctors
I most admire not only have state-of-the-art information about
their subspecialty, but they are also always available for advice
and consultation. They don’t send the house staff or their junior
partners to care for problems because it’s late at night or a
Sunday; they come themselves. They accept personal, consistent,
and complete responsibility for their patients.

On the day I graduated from medical school, my mother gave me

a copy of the Hippocratic Oath, which one of her own mentors
had given to her. I still read it at least once a week and think
about what an important promise it is and how it embodies a
tremendously important series of principles on which to build a
professional life. The Oath reminds me that our vocation is
unique: We are privy to the innermost thoughts of patients; we
are a screen on which they paint their most terrible fears, their
hopes, and their interpretation of the world around them. Doctors
have to remain the custodians and the guardians of that
information; we must not talk about what we learn in the course

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of our lives with patients, nor ever exploit them in any way, even
when they will never find out about it. Some people have called
this profession a form of priesthood, and I think that’s not too
strong a word; we do perform a unique service.

One of the most important parts of growing to be an ever more

effective doctor is to try to perfect personal virtue. It is important
to be truthful, courageous, and persistent and not to surrender to
fear in the face of such terrible realities as illness, decay, and
death. The doctor must learn to accept that some patients will die
and be prepared to help them deal with that. That means keeping
them company during that time, not turning away from them and
leaving them alone when nothing more can be done to lessen the
impact of the illness or to save their lives.

Successful physicians have to set realistic goals. You can’t cure

all people; you can’t cure all illness; and you can’t stop all pain,
discomfort, and anxiety. Accepting that and not taking it
personally when a patient becomes enraged if you don’t do those
things is also part of being a successful physician. Another good
measure of success is how often your colleagues call you for
advice or consultation – whether it’s formal or informal. In a
competitive and often professionally jealous world, it’s
reassuring if good doctors ask your opinion on complex issues.

The Doctor-Patient Relationship

For me, the best part of being a doctor is the relationship with the
individual patient. That partnership is the essence of medical

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practice. Part of its success depends on courteous and empathetic

attention to the patient, an ability to support the patient in times
of difficulty, and the ability to offer reassurance and be a
resource for the patient. The relationship is not between equals,
in the sense that the patient, as a famous psychoanalyst once
explained to me, is sick, regressed, and vulnerable. In my
experience it requires daily vigilance to control such
inappropriate responses to patients as unwarranted anger,
frustration, and irritation.

In approaching the doctor-patient relationship, a few principles

are very helpful. First, not every patient is for every doctor, and
the first interview is a careful assessment of whether or not you
are an appropriate match for the patient, and whether or not you
can be helpful – two different things. Having the courage to say,
after a sophisticated assessment, “I cannot help you” – which
I’ve done in my own practice – is an important thing to know
how to do.

Second, don’t abandon your patient if the patient can’t

collaborate in carrying out what you think is the best treatment
for him. For example, a patient may have weighed over 300
pounds for most of his adult life. While you can explain that it
would be very important to lose 100 of those pounds, he may
simply not be able to accomplish that. It becomes really
important to explain, then, that this is something you can work
on together, but that you won’t abandon him if he in fact can’t
successfully lose weight. Supporting the patient according to his
ability to carry out your recommendations, not according to what
he “should” do, is very important.

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Third, you must keep in touch with the patient, even when the
patient is disaffected or angry or frightened. If the patient is
unpleasant or difficult, it’s reasonable to ask, “Why are you so
upset?” at least a few times, and to try to get close to the problem
rather than ignore it. If a patient turns out to be inconsolable, you
can then say, “Perhaps I can help you find another doctor who
might be more helpful to you, because I believe you need care.”

A patient’s unrealistic expectations are a significant challenge

for a doctor. Patients would like you to be a magical individual –
able to cure all their pain and to rescue them from their illness,
no matter how terrible it is. They may ask you for inappropriate
things: to be their parent instead of their physician, or even to be
a magician. More than one patient has said to me at the end of a
long recital of terrible complaints, “Now I want you to wave a
magic wand and make all of this go away.” Sometimes the
patient has an inappropriate response to the physician – they
want to make the doctor a personal friend or even a romantic
object. Your responsibility as the more powerful, idealized
person in the relationship is to gently turn away these
inappropriate impulses.

About 2 percent of cases are terribly concerning. They are a

combination of a very sick patient and no diagnosis. When I
encounter this, my first reaction is to involve the best brains I
can to help me, and we literally discuss the patient several times
a day. It’s very important to keep the patient in the loop as new
ideas for diagnosis and treatment develop: to tell the patient
what’s going on, to let him know how much communication is
going on about him, and to explain – either on the phone or in

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person – exactly what we’re thinking. Keeping the flow of

information to the patient constant is crucial, so that even if we
don’t have an answer, the patient doesn’t feel abandoned or
terrified.

Learning to listen to the patient without letting your mind

wander is an important skill to cultivate. It requires you to shut
out all distracting thoughts and outside intrusions during the
interview. Control of the interview is also critical. I have patients
who will digress so much that they eat up the time that’s allotted
before you can get the facts you need to be most effective. Often
this happens because the patient is too frightened to be direct:
They resist telling me what’s really bothering them.

Controlling the flow of information so that you have the data you
need without offending or cutting off the patient requires you to
use your senses of smell, sight, touch, and hearing. Sometimes
the signals are right before our eyes. I watch the color of the skin
of my patient as he tells me his story. Some patients come in
gray with anxiety, and it’s only when the color begins to return
to their faces that I understand that they are less frightened and
more at ease.

The doctor-patient relationship is not an equal relationship. A

doctor is perceived as much more powerful – and is, by virtue of
his or her knowledge and ability to intervene. As much as
modern society likes to say the patient should take charge, the
patient can’t; the patient doesn’t have the training, the
objectivity, or the freedom from personal terror to take charge of
his or her own case.

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Doctors must be careful to remember the vulnerability of the

patient and not exploit it. Sometimes patients want to please you;
they think that by being “good patients,” they’ll get better results
from you. Sometimes they have skills or access to things that
would be helpful to you, and you must never ask them for that
without thinking very carefully about it. If you’re writing a book,
for example, and your patient is a famous publisher, it’s hard to
resist asking the patient for help. That may not be appropriate if
the patient is ill, and you should never approach them about such
things in the consulting room. That place and that time is
exclusively for them and should never be contaminated with
your irrelevant personal needs or demands.

Working With the Staff

An office “staff” – whether it’s one person or 40 people – is

terribly important to a successful practice. After all, your
patient’s first experience with you is actually through contact
with others: It’s others who make the appointment, others who
explain to the patient what he should expect when he makes his
first visit to the office. A good office nurse can be very consoling
and reassuring to a patient. On the other hand, I think it’s very
important not to let your staff members overstep their
responsibilities by interpreting tests or giving the patient
information that is best left to the physician to explain.

Respect for staff is as essential as respect for the patient. Bursts

of short temper and rudeness or even underpaying them will
undermine their ability to function. They are partners in patient

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care and should be treated as such. Personal qualities of humor

and an ability to take very disparate and often very
entrepreneurial individuals and meld them into a team are
crucial. A doctor who can collaborate and not dictate, but also
lead others to achieve important and mutually acceptable goals,
will be an effective practitioner.

The Medical Profession: Past, Present, and Future

Before World War II, we couldn’t do much to intervene in the

course of illness. We had no antibiotics; anesthesia was not very
sophisticated; and our art was better developed than our science.
We were experts at keeping patients company and paid exquisite
attention to every detail of the patient’s illness. We described it
and predicted what would happen; our entire attention was
devoted to the sick person.

After WWII the burst of important science that was developed –

in medicine, but also in the broader world of scientific
technology – refocused our attention on the phenomenon of
“testing” the patient. Through the combination of an abundance
of technology and its apparent power in an increasingly litigious
environment, we came to feel that it’s better to have the results
of a “test,” which is a black-and-white matter, than the details of
a patient’s account of his illness. A “test” was positive or
negative, reliable, and provided a better defense if we were
criticized. As a group we began to retreat from the bedside of the
patient, into the chart and the data. We found ourselves literally
making rounds at a table with a patient’s charts, and losing our

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ability – if we ever had it, depending on our age – to really see,

hear, and examine the patient and to relate primarily to him or
her. We became “dataphiles,” and our fascination with
technology and the black-and-white nature of the laboratory
chart has reinforced a turning away from the patient.

My personal aim – one of them – as a faculty member at a major

institution is to reacquaint the medical students and the trainees,
and even my own colleagues, with the story of the patient’s
illness, as told by the patient. I think the patient is ultimately the
best teacher; he or she asks some of the best questions and gives
us some of the most accurate information about the experience of
illness, its symptoms, and the details of its course. I also think
that, for me – although I like data as much as the next person –
the richest part of being a physician is that interchange with the
patients. I find the patient is the true point of the exercise and the
most fascinating of its aspects.

I now give a lecture to students on the art and science of physical

diagnosis before they have their first real contact with the sick.
When we go on rounds, I like to leave the chart far behind and
go to the bedside to teach people how to learn about illness
directly from the patient. I don’t think managed care or a third-
party payer has caused our increasing distance from the sick
person; I think technology has caused this tremendous change in
focus and emphasis.

A major concern of mine for the future of medicine is the

problem of malpractice suits. I think what’s happened to
physicians is rather shocking. We live in a litigious society, and I

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think doctors are inadequately protected from malpractice suits.

Insurance premiums have rocketed skyward, consuming a
significant portion of practice income. Simply being accused of
malpractice can be crippling: I think the public believes that if
you’re sued, you’re not as good a doctor as if you’re not sued.
More and more people are leaving medicine because of the
malpractice costs and the risk of a suit. Doctors do not set out to
do harm, and, I think, contrary to public opinion, we do an
excellent job of policing one another. I don’t know any other
profession that is as certified and recertified as ours, or whose
ongoing training and scrutiny is as intense as our own.

My particular interest in medicine is in exploring and explaining

the reasons for the differences between the normal function of
men and women and in the differences in how they experience
disease. We call the new science gender-specific medicine, and I
believe it will inform the way we practice medicine in the future.
I think as we learn more, we understand much more fully that
men and women are not identical. We are correcting what I call
the “bikini view” of women – that breast health and reproductive
biology are the only important areas that are different between
the two sexes. In fact, women are not small men, and we can’t
restrict our research to male subjects as we have done in the past.

Also, I’m confident there will be a return to interest in the

patient. I think the public will demand and reward that in
physicians. And I believe that if we intend to keep the best and
the brightest people in medicine, we’re going to start rewarding
them for their efforts, both financially and in protecting them
from malpractice suits that have little or no basis for existing.

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Dr. Marianne J. Legato is an internationally known academic

physician, author, lecturer, and specialist in women’s health.
She is a professor of Clinical Medicine at Columbia University
College of Physicians & Surgeons and the founder and director
of the Partnership for Gender-Specific Medicine at Columbia
University. She is a practicing internist in New York City.

Dr. Legato has spent her research career on cardiovascular

research on the structure and function of the cardiac cell. The
American Heart Association and the National Institutes of
Health supported her work. She won the Murray Steele Award,
the Martha Lyon Slater Fellowship, and a four-year Senior
Investigator Award from the American Heart Association, New
York Affiliate. She won a coveted Research Career Development
Award from the National Institutes of Health and sat on the
National Heart Lung and Blood Institute’s study section on
cardiovascular disease, as well as the Basic Science Council of
the American Heart Association. Most recently, she has served
as a charter member of the Advisory Board of the Office of
Research on Women’s Health of the National Institutes of
Health, and she received the “Woman in Science” award from
the American Medical Women’s Association in February 2002.

In 1992 Dr. Legato won the American Heart Association’s

Blakeslee Award for the best book written for the lay public on
cardiovascular disease with her publication of The Female
Heart: The Truth About Women and Heart Disease. Her newest
book for the lay public on gender-specific medicine, Eve’s Rib,
was published in spring 2002.

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THE INCREDIBLE VALUE OF

BEING WITH YOUR PATIENTS

MARC BORENSTEIN, M.D.

Newark Beth Israel Medical Center

Department of Emergency Medicine

Chairman and Residency Director

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The Need for the Warm and Fuzzy

My lifelong career in medicine and my professional mission

have been dedicated to the incorporation of humanistic values
and the art of medicine into the clinical knowledge base and
scientific technology that form the foundation for all physicians
independent of their chosen specialty. For many years the art of
medicine was not formally taught. Rather, it was observed and
learned at the side of a mentor with the hope that somehow it
would filter through to the student through a process of osmosis.
Some elements of the art of medicine, such as the ability to form
relationships with people, the ability to communicate, and the
demonstration of empathy, were thought to be in the realm of
“soft” science, often referred to as “warm and fuzzy stuff.” It
was generally thought that these areas could not be readily
taught, nor was credible research possible, since these areas were
not subject to the rigor and scientific discipline that could be
applied to disciplines such as biochemistry, physiology, and
scientific technology.

Medical training involves the mastery of a substantial knowledge

base, which starts in high school and college. It requires training
and education in a variety of basic chemical and biological
sciences. In medical school students spend approximately two
years studying the clinical sciences, such as anatomy,
physiology, embryology, pharmacology, and biochemistry, and
then another two years understanding the application of these
sciences to specific medical disciplines and clinical care, thereby
learning the basic approach to the major medical specialties.
Clinical rotations of varying duration in medical specialties, such

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as pediatrics, internal medicine, surgery, obstetrics and

gynecology, and psychiatry, are usually required in medical
school curricula. Additional clinical rotations in such disciplines
as radiology, the surgical subspecialties (urology,
ophthalmology, plastic surgery, otorhinolaryngology), and
emergency medicine may be required in some medical schools
or taken on an elective basis in others.

As students progress through their medical education and

subsequent residency training, they acquire many technical and
procedural skills. These range from basic procedures mastered in
medical school, such as starting an intravenous line, drawing
blood samples, and inserting a bladder catheter, to the highly
advanced and invasive procedures, requiring many months to
years of training, such as surgical endoscopy, heart and major
blood vessel catheterizations, and surgical operations.
Acquisition and mastery of these skills and scientific knowledge
are daunting. Despite the long and highly publicized hours of
residency, it soon becomes apparent to the medical novice, often
referred to as an intern, that there is insufficient time to do
everything that must get done and to learn everything that must
be learned.

Most interns and residents are overwhelmed with the enormous

demands placed upon them to just get the tasks and
documentation done that are required for delivering correct and
complete medical care in a hospital. Every day (and night) is
filled with obtaining and writing medical histories, performing
physical examinations, ordering and checking laboratory tests
and diagnostic imaging studies, studying about uncommon

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medical conditions, reading medical journals, going on rounds

with faculty and attending physicians, and, whenever and
wherever possible, getting sleep. As a result these highly
motivated but forever busy house officers pay little attention to
acquiring skills in such areas as communication, conflict
resolution, bringing out the best in others, and building
relationships. Experiencing the emotional content of medicine
and getting in touch with one’s own emotions occurring during
the intimacy of delivering medical care are not only irrelevant to
completing the tasks of medicine, but can actually be perceived
as obstructive to the rapid, efficient completion of these tasks. As
residency progresses, many physicians in training not only lose
touch with the humanistic elements of medicine, but some have
it actively driven out of them through role modeling that
covertly, or even overtly, communicates that it is detrimental or
weak to have any emotional connection to the patient.

Ironically, during the past 50 to 60 years, as teaching in

humanism and the art of medicine was decreasing in formal
medical education and residency training, public yearning for a
return to humanism and the art of medicine increased. As we
began to approach the end of the 20th century, an increasing
public awareness that humanism is essential to the role of
physicians as healers and to the role of medicine as a healing
science became evident. During this time, as we have become
more and more scientifically advanced, people are yearning for
connections to each other and themselves on a more soulful and
spiritual basis. It is probably no coincidence that with the
tremendous technological advances over the past 60 years in
medical science, there have been new and very popular

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movements to preserve the humanistic elements in medicine. For

example, look at the alternative medicine movement that is now
a major aspect of healthcare delivery in our country. It would not
be surprising to find that the majority of people in the United
States have some type of alternate care. Practices such as herbal
therapy, acupuncture, and massage therapy, which might have
appeared unusual in 1973, are now commonplace. Herbal
remedies, such as Echinacea, St. John’s wort, and saw palmetto,
are mass produced today and sold in supermarkets alongside
vitamins, aspirin, and acetaminophen. In addition, you see that
people today want and need to participate in not only how their
healthcare is delivered, but also in how their babies are actually
delivered into the world, as well as how they leave the world in
old age.

It is interesting that if you look at post-WWII America in, say,

the 1950s, it is apparent that we entered the scientific
convenience era characterized by a widespread availability of
everything from frozen food, television, and refrigerators, to
automatic transmissions. During this time, hospitals became very
prominent as centers for medical care where people went for
everything from birth to death. Along with this development of
the hospital as the center for medical care was a paternalistic
culture in medicine in which doctors said, “We know what is
best for you, and we will tell you what needs to be done.” At the
height of this era, a great birthing experience was viewed as
something along the lines of a woman being knocked out with
light anesthesia toward the end of her labor. Subsequently, she
was found waking up with her baby, all clean and tidy, being
placed in her arms by a nurse, thereby missing the whole birthing

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experience with a painless and unconscious process. During the

entire time of labor, fathers were sent away, to be summoned
back by the physician at some point after the baby was born.
From that extreme scenario, we have seen a continued demand
for the conscious, active participation of both the mother and the
father in the birthing process. There has been a dramatic rise in
requests for natural childbirth, fathers at the bedside throughout
labor, Lamaze methods, non-hospital birthing centers, and use of
midwives.

You see the same thing with death. In the 19th century it was
common for birth and death to take place in the house. Families
living in one home were often multigenerational. Both children
and adults were present to witness the process of birth and death.
As hospitals, technology, and science in general moved forward
in the 20th century, morbidity and mortality from labor and
delivery for both mother and child decreased. Home delivery
with its greater risks became unacceptable to obstetrical
specialists. Pregnant women went to the hospital for birthing.
Elderly people with serious illness were sent to the hospital
where they died. A death in the household became unusual. In
our times it is possible to meet someone 20 or 25 years old and
discover they have never seen anybody die; this was not the case
100 years ago. Today the use of advance directives, living wills,
and so on, indicate that people want clear participation and a say
in how they die and to what extent advanced medical technology
or resuscitative efforts are to be used in their medical treatment.

The human element and the art of medicine have become very
important expectations for most people who want them to be part

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of their medical care. In his book Megatrends, John Nesbit called

this phenomenon “high tech, high touch.” That is, the greater the
amount and sophistication of technology in medical care, the
more people will be looking for some type of touch and feel –
they didn’t want to be just a number in a complex technologic
process; they wanted the human element to be preserved. Paying
attention to people’s individuality and interacting with them in a
way that gives them the experience of being cared about as a
person is very important to them.

When I look at the attention being placed on the art of medicine

today, what is interesting to me is the increasing focus on how to
teach it. In fact, the Accreditation Council for Graduate Medical
Education over the past few years has developed, in association
with the American Medical Association and others, something
called the six core competencies, which are being incorporated
into the training requirements for every specialty in medicine.
Two of the core competencies have to do with professionalism,
communication, and those qualities that one might call the art of
medicine, such as humanism. These competencies have now
been formalized and defined to a high degree, so they can be
taught with more rigor than they have been in the past.

Necessary Qualities

Some of the necessary qualities for a physician that were referred

to more than 100 years ago as the three A’s were affability,
availability, and ability. These still hold true today. Traditionally,
the narrow definition of affability is likableness or pleasantness,

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but it goes beyond that in medicine. One needs what is broadly

defined as professionalism, which includes the talent and ability
to form relationships, acknowledge others generously,
communicate, provide service, and demonstrate empathy, care,
and concern for others. Availability is certainly essential. If one
does not have access to healthcare, especially for emergency
medical care, from a regional or national perspective or to the
doctor on an individual basis in the doctor-patient relationship,
then things break down. Ability is basically everything it takes to
do the job right.

It is essential for the physician to experience a sense of calling to

the profession. Medicine is not for everyone. It requires that you
place the welfare of others before your own personal desires and
needs. That is what drives physicians to put in the hours that they
put in during residency or to do whatever it takes to get the job
done. I believe that is what drives the physician to not only be
awake while on duty all night but to be alert and even
hypervigilant. That driver is a mandate that comes from within.
It is experienced as innate and fundamental. It is a quality of
being that calls you to put the needs of others before your own,
to have an innate desire to be of service to others and to enhance
the quality of life through greater well-being and health for
people. That does not mean you cannot be compensated for your
work or have other interests in life, such as traveling or enjoying
leisure activities. At the same time, if you were to enter medicine
only for personal gain, such as social prestige or financial
compensation or other self-centered reasons, the inner sense of
motivation and innate drive would simply not be great enough to
pull you through when the going gets tough. Ironically, you

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might still be able to deliver great technical care, and patients

might be all the better for it, but an inner sense of fulfillment and
satisfaction would in all likelihood be missing both for the
physician and the patient. So you have to have the sense that this
is a calling and that it’s your life’s work. I don’t think this is,
however, unique to medicine and the healthcare profession.
People in professions as diverse as theater, art, music, teaching,
and other social and community services, such as firefighters and
police officers, have that similar sense of placing community
service and contribution to society above one’s personal needs
and desires.

Certainly a physician must also have intellectual ability and a

substantial amount of specialized knowledge. But perhaps more
important, there must be a view of study as an ongoing journey –
a willingness to stay fresh and current, to abandon certain ideas
and viewpoints when newer perspectives render a particular
mode of thinking obsolete. There is an old phrase called
“hardening of the attitudes,” which has been said in medicine to
be worse than hardening of the arteries. If you have that
condition in medicine, you will be especially unlikely to provide
great care as you progress through your career. This is because
attitudes and opinions in large part shape who we are with
patients, and it is who we are that determines what patients will
be left with as an experience of us.

Traditional medical education devotes substantial time to

teaching physicians what to do. As a residency director, I am
constantly asked by my residents what to do in every situation. I
am frequently asked by my interns in emergency medicine, “If a

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patient comes in with a myocardial infarction, can you just tell

me what I should do?” As they advance in residency, the quest
for knowing what to do becomes more specific and detailed, “If
a patient comes in with an inferior wall myocardial infarction
complicated by hypotension and bradycardia, what do I do?” In
addition to performing the tasks necessary for providing the
correct medical treatment, residents also want to do medical
procedures correctly, accurately. And we train them to perform
the right medical tasks for providing medical treatments or
performing medical procedures. However, little time, if any, is
spent exploring who we are with patients when we are
performing the right tasks. Patients have no way of evaluating if
what I am doing as a physician is medically correct. They take
for granted that I am placing the sutures in the right location and
that the laceration even needs sutures. Patients usually do not
even remember what I am doing. They will, however, remember
with great clarity who I am while I was with them doing
whatever I was doing.

The problem for the physician and people in general is that we

are oblivious to who we are being with people. We have our
attention on what we are doing. So if I am being quiet while I am
placing the sutures (perhaps because in my world, being quiet is
how I focus and concentrate), the patient may leave with an
experience of me as being aloof, rude, or disinterested (perhaps
because in the patient’s world, quiet communicates dislike). This
mismatch of experiences usually remains concealed to both the
patient and the physician during the medical encounter but may
surface in a patient satisfaction survey in which the patient
writes, “The doctor was uninterested in me,” and gives the

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doctor a poor rating. The doctor, in turn, receives this

commentary and with great frustration states, “I did everything
right for that patient, meticulously suturing a complex laceration,
giving it far more attention for a great cosmetic closure than
most physicians would have. What is the matter with that
patient?” Thus, for a physician to be able to deliver excellent
medical care (all the right things done right) and provide that
medical care in a manner that makes the patient feel taken care
of and valued as a person, it is essential for the physician to use
external experiences of others as a mirror to gain insight into
how he or she is with others that might not be apparent from an
internal viewpoint of oneself.

A physician must have an innate interest in how his or her

behavior affects others and a desire to gain access into how his
or her behavior is experienced by others. There used to be a time
when much was overlooked with regard to the ability to form
relationships, communicate, and provide people with an
experience of being taken care of and valued as a person. Even
today you hear people say, “That doctor has no bedside manner,
but he is a great surgeon in the operating room.” Some patients
will say, “I don’t care what his or her bedside manner is – I just
want someone who can take my gall bladder out without any
complications.” But more and more we are seeing that it is not
sufficient to have the technical skill without the human elements.
Patients are increasingly unwilling to settle for half of what they
want. The public wants it all.

To be successful, today’s physicians need their work to come

from the heart. They need to love others and be moved by that

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concern for others. They need to have some type of burning

desire to achieve excellence, to go on a life’s journey of learning
and teaching, and to retain the qualities of empathy and
compassion. The word “demonstrate” must be used pointedly,
because you cannot just feel something internally and expect
others to see it. When you are working with people, it is essential
that qualities such as empathy be demonstrated outwardly by
who you are being so that others experience it.

As a doctor you have to listen. The power of listening is

extraordinary, so listen to your patients and to others, and listen
for new ideas and fresh approaches. Find the good in everybody.
See the value in each person and what they contribute to the
well-being of the patient. If you put patients first, almost
everything else will become clear about what needs to be done in
a given situation. Also, put the needs of others ahead of yourself
and focus on the concept of service and its value as a
contribution to the world.

The pursuit of knowledge and the willingness to continually

grow as a person, and to teach and contribute to others, are
important qualities in a physician. Notice that none of these
things have to do with getting an “A” on your exams or doing
well on the MCATs. We do look at those things when people
apply to medical school and our residency, as it is important to
have a command of our knowledge base, but a lot information
can be looked up. It is surprising how much information can be
looked up and how often information does not make the
difference anyway, because in life it seems that we often know
what to do but are just not doing it.

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Of course, information is very important, but we often know

where to get it. It is applying the behaviors and actions and
interacting with people and the world in a way that makes the
world a better place that is important – things that don’t get
measured on a test. In the end tests are not what make the
difference. What counts is paying attention to detail, thinking
that everything matters, and that every aspect of how you
interact with a patient can contribute to their well-being.

No job in providing medical care is too small. For example, it

has been shown that patients who feel someone in the healthcare
profession cares about them as a person heal faster. They spend
less time in a hospital and die less often. So, if a hospital
transporter is taking a patient from on a 10-minute trip from the
emergency department to a bed in the hospital and interacts with
the patient in a way that the patient feels valued and cared for,
then that transporter could actually contribute to that patient’s
well-being. The patient might actually heal faster and possibly
even leave the hospital sooner. That is an amazing thought: that a
hospital transporter might have something to do with decreasing
patient’s length of stay. We do not tend to think that way, nor do
we think to examine the performance and contribution of
excellence in the jobs such as hospital transporter. All too often,
hospital management may overlook these types of jobs and the
persons who have been hired for them, thinking that anyone can
do the job. But excellence in any job is highly important and
valuable. And excellence in hospital transport services may have
the potential for far more impact in the hospital than just
transport time from A to B. We do know that when people feel
better about themselves as a person they heal better. So who is to

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say that the person transporting a patient could not make the
difference in that patient feeling better about himself or herself
as a person?

The Doctor as a Leader

The qualities and characteristics that contribute to effective

leadership are not the same qualities and characteristics that are
essential to being a great physician. Sometimes physicians find
themselves in positions of management and leadership because
of excellence in areas such as research and clinical care –
excellence in these areas generates a great deal of respect in our
profession, and thus it is possible to be elevated to a position of
leadership or management as a result. However, such a physician
may not necessarily have the skills to motivate others, because
leadership requires an ability to articulate a vision and be in
touch with a sense of purpose. To be a leader in medicine, you
have to walk the walk and talk the talk. But it is essential that
you do so as a natural expression of who you are.

Leadership requires that we bring out the best in others, and our
accountability as leaders is measured by the productivity and
outcomes that others produce. Many physicians are trained to
produce outcomes by themselves. Often they are taught not to
trust the work of others and to check everything personally. This
healthy skepticism can have potentially life-saving benefits for
patients. At the same time, these physicians may have a quality
of the “lone ranger” and not work well with others or be
effective in leading others. When you are trained to produce

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outcomes yourself, that is different from working with others in

such a way that your success is measured by the outcomes they
produce. It is the difference between coaching and playing in a
sport – some people can bridge that gap and are very successful
at both; some people are great coaches but not great players; and
some people are great players but not necessarily great coaches.
So I think many times the necessary skill sets and what you are
naturally called to do as a doctor are different from what is
required to be a leader.

I have been a residency director or involved with building

residency programs for about 14 years, and I actually see part of
my life’s mission as working with others to help them be their
best, to fulfill their dreams, and to achieve things they did not
think were possible. When people apply to my residency
program, I tell them I am interested in people who want to work
with people. I am interested in working with people who are
looking to take on more in life than they thought might have
been possible for them before they started residency training.
There has to be some natural motivation to take these sorts of
positions because they take more time and are more all-
consuming, so it had better be something you love. You have to
be enthusiastic and have a natural tendency toward optimism –
you have to be able to make lemonade from lemons and take
time to “mine for the gold” in people and in situations. You have
to be able to keep people focused on their missions.

Mother Teresa once said:

People are unreasonable, illogical, and self-

centered. Love them anyway. If you do good,

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people will accuse you of selfish ulterior

motives. Do good anyway. If you are successful,
you will win false friends and true enemies.
Succeed anyway. Honesty and frankness make
you vulnerable. Be honest and frank anyway.
People really need help but may attack you if
you help them. Help them anyway. Give the
world the best you have, and you will get kicked
in the teeth. Give the world the best you have
anyway.

I think you have to have some of that attitude as a physician.

Margaret Mead said, “Never doubt that a small group of

committed citizens can change the world. Indeed it is the only
thing that ever has.” These are some of the ideas and
philosophies regarding life that give me inspiration in seeking to
deliver excellence in healthcare, no matter what. Today,
especially in the emergency department where we provide care
for so many people who might otherwise not have access to
healthcare, our mission is to deliver excellence and create an
environment where anybody can walk in and have an experience
of dignity. My mission is to train people to be true to that. We
have not gotten there yet, but it is worth working on.

The Importance of Being With and Communicating With

Patients

As mentioned earlier, people are often aware of what they are

doing, but they are not often aware of who they are being when
they are doing it. Frequently we pay attention to training people

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in terms of what to do, but not how to be with people. For

example, if I am starting an intravenous line, I may use all the
necessary techniques to get the job done, but the patient may not
feel taken care of. The patient’s feeling taken care of is a
function of who I am being with the patient. Am I being kind,
caring, a good listener? These are all in the domain of being. It is
a very interesting and important area, but we do not spend a lot
of time on this in teaching.

Most of us are not aware of who we are being. But often the only
thing patients remember is who we were being. They cannot
actually assess the technical aspects of what we are doing. It is
similar to the airline industry, which has been used as an analogy
in patient satisfaction and service. When we look at airplane
travel, we often use what are called surrogate indicators to
determine what airline we will choose for travel. Surrogate
indicators include things like the comfort of the seats or the
pleasantness of the flight attendants. What really matters,
though, is how often a particular airline services the airplane
engines or how often they train pilots and update them on new
technology or flight simulators. We do not tend to think about
that; we just assume it’s all done.

Similarly, when you walk into an emergency department, you

assume the doctor knows what he or she is doing. We do not get
any points for putting the stitches in the right place, and you
would not even know if we put them in the right place, anyway,
because you cannot really evaluate that. If, while I am suturing, I
appear to be distant and uncommunicative, people will tend to
personalize what is going on and may assume that my

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disposition has something to do with them. Most of us tend to

take our past experiences and incorporate them into the present,
so a patient might assume the doctor is not appearing friendly
because the patient is on welfare, or because of his or her racial
background. It may have nothing to do with that, and yet that is
the conclusion they draw. So it is extremely important that we
teach our physicians to be aware of who they are being with
patients. It’s also important to remember that a neutral way of
being doesn’t work, either, because people don’t know how to
interpret neutral. You have to actually show compassion with
your voice, your facial expressions, and mannerisms.

A number of communication approaches or techniques can be

taught, but none of them is a substitute for innate sincerity and a
love for people. That can’t be taught; it has to be there from the
start. Unless you are in a removed research arena in which you
have no contact with patients, medicine is a people specialty,
where you work with people. No matter how you look at various
equations and scientific processes, as soon as you inject the
human element, it is people, and they do not conform to all the
formulas; people are not algebra or geometry. It’s important to
appreciate that we are working with people, to have a basic love
of people, and to learn from the people you come in contact with.

The old saying, “Physician, heal thyself,” has to do with the

notion that there is a personal journey available to a physician,
and the access to that journey is through the patients and other
people we work with and come in contact with, such as the
nursing, healthcare, and management staff, and family and

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friends. Once you start with that, there are ways to open things
up with patients.

When you first meet a patient, introduce yourself, and let the
patient know who you are and what your role is in their
healthcare. It sounds very basic, but it is so important. If the
patient has been referred to you in your office, that relationship
may already be there. In emergency medicine, however, the vast
majority of people we encounter as patients have not met us
before, which is unique to this specialty. They are coming into
an emergency department, sometimes under the most difficult of
circumstances. There is a fear of not knowing. People come in
without knowing the extent of the illness or injury they have and
may fear the worst. There may be financial factors because this
has happened unexpectedly, and there has been no preparation
for it, and the extent of the cost may not be known. The patient
does not know the physician or staff, and may have been taken to
a hospital he or she has never been to before. In that setting an
emergency physician needs to be able to establish a relationship
of trust and safety. Without safety, people cannot communicate
what is really on their minds. A relationship of safety requires a
situation in which no judgment is applied to the patient. The
physician has to demonstrate an interest in the patient through
tone of voice, eye contact, body language, and choice of words.
All of these things matter. Other examples are sitting down with
the patient and shaking hands or making some type of contact to
let the patient know you are there for him. These things in an
emergency department are very important.

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It’s also important to be willing to set aside stereotypes and

opinions. Of course, being human, many of us are sometimes
unaware that we are harboring or holding various opinions of
people. It is very important to set those things aside and listen to
the person – and always listen from the standpoint that if
something does not make sense initially, you should start from
the perspective that maybe the patient is describing something
that is new to you or that you’re unaware of. So rather than
dismissing it, it is much better to think that maybe this is
something you are unfamiliar with, and it might be something
you need to look into and learn more about. These things can
really help you get established with the patient.

Another thing that might seem basic in a way but that is often
left out when communicating with patients is illustrated in the
following scenario. A patient comes to the emergency
department for an injury: He has fallen and broken his wrist. You
see there is something else affecting that person’s health that
might be germane, and you believe it would be important to
discuss it with the patient: Your exam shows the underlying
problem is alcoholism.

Fifty years ago perhaps the doctor had implicit permission to

intrude because the old medical paradigm was one in which the
doctor had a highly paternalistic role. The doctor could chide the
patient about his drinking problem, admonishing him to stop.

Now, back to your patient who has fallen. Today you cannot
have an intrusive conversation with a patient about lifestyle
issues or drug or alcohol abuse without obtaining permission. If

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the patient comes to an emergency department seeking care for a

fractured wrist, this person has not necessarily given you
permission to discuss alcoholism, and you might be intruding
unless you specifically say something that establishes
partnership and requests permission to go further. So you might
say to the patient, “As your physician I can see something that
may be affecting your health that could be part of what is going
on here, but I would like to ask your permission to talk to you
about it.” Most patients will agree to do so. Some patients may
say no, in which case I would respect their decision.

People establish boundaries for what they are comfortable with

and how far you can explore something, but many patients will
allow you to go ahead. I would then say, “I am aware that
alcohol is beginning to affect you in ways it has not in the past. I
can see from your blood work your red blood cells have become
affected.” I have actually had situations where patients have
stopped smoking as a result of a conversation crafted in this
manner in the emergency department. In contrast, if I just went
up to a patient and said, “Smoking is bad for your health; you
should stop” – as if I were the patient’s parent – it’s not going to
work. On the other hand, if a patient comes in with a
deterioration of bronchitis or emphysema, and I say, “There’s
something I’d like to speak with you about that is affecting your
ability to breathe. I am concerned about it and your well-being,
and I would like to speak with you as someone on your side” –
most people would say yes. If I discuss how I see smoking
affecting their oxygen content, and then acknowledge that maybe
years ago, when they were younger, it didn’t affect them,

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patients will stop and listen because they see you are on their
side, and you have asked permission to intrude.

In an emergency situation when I am meeting someone I have

never met before, I need to establish a relationship of trust and
safety. I need to ask permission to go beyond what might be
considered normal boundaries. I need to demonstrate empathy
and concern. And I need to communicate professionalism with
every aspect of who I am. That is why it does matter what you
look like, because people draw conclusions about you in less
than a minute. If I look sloppy, people might conclude my care is
sloppy. If my tone of voice sounds harsh, people might conclude
I am not caring, even though that may not be true.

We usually do not teach doctors their voices can be used as

instruments; yet the power of the human voice is partly why
singing as an expression of music is so essential to us. Take
Beethoven, for example. An astonishing thing he did, around
1820, was to take the symphonic form, which conformed to a
very well established structure at that time, and alter the form to
include the human voice. Thus, his Ninth Symphony was
groundbreaking and actually revolutionary in its time. But what
was behind this startling introduction of the human voice? The
need to use the human voice to create a level and complexity of
musical expression that Beethoven could not achieve with
musical instruments alone. Sound and the human voice are
enormously valuable and can be used in healing, but these things
are not discussed or taught in traditional science or medicine.

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Greatest Challenges

It is increasingly difficult to deliver healthcare in our

environment. Tremendous demands are placed upon the
healthcare profession and physicians for documentation and
compliance with a variety of federal and local accreditation and
licensing standards. Maintaining the documentation is very time-
consuming. Some of the compliance rules are complex and
require fulltime work to understand the laws and create the
paperwork and documentation for compliance. This is different
from being a doctor. An enormous amount of administrative
work is required to deliver healthcare and be a physician. The
process of billing is very complicated, and the administrative
work necessary to bill takes up a large share of the healthcare
budget. A tremendous amount of work and time is required
simply to go about the business of accreditation, compliance, and
billing.

Being a physician is actually not difficult for most physicians

who are trained to do what they do and who do it well.
Sometimes people think being an emergency physician must be
so stressful for me – to be in an emergency department with
serious situations coming in, such as heart attacks and gunshot
wounds. Of course not every situation and patient encounter is at
the highest levels of acuity and severity; even in the busiest of
places these do not happen on a continuous basis. But when
patients with life-threatening illness or injury present to the
emergency department, I find that for me, I am trained to
manage those situations, and when something of that nature
comes in, I find myself focused, relatively calm, and clear about

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what needs to be done. I do not find those sorts of things

stressful.

What is very stressful for many physicians is that it is not easy to

deliver excellence in healthcare, particularly from a large
systems or organizational perspective. In other words, what it
takes to actually get your hospital accredited or surveyed
successfully, to get your residency training program sufficient
educational and teaching resources, to deliver healthcare in
urban or lower socioeconomic regions, and to train the next
generation of physicians is very difficult in today’s environment
because there are fewer and fewer dollars available.
Furthermore, at the same time, more and more documentation is
required to get the shrinking dollars that are out there.

This is a very highly regulated industry, and it is sometimes

difficult to be creative in certain ways with management
approaches because the regulations may preclude that. So I think
it is very stressful for physicians and everyone working in the
healthcare professions, including non-clinical personnel such as
administrators.

Additionally, I believe physicians want to have the human

element as a component of their practice, but cognitive and
humanistic skills of physicians are not emphasized in the way in
which dollars are allocated for reimbursement. The emphasis by
third-party and governmental payers is on compensation for
technical procedures. Technology does hold a certain allure and
amazement about what can be done. I think it is really
miraculous to be able to put a valve into someone’s heart, or to

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provide a hip prosthesis so someone can walk again, or to pass a

catheter into someone’s blood vessel and open a coronary artery.
On the other hand, spending sufficient time with someone to
arrive at a difficult diagnosis or opening new perspectives
through counseling or therapy can require highly skilled
cognitive work and produce equally miraculous changes in
people’s lives. New approaches to well-being (such as losing
weight, stopping smoking, changing to a more active lifestyle, or
resolving destructive situations in their personal relationships so
their relationships or outlook may be healthier) can have life-
long benefits, including reduced use of healthcare resources.
That kind of work with patients, which often includes the
humanistic elements, however, is not always reimbursed, which
means many patients will have decreased access to preventive
care, medical counseling, stress reduction, and mental health
care.

It is difficult to deliver the excellence in healthcare that everyone

is looking for in an environment in which there are decreasing
resources and less money. It is easy to say on a national level,
“Let’s not do so many CT scans,” or, “Let’s not provide this type
of technology,” or, “Not everybody needs this level of care.” But
if it is you personally or your family member, the individual
medical care is everything to you. You cannot apply statistics to
the individual. If the odds are 100-to-1, chances are it will not
happen to you, but if it does, it is everything to you. If you are
the one who needs the care, you want what is currently perceived
as the best. It is a very difficult thing to ration healthcare to the
individual patient standing in front of you.

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There is also a great deal of information out there on the Internet,

which is certainly going to change healthcare, and already has.
People have access to far more information about the outcomes
produced by hospitals and physicians. I just finished my survey
for the New York state physician database, and people can now
look up information about me and my medical background,
whether there have ever been actions taken against my license,
and so on. With this kind of information out there, people will
make more medical selections regarding which hospital or
physician they use based on information from the Internet. They
will also be able to learn more about diseases. If fewer and fewer
dollars will be available, how do you say no to a patient who
may have read about a certain test that, at least from their
perspective, should be run in their situation?

Numerous other challenges abound, as well. There are major

challenges in delivering pre-hospital care by ambulance squads
and paramedics. Public funds are decreasing for maintenance of
paramedic units, and voluntary squads are not available in all
communities. There are major challenges in maintaining the
emergency departments around the country. And there are
increasing numbers of uninsured or inadequately insured
patients. Access to healthcare is limited for many people in our
country.

We face significant issues now that are expected to worsen in the

years ahead. Most important is that there is a national and even
international nursing shortage. Also, the resources and teachers
needed to train the next generation of doctors will be a major
challenge. There is a national crisis in the medical malpractice

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insurance industry. Several large national malpractice insurers

have either closed or stopped offering malpractice insurance.
Significant numbers of physicians in certain specialties, such as
neurosurgery, orthopedics, and obstetrics and gynecology, have
either stopped practicing medicine altogether or stopped working
in certain aspects of their practice, such as obstetrics. It will
require a lot of creative work to look at all these areas and
develop new solutions.

From a more individual perspective, doctors also face the

challenge of staying on top of a rapidly evolving field. I use
several approaches to staying current. First, my involvement in a
residency program keeps me continuously challenged to stay
current and learn new things because my students challenge me
to examine things in fresh and new ways. One of the wonderful
dynamic tensions is that which exists between the older,
experienced physician and the younger resident physician or
medical student. The fresh, almost naïve perspective of the
younger physicians and students permits them to seek answers
and think about possibilities in ways that allow the question,
“Why not?” This environment of inquiry and scholarship is
reflective of any teaching environment. That keeps me awake to
new ideas.

Another approach is to continually read journals, particularly

professional journals, because they bring us the latest in
scientific developments and analyze things from a peer-reviewed
perspective. I also look at textbooks on a regular basis, exchange
ideas with colleagues, and am generally willing to rethink things.
That is what I mean about not having a hardening of attitudes: to

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carry a certain quality of innocence or childlike inquiry into

one’s work and to always be willing to look again and consider
not knowing. It’s very powerful to consider not knowing.
Experience can sometimes be a bad thing, because it can give
you the impression that you already know, and then you may not
discover something new. I also go to conferences several times a
year, and consult with my colleagues around the country.

I seek to keep in touch with my humanity through the impact that

art has in the world. It is very valuable to look at art, listen to
music, go to movies and theater, and experience all sorts of
cultural endeavors. This helps because part of the work of the
artist in the world is to have us rethink ourselves and challenge
ourselves, and I think art throughout the centuries has forced us
to stretch ourselves to think beyond where we currently are.
Being in touch with things outside of medicine (such as
friendships and culture) helps, as does travel, which exposes us
to other countries’ ideas about healthcare and well-being. These
are wonderful ways to stay fresh and current and to consider new
approaches.

Marc Borenstein, M.D., F.A.C.E.P., has been Chairman of the

Department of Emergency Medicine of the Newark Beth Israel
Medical Center since 1999 and its Residency Program Director
since 2000. With 23 years of clinical experience and 19 years of
management experience in both urban and suburban teaching
and non-teaching emergency departments, he has been actively
involved in academic emergency medicine and residency
training since 1988.

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An associate professor in the Department of Medicine of the

Columbia University College of Physicians and Surgeons, Dr.
Borenstein also serves as an examiner for the American Board of
Emergency Medicine and as a reviewer for Annals of Emergency
Medicine and Academic Emergency Medicine. He is the cochair
of the Education Committee of the New Jersey Chapter of the
American College of Emergency Physicians, as well as cochair
of the Sickle Cell Anemia Task Force at the Newark Beth Israel
Medical Center.

Dr. Borenstein received his M.D. from New York Medical

College, Valhalla, New York, and his B.A. in biological sciences
from Columbia College in New York City. He took post-graduate
training at the Mayo Clinic, the Norwalk Hospital in Norwalk,
Connecticut, and the Stamford Hospital in Stamford,
Connecticut.

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THE COMPASSIONATE
PHYSICIAN:
STAYING ALIVE IN TODAY’S
BUSINESS OF MEDICINE

ARTURO CONSTANTINER, M.D.

New York Downtown Hospital

Director of Nephrology and Dialysis

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The Importance of Passion and Compassion

Medicine is much more of an art than a science. Although a lot

of the data in medicine is based on scientific data and scientific
research, every individual is different; therefore it’s a science
that is far from exact. As a physician you must apply a great deal
of common sense and a well-informed interpretation of the
scientific data to each individual patient. You have to use clinical
judgment and not treat every disease and every patient like a
recipe in a cookbook. For example, you really have to know the
social condition of the patient. Prescribing medications the
patient cannot take or tolerate or afford may represent the use of
good scientific data, but it will not be helpful to the patient.
Medicine is an art because you have to be creative in how you
treat a patient.

The most important quality is to be able to communicate with

your patient. It is critical to listen to the patient and talk to the
patient at a level that he or she will understand. A doctor should
not give a sermon or a speech to the patient; a doctor should try
to exchange ideas. A doctor should let the patient talk and not
interrupt because many times the doctor will miss some of the
symptoms of the patient. The doctor has to be compassionate and
available. The doctor must have tremendous respect for the
patient, in every sense of the word. A doctor should show care
and warmth, and make the patient feel at ease so he or she can be
open and disclose necessary information to the doctor. If a
physician intimidates a patient, makes him or her feel
uncomfortable, or is judgmental, the patient will reserve a lot of

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information that would be very helpful for the physician’s

diagnosis.

I admire different types of doctors. I admire a physician who has

a tremendous amount of knowledge, but if that knowledge is not
combined with human warmth and dedication, then I can’t fully
admire him or her. My role model is a physician and friend of
mine. I don’t think I’ve ever seen her say “no” to a patient or not
be available, or not have a kind word or a smile for a patient. She
is a physician who is completely devoted to her practice.

The practice of medicine must be pursued with passion.

Governmental bodies are currently trying to restrict physicians
from working more than 80 hours a week or 24 hours in a row,
but the medical profession is far from being a nine-to-five job.
While I realize a person under fatigue cannot perform as well as
someone who is well rested, one has to understand that in this
job you know when it starts, but you don’t know when it ends. A
doctor cannot lock the door on a patient and say, “OK, I’m on
my way out.” In a way, medicine has become more difficult,
because although technology and drug developments have
helped us, we’re creating more technicians than people who
really know how to practice the art of medicine.

The Doctor-Patient Relationship

A doctor must always be sensitive to the needs of the patient. If a

patient has a headache, for example, the doctor should try to
gather information about all the symptoms associated with the

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headache in a brief interview. A headache is one of the most

common symptoms that bring patients into the office, and
although, fortunately, most headaches have no organic cause,
such as a brain tumor or other serious condition, it’s important to
search for clues that might point to a more serious or systemic
disease. You must be sensitive to the anxiety of the patient,
because most patients, especially those who have never had
headaches and are experiencing a headache for the first time, are
probably thinking about the worst-case scenario. We have to be
sensitive to their anxiety and preoccupations, while at the same
time we have to reassure them that we understand their pain, and
that we will go all the way to find the cause of and a treatment
for their condition. We have to be sensitive and not alarm the
patient unnecessarily. Again, we must make the patient aware
that there are certain parts of the physical exam, and maybe
ancillary tests as well, that will have to be done to get to the root
of the problem.

Today, patients are savvier because of the Internet and the

amount of information they have access to. Reading newspapers,
books, and magazines, listening to the radio, watching television
– all forms of media have made patients more educated. While it
is clearly advantageous to have more educated patients,
sometimes the information that is spread does not have enough
of a basis to make it valid. Sometimes the patient thinks the
doctor is doing something wrong or ignoring important
information because the patient found some data in the
newspaper; this can be frustrating for the physician.

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The patient sometimes feels the doctor should be able to respond

within minutes of his or her phone call. Although most
physicians do try to respond, in many situations it is impossible.
In an emergency the doctor will always be available, but the
patient should not consider every little situation an emergency.
There’s a misconception by patients that doctors make them sit
and wait unnecessarily in the waiting room. The truth is that the
practice of medicine is not something you can plan on a daily
basis with a fixed schedule. Emergencies happen, and patients
call with needs that must be addressed that day, and the doctor
has to schedule those patients on an emergency basis. When a
physician makes a patient wait, it is not intentional; it is the
result of the unpredictable nature of the practice of medicine.

Some patients also have the misconception that physicians are

extremely expensive and exist merely to exploit patients and
gain money. Although there may be physicians who practice that
type of medicine, most physicians are not in the business of
medicine to generate massive profits. Obviously it’s an income-
producing profession, but if an individual were to choose a
profession based on money, he would not choose medicine.

Most people, when calling to make an appointment, have some

degree of anxiety; whether they need the attention immediately
or not, the patient seeks some relief of that anxiety. My approach
is to provide my patients with access to my office almost as soon
as they call. I try to communicate with the patient in the best way
possible, and to respond to their questions and make myself
available by telephone to clarify or expand on the encounter.
Many times we think a patient understands everything explained

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in the office, but often a patient will leave the office and after a
few minutes, he or she will become completely confused about
what was said or the directions for the medications, primarily
due to a high level of anxiety. So a follow-up phone call to
clarify instructions, directions, or the diagnosis can be critical.

I try not to bring the patient to the office repeatedly unless it’s
absolutely necessary. In my practice I personally give my
patients their results via telephone; I don’t use my secretary for
this task. I instruct my patients to reach me within a few days
from when their blood test or other tests were ordered. I bring
the patient back to the office for a follow-up or a treatment only
if we discover a condition detected by the blood tests or other
ancillary tests.

Unfortunately, you have to tell some patients – hopefully very

few – bad news. In those situations I definitely bring the patient
back to the office. A physician should never give bad news over
the phone. If I have doubt or fear about results I reschedule the
patient to come and discuss them. Occasionally I even make up
an excuse – that the blood test was lost and I need to run a new
one, for example – just to avoid breaking bad news over the
phone. Perhaps because of the culture I come from I find it
unethical to break bad news over the phone. In American
medicine the usual practice is to be 100 percent open and
completely up-front. I find that many times this can be cruel to
patients, especially when there’s always a possibility that things
are not as bad as they initially appear. With many patients a
doctor should not tell them they have cancer until they actually
have the diagnosis in their hand, with a biopsy. I’ve found many

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physicians who, because of the need to be totally up-front, will

throw a lot of diagnoses on the table and worry the patient
unnecessarily, creating much more anxiety, and then call to say
there is good news. I think it’s important not to hide information
from the patient, but it’s also important to avoid alarming the
patient; the information should be disclosed in a very smooth
way.

I recently made rounds at the Veterans Administration, and to

my dismay I found that people were looking at me as a rare
animal in the way I approach a physical exam. Unfortunately,
younger students and physicians are more used to receiving data
and information from lab tests, MRIs, and CAT scans, and the
physical exam is in some ways falling by the wayside. One
should attempt to catch up with the times and not try to live in
the “glory days” of physical exams, but there will never be a
substitute for a good history-taking.

Twenty or 30 years ago scientists were trying to develop a

computer that would interview the patient. The personal
interview reflects the art of medicine. That dialogue between the
patient and the physician gives the latter a feel for something that
could never be substituted by a machine. We do have to keep up
with the times; we can’t say, “Things were done this way 40
years ago, so we have to keep doing it,” but the patient-physician
relationship should not change. I don’t like the idea of robot
doctors. There is already long-distance surgery, with a surgeon
from New York operating on a patient in China, using robotics.
The technical part of medicine will change and is changing, but
there are certain things that will never change.

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The doctor-patient relationship has changed significantly in the

past 10 to 15 years, primarily because of managed care. The
loyalty of a patient to a physician has changed because every
time a patient’s insurance changes, he or she has to change
physicians. A long relationship of 30 or 40 years between
patients and doctors is rare. Doctors also sometimes cannot be
loyal to their patients because, for one reason or another, the
doctor may decide to stop accepting the type of insurance a
patient uses, which will cause a patient to have to change
physicians. In that respect the relationship has changed
significantly for the worse. This can frustrate the doctor, in the
sense that he or she has lost the freedom to refer patients to
physicians who are reliable and responsible. Instead, he or she
has to use the managed-care “yellow pages” to make a referral.
The process is time-consuming for the physician, and he or she
will not get the same results or response as from someone the
physician knows personally. The patient-doctor-office
relationship has become much more difficult, and there is much
frustration on all sides.

Managed care has taken away the dollars from the hospitals and
the physicians to put them in the pockets of investors and
managers. It has not added much to satisfy the patient or the
physician. However, the idea of being able to use preventive
medicine is fantastic, and managed care seems to implement this
practice more than the old type of insurance. Preventive
medicine is something we should be looking forward to in the
future, especially since we know there are so many ways to
prolong life – and I mean by that the quality of life, not the
number of years.

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The principle of managed care was, in theory, very good, but in

practice it’s outrageous. Some managed-care companies –
especially the capitated ones – encourage you to keep the patient
away from your office to make a buck. The selling point is that
you get a flat fee per month, whether you see the patient or not.
The flat fee does not cover any of the real costs, so you make
money by not seeing the patient. When I hear that, my hair just
stands up. It was a good way to control inflation in medicine, but
medicine, like education, is a field where inflation is difficult to
control, especially if you want to be in the forefront of the field.
You can’t be at the top in medicine and do the most research
without spending a lot of money. Something is definitely wrong
with the system; 40 million people are uninsured, and I think
that’s very wrong. .

I am familiar with other countries’ approaches to medicine, and I

don’t find them to be better. Sweden seems to have a perfect
system, but that’s primarily because of the homogeneity of their
society. It wouldn’t work like that in the heterogeneous society
of the United States. The stories I’ve heard about England, where
people over the age of 60 were not able to have dialysis because
60 was the cut-off age, are astonishing. In some countries you
have to wait six months to get a bypass, but you could go to a
private physician and get it done within 24 hours.

I think the medical system in America has worked best, but

unfortunately it’s being eroded and destroyed. Hospitals are
experiencing tremendous deficits, especially teaching
institutions, and that really curtails the possibility for training
scientists in medicine. The only hospitals in America that make

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money are for-profit private institutions, and those institutions

are not interested in research or development; they’re interested
in the bottom line. The crisis of the deficit of university centers
is going to impact the long-term research capabilities of this
country.

The Business of Medicine

As in any business, one starts from the premise that the patient
comes first. We have to cater to the patient in the best way we
can. I emphasize to my staff that they should sometimes put
themselves in the patient’s position. You have to be sensitive to
the anxiety of a patient who waits a long time on the phone with
no response, or who sits in the waiting area for a long time, or
whose phone call is not returned, or who is not treated with
respect. I instruct the people in my office that we’re not dealing
with a business in which, if you make a mistake on an order or a
shipment, it can be corrected. Here we are dealing with disease,
with life and death. The margin for error should be zero. That’s
not to say that we have not made errors, but luckily we’ve not
made any major mistakes. Any physician who has made no
errors or oversights is not practicing medicine. A surgeon once
told me, “If you’ve never taken a healthy appendix out of a
patient, you’ve never done surgery.” Nowadays, with
technology, these errors have been reduced (everyone gets a
CAT scan), but to take out a sick appendix, you have to take out
a few healthy ones.

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As in most professions, doctors need to be on top of new

developments in the field. I use as many media as possible.
Reading a newspaper gives you quick information on what’s
going on and will update you on new fields and technologies in
medicine. An internist has to gather a lot of information. The
newspaper is just a summary that provides quick motivation to
examine a current trend extensively. Journals such as the New
England Journal of Medicine or the Annals of Internal Medicine
have peer-reviewed articles that are very useful.

The Internet also provides a great deal of information about what

is going on. Every day there is health news online, describing
something new that is being discussed. That doesn’t mean you
should instantly believe in the new technologies or practices
described, but it makes you much more aware of what’s going
on. There’s a program, developed by a nephrologist, that covers
most of internal medicine, called Up to Date. Every three months
you get a new CD-ROM updating what’s going on in the
medical field. It’s a fantastic program that allows you to see
what’s happening currently. Textbooks are rather anachronistic
because once they are published, the data is three or four years
old. The Internet and monthly publications are very helpful in
providing volumes of useful information. Attending conferences
is also important because the information is being presented as
it’s being developed.

Many of us, considering the frustration we experience today,

might quickly say we would absolutely not recommend that our
children go into the practice of medicine. The profession is not
as lucrative as it once was; some physicians are barely making

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enough to cover their overhead. More important, I find the

current system humiliating in the sense that physicians
occasionally have to contact 800 numbers to seek approval for a
medication or a test from people who are completely ignorant of
medicine. I once received a call from a managed-care company
seeking justification for placing a patient in an intensive care
unit. They said the patient had sepsis and was in shock, and the
next question was, “Does the patient have an intravenous line?”
At that point you know you’re talking to someone who doesn’t
have any idea – you don’t get admitted to the intensive care unit
with sepsis and shock, and you don’t get an intravenous line, so
obviously they had a form to fill in to justify the placement.

Even having said that, I think I would still encourage my

children to study medicine because the gratification and the
intellectual motivation are beyond understanding. You have to
be there to understand it. Again, though, I would encourage
people to go into medicine only if they really have the passion
and the devotion for it. It’s not a profession you can do halfway.

If you can satisfy your personal life with your family and
interests other than medicine, then you will be able to bring
satisfaction and pleasure into the practice of medicine. Every
individual makes of their own profession whatever they want;
some people who are workaholics feel that working 24 hours of
medicine is what gives them pleasure and satisfaction. That’s
fine, but personally I find that family is very important, and I like
to spend a lot of time with my family. I also like to do charity
work to complement medicine and give myself personal
satisfaction. I think the profession of medicine is the most

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rewarding of all professions, in terms of the amount of gratitude

from patients. A card from a patient, a note saying you’ve done
something well, hearing from a patient that you’ve saved their
life – there couldn’t be any more personal gratification.

Medicine is by far one of the most intellectually stimulating

careers because you have to keep studying, reading, and
attending conferences on a constant basis to keep up with the
rapid changes in technology. The intellectual stimulation and
motivation are incredible. Not having practiced any other
profession, I cannot say that it doesn’t exist in other professions,
but I think that when you’re dealing with human suffering, pain,
and anxiety, being able to help someone gives you tremendous
personal satisfaction.

The Golden Rules of Being a Doctor

1. Use discretion. As a doctor, you deal with very sensitive

information about individuals, and in many respects you
have to practice complete discretion and privacy about what
you say, where you say it, and how you say it, because you
never know who you’re talking to and who would find out
something.
2. Be respectful to patients. Be sensitive to their needs,
feelings, and emotions.
3. Recognize that you are only human. People will always lack
information and make mistakes. Do your best, and when you
hit a wall, ask for help and advice from other people.
Recognizing your shortcomings doesn’t minimize you. On

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the contrary, it lets you practice better medicine, learn from

other people, and, most important, help the patient.

Arturo Constantiner, M.D., F.A.C.P., is the director of

Nephrology and Dialysis at New York Downtown Hospital and
associate professor of Clinical Medicine at New York University.
He is also in private practice in internal medicine and
nephrology, with special interest in hypertension and kidney
stones.

Dr. Constantiner is a member of the American Society of

Nephrology, the International Society of Nephrology, and the
New York Society of Nephrology, and is an Honorary New York
City Police Surgeon. He is a member of the Board of Governors
of Tel Aviv University and a member of the American Friends of
the Tel Aviv Sourasky Medical Center.

Born in Mexico City, Dr. Constantiner graduated from the

Faculty of Medicine, National University of Mexico. He did post-
graduate training in internal medicine at Elmhurst Hospital in
New York and a fellowship in nephrology at Mt. Sinai Hospital
in New York.

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A RELATIONSHIP THAT WORKS:

THE DOCTOR-PATIENT
PARTNERSHIP

MARTHA S. GRAYSON, M.D.

New York Medical College

Senior Associate Dean for Primary Care

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Defining the Art and Science of Medicine

The art of medicine lies in the ability of the physician to

individualize patient care. The physician must evaluate the
patient’s medical condition, his or her beliefs, and his
preferences for how things should be done. The physician may
have two patients with the same disease, but use totally different
methods in treating them. There is also an art to communicating
with patients. Some physicians are natural communicators, while
others gain this skill with experience. There has been significant
research into the art of communication – what works and what
doesn’t.

The science of medicine involves, first, taking an accurate and

objective medical history, followed by a thorough physical
examination and, second, knowing how to evaluate information
obtained from this assessment and any diagnostic tests. As a
doctor, and especially as a primary care physician who takes care
of patients with a wide range of medical problems, I cannot
reasonably know about every possible diagnostic test or therapy.
But, as a scientist, I must know where to find accurate and
reliable information, and how to make sound judgments based on
the information obtained. Medical schools now acknowledge the
importance of this aspect of medicine – it is called “evidence-
based medicine.” We teach our students early in their medical
careers how to obtain and evaluate medical information on
prognosis, diagnostic tools, and therapies.

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How to Be a Successful Doctor

There are a number of qualities important to being a successful

doctor. Certainly, strong interpersonal skills, such as compassion
and respect, are critical. A successful physician must be able to
look at the many factors that determine how a patient relates to
both health and disease, including the patient’s culture,
background, spiritual beliefs, family relationships, and
community. Again, communication skills are critical. The
physician needs to explain things clearly. He has to be attuned to
the individual’s level of understanding about a certain disease or
a treatment, and try to communicate at that level.

It’s also very important to have strong analytical skills. A doctor

cannot think only in terms of black and white; he or she must be
comfortable looking at things in different ways and noticing the
shades of gray. Another important requirement for success is
staying current in one’s field. So a certain amount of curiosity
and a desire to continue to learn are important. It is imperative
that a good doctor follows his or her vision, acts in a professional
manner, honors confidentiality, and is kind.

I also believe that a doctor should serve as a role model for

healthy lifestyles. I sometimes share tips with patients on how I
fit exercise into my daily routine, or remember to take calcium
during the day. They appreciate the pointers and like that I
practice what I preach. Sometimes as I am walking into the
hospital, I see doctors or nurses smoking cigarettes outside the
entrance door. This sends a terrible message to our patients. If a
health professional is unable to serve as a role model for healthy

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lifestyles, he or she should, at the very least, not publicly flaunt

dangerous or unhealthy behavior!

Setting goals and having a timeline are important. It is useful to

review your goals and examine what you have accomplished. It
may help to make a one-, five-, or even 10-year plan, bearing in
mind that none of us can perfectly foresee or control the future.
In my profession, working for both a hospital and a medical
school, this is a little easier because there are annual reviews that
other physicians do of me and I do of others. If I have grants,
progress reports, or annual reports to write, I often discuss the
goals I have and how I have worked toward them. My personal
goals often involve exploring things that are new or different, so
I will look at an area that I may want to learn more about. For
example, this year I did a leadership fellowship for women in
academic medicine, and I learned a great deal about
organizational, administrative, and financial skills, areas that are
important at this point in my career.

I rely heavily on scheduling; I use the calendar on my personal

digital assistant (PDA) for both professional and personal
activities. By having my outside interests scheduled in along
with my duties as a physician, I keep some time in my life for
these activities. Making plans is important to ensure that I have
time outside of work, because in medicine, there can always be
more to do. I think it’s also very important to have a strong
coverage system, so I can be comfortable with whoever is
treating my patients while I’m away. Additionally, in academic
medicine I need coverage for my teaching programs and
administrative roles, as well. I need to feel just as comfortable

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with my coverage for these aspects of my professional life as

with the coverage arrangement for my patients. It’s really
important to take appropriate vacation time. In my position I
have a certain number of weeks off each year. After a vacation I
come back refreshed, rejuvenated, and once again ready to work.

There is no one way to learn how to be a competent doctor, but

there are a lot of new and interesting ways to train our medical
students and residents. One innovative approach involves using
what is called standardized patients. An actor plays the role of a
patient with a certain disease, and the student or resident does the
interview. The actor has a checklist of things the student is
supposed to do. He gives the student feedback by saying, “You
forgot to listen to my heart,” or “You put the stethoscope in the
wrong place,” or “You forgot to ask a key question.” It’s a role-
playing approach to learning how to have a patient encounter,
how to take a history, and how to conduct a physical exam.

There are many interesting computerized programs, as well, to

complement the standard textbooks. For example, using cases
from a computerized program, a student might order a specific
test and receive immediate feedback from the program as to
whether that test was appropriate. Such a program allows the
student to try out and test what he or she learned from a lecture
or from reading a textbook.

Further along in training, a student must determine not only the

field of medicine he would like to enter, but also the type of
career he would like to pursue. There are so many specialties to
choose from, from the primary care physician to the super

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subspecialist. In addition, a doctor can take on so many different

roles, including being a clinician, a teacher, a researcher, an
administrator, or some combination. Once the new doctor
decides on his role, he must determine how to gain the necessary
skills to become that type of doctor. For instance, if he wants to
have his own practice, he may need to learn how to run an office
or develop some business skills. This may call for courses in
practice management or a business education. If he wants to
pursue academic medicine, he needs to learn more about
research or teaching. There are a variety of fellowships and
programs to help obtain these skills. In making a career choice it
often helps to speak with someone in a similar position, or a
mentor.

What separates a “good” doctor from a “great” doctor is that the

great doctor sees his profession not as a job or a career, but as a
calling. What he or she does in the world is viewed as a mission,
or a vision. I think the really great doctors that I know – whether
researchers, physicians, teachers, clinicians, or some
combination of these – want to make a difference.

I respect doctors who are kind, dedicated, knowledgeable, and

organized, and who really see patients for the individuals they
are. No two patients are alike, even if they have the same
disease. I’m also impressed with the doctors who, in addition to
seeing patients (and especially if they’re in a full-time practice),
contribute to the training of other doctors, medical students, and
residents. At my medical school, we have a whole cadre of
physicians – hundreds – who volunteer their time training young
medical students in their offices. I think it is admirable that, as

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busy as they are, they volunteer their time to do that. As it turns

out, they get something in return. I’ve studied the effects on the
mentoring physicians, and I’ve found they actually enjoy the
practice of medicine more when they have an inquisitive mind in
their office asking them questions.

Some practical advice that’s been useful to me is to avoid acting

as a doctor for family and close friends. A doctor needs a certain
amount of objectivity to provide the best care. At the same time,
when I see patients I often think, “How would I treat this person
if he or she were a family member?”

I advise others not to use medical jargon when speaking with

their patients. When working with patients, I also write things
down as much as possible. Patients frequently forget many of the
things said to them, so even if it’s something as simple as the
type of over-the-counter pain reliever I prescribe for them, I’ll
write that information down as a reminder. I like to individualize
what I do with my patients and check on their understanding.
When we talk about something the patient should do, taking
medicine for example, I try to determine if they agree with this
approach. Will they really take this medicine? It is important to
understand their reaction and how receptive they are to what we
are discussing, rather than just telling them to do something.

The Challenges of Being a Doctor

I wish it were possible to create a pill that, when swallowed by

the patient, would make them automatically follow a healthy

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lifestyle. My “miracle drug” would get my patients eating right,

exercising, avoiding tobacco, and wearing their seatbelts. With
regular use of my “drug,” the number and severity of the
diseases they might develop would be greatly reduced. That is
my fantasy!

But, getting back to reality, one of the major challenges in

medicine, particularly for a physician in primary care, is keeping
up with the steady stream of new information. Sometimes I feel
overwhelmed. But in reality it isn’t necessary to know
everything. I can always talk with other physicians or gather
necessary information as a case arises. If I have questions about
the care of a patient, I speak with colleagues, look things up, use
the Internet, look in my books – I use many resources. In
medicine we have to accept the fact that nothing stands still.
Everything changes, and we have to be comfortable with that
and devise a strategy to keep up with ongoing change. Teaching,
more than anything else, keeps me up to date in my field. The
academic side of my career motivates me to stay current and
ultimately helps me with patient care. So I am always developing
programs or looking up information for my students. I recently
took over the directorship of our course on teaching clinical
skills, and that has forced me to review all the skills required for
performing correct physical exams.

Keeping up-to-date doesn’t necessarily mean waiting for a

journal to come out – although I do like to see what is being
printed in the news, because patients ask about the things they
read in the newspapers. I do extensive research for the
educational programs I run, and I research issues related to my

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patients. There are a number of books online that are constantly

updated and special programs that analyze and update the
literature on selected topics. For example, if a patient is traveling
through a country where certain infectious diseases occur,
having an online site that is constantly updated is very useful. If
there were a sudden outbreak of an infectious disease there, I
would know about it right away.

More recently, the economics of healthcare have become a

challenge for me. Recent developments have brought us new
medical technologies and medications, but all of them come at a
price. There are a growing number of uninsured people in the
United States, and an increasing number of people who are
having a difficult time paying for the medications they need.
Another concern is the ever-increasing amount of administrative
tasks and paperwork. This adds to the time and cost of caring for
a patient.

Any doctor you speak to now will tell you he or she is much
more overworked than in the past. The causes are fewer
healthcare resources and changes in financing. Physicians who
practice full time find it necessary to see more patients, and for
briefer appointments. In the academic world physicians who
both teach and see patients are spending more time in clinical
work to generate the revenues to support their academic work.
They also spend more time trying to get grants to support
themselves.

One of the challenges in academic medicine is to make certain

physicians still have enough time for the training of the next

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generation of doctors. The knowledge base of our physicians has

vastly increased, not just in terms of new technology, but also in
the understanding of patients and how to relate to them. We need
time to teach all this.

One of the challenges that all doctors face is dealing with a

terminally ill patient. How much information should the doctor
give to the patient? Is blunt talk in order, or is false reassurance
better? I try to take my cue from listening to the patient and
talking with the family.

Changes in the Medical Profession

The role of the doctor has changed in a variety of ways.

Computers have revolutionized the way we get information.
Medical records, laboratory results, and x-rays are available
electronically in an increasing number of hospitals and doctors’
offices. It is enormously helpful to use the Internet and have
computerized texts and journals available to both doctors and
patients. In addition, regulations have had a major impact on
both the way we practice medicine and the way we train our
future doctors.

Another change is that alternative, or complementary, medicine

has become more mainstream, and physicians are now more apt
to recommend it. Many doctors and patients choose acupuncture
or massage therapy, for example, to complement traditional
medical therapies.

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In addition, more and more patients are taking an increasingly

active role in their healthcare. They research their symptoms
before coming to the doctor and seek multiple opinions. It is a
welcome trend, beneficial to both the patient and the doctor.

I practice in New York City, so I am not sure how much I can

generalize, but there also seem to be more patients with fewer
family members and less personal support. I see elderly people
without anyone to visit them in the hospital or take them home
when they are discharged. And many people are isolated, lacking
the important family and personal support structures people had
in the past. We need to come up with new ways to care for those
who do not have the social or family support in their lives to help
them when they are ill.

In the next few years I think we’ll see a continuation of several

recent changes in the field. For instance – going back to
computers and the Internet – I am personally trying to improve
my skills at using information technology and am constantly
seeking advice on how to use new medical programs for both the
computer and the PDA. We are now able to carry large amounts
of medical information on our PDAs, ranging from dosages, side
effects, and interactions of medications, to a listing of our
patients’ diagnoses, allergies, and appointments. The portability
of this information will also lead to new rules and regulations
about protection of patient confidentiality.

Within the next few years we should be able to have access to an

expert in any area of medicine with the help of the Internet.
Some areas of the country are already using telemedicine to

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allow patients in small towns to be evaluated by a specialist in a

large urban center on the other side of the country. For instance,
you can hook up a stethoscope to a computer that sends heart
sounds to a cardiologist at a distant site, or you can have a local
doctor look into the ear of his patient and send that image to a
head and neck specialist for evaluation. At this point it is just a
matter of learning how to use and become comfortable with
these diagnostic tools and technologies.

We will continue to see miraculous strides in patient care with

new medications, advanced treatments for diseases, transplants,
artificial organs, and so on. We will continue to see state-of-the-
art drugs and treatments. I think genetics will also play a bigger
role in the future. We will be able to identify patients who are at
risk for certain diseases, and improve our counseling and
preventive therapies.

On the flip side, all of this new and improved technology

challenges us with the question of finance. These advancements
inevitably have a cost, and we will have to determine what
resources are available for healthcare and how much we are
willing to pay. Unfortunately, one can predict that the number of
uninsured, the number who lack appropriate access to healthcare
and medications, will continue to grow. Our nation will need to
address this issue so all individuals can have access to
healthcare. Facing the challenge of allocating healthcare
resources will be difficult. We will have to make difficult
choices about what medical care can be provided and what may
need to be curtailed. A large portion of our healthcare dollars are
spent during the last six months of a patient’s life. We will need

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to examine what we are doing for our patients who are at the end
of their lives, and redirect our energies and resources toward
providing pain management and comfort.

Finally, patients will take even more control over their

healthcare, because they will have access to so much more
information. The old paternalistic role of the doctor will become
passé. We will find a much more active, inquisitive type of
patient who will want to play a major role in healthcare
decisions. The doctor and the patient will become true partners.

The Golden Rules of Being a Doctor

1. The Hippocratic Oath (truly the Golden Rule): Do no harm.

2. Respect your patients.
3. Be honest; practice with integrity.
4. Serve as an advocate for your patients.
5. Have concern and compassion.
6. Be a life-long learner.
7. Be an educator.
8. Make a difference!

Martha S. Grayson, M.D., graduated from Tufts University and

earned her medical degree from the Albert Einstein College of
Medicine. She completed her training in Internal Medicine
through the Social Medicine Residency Program at Montefiore
Hospital and Medical Center in the Bronx, New York. In
addition, Dr. Grayson completed a Primary Care Faculty

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Development Fellowship sponsored by Michigan State

University and the Executive Leadership in Academic Medicine
Fellowship for Women sponsored by MCP-Hahnemann
University School of Medicine.

Dr. Grayson has been in academic medicine throughout her

career. She is currently the Senior Associate Dean for Primary
Care and Director of the Center for Primary Care Education
and Research, as well as associate professor of Clinical
Medicine, all at New York Medical College. She has served as
both a course director and a teacher for a number of educational
programs for both medical students and residents, and has been
the principal investigator for numerous educational grants. Dr.
Grayson has published research on the effectiveness of these
teaching programs in national medical journals, including
Academic Medicine and the Journal of General Internal
Medicine.

Dr. Grayson is a practicing General Internist and serves as the

Chief of the Section of General Internal Medicine at Saint
Vincent’s Hospital and Medical Center in New York City. She
has been selected in listings of top primary care physicians in
the Castle Connelly Guide of Top Doctors, New York magazine,
and Town and Country magazine. She has been selected a
Fellow of the American College of Physicians and has served as
the elected president of both the New York City Metropolitan and
the Mid-Atlantic Regional Division of the Society of General
Internal Medicine.

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MEDICINE: EMERGENCY ROOM,

LOCKER ROOM, BOARDROOM

NICHOLAS A. DINUBILE, M.D.

Hospital of the University of
Pennsylvania

Department of Orthopaedic Surgery

Clinical Assistant Professor

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Sports Medicine Calling

For as long as I can remember, I always wanted to be a doctor,

specifically, a surgeon. My athletic background and my early
interest in fitness and exercise pointed me in the direction of the
care of athletes. In the late 1970s I saw sports medicine as an
amazing new emerging field of medicine. However, when you
first start out in practice, you don’t necessarily pick and choose
what you do; you do a little of everything. I initially did what
general orthopedic surgeons do: a lot of trauma and emergency
room calls, which involved taking care of broken hips, broken
necks, and any number of injuries. Over time, as you develop a
reputation and a name, you can focus on what you want to do.

Some people stay generalists for their whole career, but I always
had a goal in mind of being very focused on athletes and active
people. Part of that drive comes from a very strong parallel
interest I have in exercise, fitness, wellness, and prevention.
Those interests don’t necessarily jive with the crux of what a
surgeon is; during my surgical training and in medical school,
we were always taught to wait until things break and then fix
them. But even before it was in vogue, I was oriented toward
prevention, which is fairly unusual for a surgeon. I always had
an interest in exercise and taking better care of oneself, and I did
a lot of writing and speaking on those subjects early on.

The reason I love sports medicine is that it allows you to

combine these interests – you deal with extremely motivated,
active people who want to keep going at high levels, even if they
get injured or have problems. I found ways to combine all of

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those interests in one specialty, and I think over time I evolved

into also being a knee surgeon, but I also do a lot of educational
work nationwide in the area of exercise and wellness.

Early on, when I was in my training as a resident, I started

working with the dancers here in Philadelphia – the
Pennsylvania Ballet – and when I went into private practice, I
became their orthopedic consultant; I’ve done that for 20 years.
Dancers are incredible athletes, and working with them has
opened my mind tremendously because they were in tune with a
lot of innovative body work that I thought had application to
other athletes. They were doing Pilates in the early 1980s,
talking about the benefits of massage, and even acupuncture –
alternative medicine before it had a name.

When I was a resident, everyone said, “Don’t work with dancers.

Don’t ever take a dancer as a patient – they’re crazy. Don’t ever
operate on a dancer.” I can’t say how many times I heard that,
and I found just the opposite to be true. I found that if you spend
the time to let them know you care about their craft and their
sport, or their art – whatever you want to call it – and let them
know you aren’t going to tell them to stop doing it, and that you
are going to find ways to keep them going, and if they trust you,
they are a tremendous group to work with. Even now, I’ve found
dancers are the most appreciative athletes I work with. They are
the smartest; they want to learn more about their bodies; they are
interested in prevention; and they have a natural inclination in
that direction. From students in dance class to professionals all
over the country – even advising Rudolph Nureyev on a foot
problem – I’ve found this to be true.

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Zebras and Creativity

There’s no question that being a doctor is both an art and a

science. In terms of direct patient care, not everything is black
and white in science, though we’d like to believe it is. If you
read about a certain condition in a medical school textbook, you
may assume that’s what will present itself every time, but I
would say there are more zebras than straightforward black and
white situations out there. You have to have a sixth sense; you
have to have intuition; and you need to be a bit of a detective.
The art is also in communication with patients; if you don’t fine-
tune that aspect of listening and reading between the lines –
between what somebody is saying and what their concerns and
fears really are – I don’t think you’ll be as effective as you can
be.

In terms of direct patient care, I think the art is a matter of

realizing there will be times when you need to use guesswork
and intuition. Hopefully, you will use intelligent guesswork that
is driven by your underlying scientific training.

On the other side, creativity is required to innovate. That’s not

present in direct, one-patient-at-a-time patient care, but it is
when you write and try to look at things differently. When I was
at Penn, I spent a year researching articular cartilage, which is
the surface of joints. We had a chairman who was very excited
about research, who said, if you can have one original thought in
your life, you’re way ahead of the vast majority of people. I
think I’ve had several original thoughts. Many people can be
presented with the same information, but you have to see it

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differently from everyone else, and that’s a creative process. I

also like to write; I am working on a new book titled Body Built
To Last, which will be more for the lay public, and I think it will
be very innovative in some of its concepts. It will certainly break
new ground. I don’t want to write a book that’s already been
written; I want to do something different. I’m always pushing
myself that way.

An example of creativity is that I coined a term a few years ago

called “boomeritis,” which made national media – just about
every TV show and every newspaper, from The New York Times,
The Washington Post, and the Los Angeles Times to CNN,
picked up on this, and they continue to use it. I do one or two
interviews a week on “boomeritis.” Basically, it was just
thinking a little more deeply about baby boomers and their aches
and their pains, and why that’s happening, and how it’s a really
new phenomenon, and just coming up with a creative, cute name
that stuck. The more I thought about it, the more I wanted to
write about it, so now I’m writing a book that covers more
ground on what happens not only to baby boomers, but to
anyone, young or old, who has had their frame fail on them. It’s
about the “weak links” we all have, or develop, and how to
navigate them on the road to staying healthy.

There are always opportunities for creativity. I served on the

President’s Council on Physical Fitness and Sports under Arnold
Schwarzenegger during the first Bush administration. I was a
Special Advisor and medical consultant. Way back then – and I
don’t think this was my unique idea, but the way I developed it
was unique – I helped develop and pioneer the concept of

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“exercise as medicine.” That is, doctors need to look at exercise

the way they would any pharmaceutical product, because of its
powerful effects on the body. We recommended teaching it in
medical school, and I can remember writing very creatively,
many times, on that topic, just trying to get people to think a
little bit differently about something so obvious.

The science side is every bit as important. With evidence-based

medicine, you have to be vigilant about looking at studies and
determining what is correct and what isn’t. You can’t just go on
intuition or say, “This is how we’ve always done it, so this is
how we’ll keep doing it.” You have to listen to science, but
realize science isn’t always right. You need well-designed
studies, and you need them to be repeated, flawlessly and
without bias. You have to always understand that scientific
process. It helped that I spent time in a research lab, where I
learned to critically analyze research and studies – to determine
what is and what is not a good study, to know what needs to be
repeated, and to know how you make a study better – and then
learn to apply that information to direct patient care.

Science actually should drive everything you do. Even though I

am open-minded – more so than the average orthopedic surgeon
in terms of alternative medicine, chiropractic care, and other
nontraditional interventions – that does not mean that at some
point those alternative techniques should not be proved
scientifically. If you take care of patients and make
recommendations, at some point you have to look critically at
what’s being done and be willing to talk to patients about it.
Every week, it seems, some new study is coming out that denies

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what was said the week before, but when the evidence starts
becoming very clear, and the science gets strong, you really need
to adjust what you’re doing – but always stay tuned. George
Bernard Shaw once said, “Science becomes dangerous when it
imagines that it has reached its goal.” Medicine should always
strive to be a more perfect science.

Defining Success as a Doctor

Success depends on the specialty you choose; in some specialties

in medicine, you never come face-to-face with a patient. For a
pathologist, for example, many of your patients are no longer
living, and there is little if any direct patient care, so I don’t
know that you need great interpersonal communication skills in
that setting. But for doctors who work with patients – and that’s
the majority of us – success comes only with a caring attitude.

You have to care; you have to be willing to work very hard and
put your profession and your patients first. Fame and success,
especially as a surgeon, come to a doctor who knows how to
communicate. The word “doctor” comes from a Latin word that
means, “teacher,” and I think a doctor is a teacher first. I come
from a family of teachers, and I think that’s where I may have
picked up some of those skills. It’s not something you learn in
medical school; you either have it, or you don’t. You can always
improve it, but some people are just more natural. You need that
combination of communication skills and, obviously, the
technical side. You can’t just talk a good game; you also have to
be, as a surgeon, very good technically. My area of expertise,

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arthroscopic knee surgery, requires an almost video-game

mentality and agility with good 3-D skills. But if you can put
those two things, the interpersonal and the technical, together I
think you’ll be one of those standout doctors, or what they call
the best.

Because my practice is so specific in terms of the surgery I do

(i.e., knee surgery and arthroscopic surgery), half the patients
who call my office wind up having me refer them to someone
else. People trust me; I get calls from people from around the
country asking me for advice on whom they should see for
certain orthopedic or even medical conditions.

Whenever I recommend a doctor – whether it’s an orthopedic

surgeon, an internist, or any other kind of surgeon – for me to
give a strong recommendation I need to see two qualities in a
doctor. They have to be knowledgeable and technically very
good as a surgeon – that’s a given, but it’s only one side of the
coin. Before I recommend them highly I also want to know they
will treat that person nicely in the office. That goes beyond just
face-to-face communication – they need to be considerate,
caring, and professional. I want a doctor who’s not going to have
people sitting around for two or three hours and not spend time
with them, not look them in the eye, not answer all their
questions, and be too rushed. That’s a challenge for all of us in
today’s managed care–driven healthcare environment, but I still
think it can be done. I look for knowledge and technical skills,
but I also want them to treat people nicely, as they would a
member of their own family or a loved one.

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Sometimes I’ll tell a patient, “Look, I know this individual is a

great surgeon, but I don’t know how well he’s going to treat
you,” so I don’t give him the big two thumbs-up; I just give him
one thumb-up. There are times when that might not matter; if
you have a brain tumor and you want the best brain surgeon, for
example, I would say, “Don’t look for this guy to be your best
friend, but take his technical expertise.” In some instances you
don’t need that best friend, but I think any time you are ill, a
little hand-holding and compassion can go a long way. I believe
it influences the healing process, patient satisfaction, and
ultimately your outcomes.

I believe you can influence your patient’s attitude, and I believe

their attitude affects their healing and recovery. The more you
talk to them up front, and the more their expectations are set
properly about what will happen and what degree of success they
can expect to have after a surgery or other intervention, the more
likely they will be a happier patient afterward. I think outcomes
are fueled by patient expectations, and I think that’s one place
where doctors don’t do the best job. Some doctors don’t spend
the time to let people know what to expect, so no matter how
well the patient seems, even if the doctor says they’re doing
great, if they are not doing as well as they thought they would,
they will not be happy.

The best advice for doctors is to put the patient first. I try to treat
a patient as I would if he or she were one of my relatives – my
mother, my sister, a best friend. Quite often you see surgeons
who do a certain kind of surgery, but when their own relatives
get sick, they don’t necessarily recommend it right away; they

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have a double standard. I try to treat everybody well, and I try

not to necessarily act in terms of what’s best for me
economically. With many patients it’s like a friendship that you
develop over the years, where they really trust you. I make my
living doing surgery, so when I talk patients out of surgery, they
are somewhat surprised, but there’s a level of trust that comes
right away.

In terms of being a successful surgeon, one of my teachers gave

me a different kind of advice that I have found to be very true
but not often taught: “When you’re in your training, you learn
how to operate. Afterward, with a little bit of experience, you
learn when to operate, which is the indication of whether you’re
using the right surgery at the right time.” It’s not just a matter of
whether you can technically do it; it’s really about making the
decision when it is appropriate.

“With experience, you learn the most important thing, which is

when not to operate.” That takes a bit of a learning curve,
because when you’re finished with medical school and your
residency, you’re very enthusiastic, and you think you can cure
everybody with your talent and your knife. At that point you
have to realize there are some things you’re probably better off
not meddling with, that you actually can make people worse, and
that complications can affect the suitability of surgery. Unless
you’re clear that the odds are very heavily in favor of
tremendously helping someone, then maybe you’re better off
passing on it, even if they’re looking for surgery. Many patients
come in looking for more surgery, and it’s not easy to sit down
with them and say no, because you know some of these patients

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will go to one of your colleagues and get the surgery anyway. It

takes restraint, but if you put the patient first, the decision-
making gets easier

Balancing Personal and Professional Lives

Unfortunately, I may not have done the best job in balancing my

personal and professional lives. I grew up in a house on Broad
Street, the busiest street in downtown Philadelphia, and my uncle
was an orthopedic surgeon named Frank Mattei. We had a three-
story brownstone, and his office was on our first floor, so there
was a doctor in my home where I grew up, and I interacted with
him, and he influenced me tremendously. Maybe directly or
indirectly, I learned some things there. I saw a guy who worked
day and night, who worked endlessly, who put his career before
anything else. To me it was very exciting back then, that he’d
have to go out in the middle of the night all the time and take
care of people who were badly injured. He helped so many
people. These days I would cringe if I had to do that every night!
But at that time in my life, it motivated me.

Your reasons for becoming a doctor change as you stay with it; I
have different reasons now for loving it. Interestingly, the things
that drew me to the profession originally are not the things that
make me love it now. I think I realized through my uncle what
kind of commitment a career in medicine took. I knew from the
start that I would have to wait until I was really set in medicine
and when I was really the best I could be, before I could put
anything like marriage first. Unlike a lot of my friends who got

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married early and had a lot of struggles balancing a family and a

marriage with a more-than-full-time profession like medicine, I
waited until I was in my forties to get married. I just turned 50,
and I am blessed with wonderful children whom I can put first,
because I’m established and I’m not running out every night for
a meeting or in the middle of the night with emergency calls; I
really can devote my time to them.

But short of them, I really think my own personal life outside of

my family does suffer. I have very little leisure time outside of
my family, and the little leisure time I have I put to working out,
exercising, and staying healthy. I spend hardly any time with my
friends, and that is something I really need to work on. In the
past I skied and played tennis, but I’ve found there’s only so
much room, and if you want to be the best in your field and a
great family person, that creates a challenge for your other
personal needs.

During the 76ers basketball season, things really get tight in

terms of time. Caring for pro athletes is a major commitment. So
I try to find ways to do the things I like with my family, and that
becomes my fun stuff. Again, you try to figure out ways to do it,
but in my instance, focusing 100 percent on my career early on,
before marriage, was a wise choice. My family can now be my
number one priority. What gets me into trouble is that I don’t
just see patients, teach, and have my family; I have many outside
interests, and I do a lot of media-related work – TV, print, and
Web. I would say I’m one of the few most quoted doctors in
America, if not the most quoted doctor in America. I do three or
four major media interviews a week. A lot of that is because I am

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interested in educating the public, and I’ve developed a good

name for that with the press. That takes a different set of
communication skills and a real understanding and sensitivity to
the reporters’ needs and deadlines. I get calls all the time from
national sources, and I find it very rewarding to help influence so
many people. The power of the media for health is really
untapped, and I think we are entering a new era with the Internet.
I also like to write, so it gets tough – there’s certainly not enough
time and way too many time vampires. I wish the days were
longer, or I didn’t need to sleep.

Staying on Top of the Game

Staying on top of medicine is a never-ending process. I trained in

a very academic, high-intensity program at the University of
Pennsylvania. The orthopedic program there is one of the
highest-ranked programs in the world, and I can tell you that
within a few years of finishing there, we were no longer
practicing the same things I learned in my residency. There are
always new things, and you have to be vigilant about what you
need to read and about learning new techniques, technology, and
information, especially in your own specialty.

I also try to keep a broader perspective, not only across my

specialty but also in other areas of medicine and general health; I
try to keep up with what’s going on. Of course, it’s impossible to
be a true expert on everything. That’s why I think being a
specialist or a subspecialist is positive in that I can know
everything in my field. There’s virtually nothing I’m not current

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on regarding the knee, and I can embrace even new technology

as it is emerging, and I can understand it and build on what I’ve
already learned. It is a building process; technology evolves and
gets better, but you don’t have to necessarily throw out your old
knowledge; you change it slightly, modify it, and add to it.
Staying current, if you do it regularly, is not a painful process.
It’s really an exciting process.

In many instances I feel I’ve contributed to medicine from a

creative standpoint. I enjoy innovating and looking to the future.
I consider myself a very creative person; I came into medicine
always wondering if I would miss the other things I loved in life,
which were music, writing, and the arts. But I think I’ve found
some ways to include the creativity in what I do as a physician. I
don’t think all physicians can say that, but I think I’ve found
ways to blend that.

Orthopedic surgery is one of the most exciting fields to be in

right now because of the technology explosion. Tremendous
things are happening now or are around the corner. The future is
very bright in our field, and it’s very exciting. That’s one of the
things that motivate you to keep going when the day-to-day work
can get pretty tough and sometimes frustrating. In my field,
especially in knee surgery, I think one of the things that we’re
just making breakthroughs in is that when your joints are
damaged, there’s never been a way to repair them. Even
Hippocrates said that when our articular cartilage – the surface of
your joints – is damaged, it will never repair; it will only
deteriorate. That was true until recently. We now have some new

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technology that allows us to actually grow cells and resurface

certain areas of joints that are damaged.

One thing that will evolve is repairing larger areas of damage,

which will allow us to treat – and possibly for the first time halt
or reverse – arthritis. In arthritis you have more general damage
throughout the area, not just in a focal area. The new technology,
whether it’s cell technology, such as growing your own
chondrocytes and transplanting them, or some of the genetic
therapy that’s out there, will dramatically alter the future
approach to musculoskeletal disorders and even the aging
process. New technologies in dealing with both joint surface
damage and tendon damage are unbelievably exciting areas in
orthopedics. There are new lubricants we’re putting into joints –
an area called viscosupplementation, for example. Synvisc is a
product you can use instead of injecting cortisone into the joints.
It’s a lubricant you can actually put into the joints and have
arthritic joints function more normally.

Researchers have actually come up with a disc prosthesis – an

artificial disc for back problems. Joint replacements are
becoming more and more sophisticated. We are doing major
knee ligament reconstructions thru the arthroscope with minimal
down-time and rapid recovery. Our field is exploding with
innovative technology.

When you look at the aging population, musculoskeletal care is a

major portion of their issues. Right now we spend a trillion
dollars on healthcare, and musculoskeletal care is 15 percent of
the healthcare dollar – that’s staggering. As our population ages

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that’s only going to increase. There will be more people with

arthritis, osteoporosis, tendon problems, and bad backs, so it will
be great to have more options for them. But it’s so much better if
you can prevent these things from happening.

With osteoporosis, it’s great that we have new drugs to build

bones in 70 year olds, but it really starts when you’re a teenager,
drinking milk and exercising. If you can go into your older years
with good bone stock, you won’t have problems. We have a
generation of kids coming up now that worry me because they’re
not taking care of themselves. They’re not taking calcium, and
they’re not exercising. At the national level we really need to
focus on ways to move people in the right direction in terms of
caring for themselves and employing preventive measures. We
haven’t been able to introduce these things in a widespread
enough manner that their effectiveness might allow us to need
less high-tech interventions down the line.

The Future of the Medical Profession

Yogi Berra once said, “The future isn’t what it used to be,” and
that is certainly true in healthcare. The power base that
physicians once had, and perhaps took for granted, has slipped
tremendously, and I believe medicine and the healthcare of our
nation will pay the price for that. I never thought doctors should
be deified, but I also believed that we are and must always be a
critical part of the bigger-picture decision-making process, and
that is no longer the case. It’s unfortunate because there is no
greater patient advocate in the whole process than the physician.

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I personally know of no harder working, more honest group than

physicians, but we as a whole have let things slip dramatically on
the administrative and business sides. The insurance companies
have taken much more control; the government has stepped in;
the hospitals have consolidated and formed large systems; and
they have all developed much more power, to the detriment of
the individual physician. Just looking back to Hillary Clinton and
her ambitious healthcare reform efforts, I do not believe there
was a single practicing physician on that panel, or at all involved
in that process. That says it all, in many ways. I do believe
healthcare is a team effort, but physicians need to re-assume
their role as captain of the team, not a bench player.

On the other hand, the whole system would come to a stop

without doctors, so we as physicians and our organizations that
represent us need to realize we do have tremendous power and
tremendous clout. We can’t be replaced by a robot or a computer
or the latest clinical guideline or pathway, where anybody can
figure out what to do for a given patient or ailment. At the same
time, we have to be smarter about how we use our power, and
we probably can then regain some of the ground we have lost.
Doctors must be willing to stand up for themselves and really
fight for what is right and what is fair. Unfortunately, that does
not happen too often. This power shift has also affected the
reimbursement side, because, as private practitioners in this
country, we’re still the most easily squeezed from an economic
standpoint, and I think that will happen further as we go into the
future. The little bit of control we got on healthcare spending in
the 1990s has now stopped, and we’re looking at double-digit
inflation in healthcare spending, which could be 17 to 18 percent

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of our GDP by 2010. I don’t think our government will allow

that to happen, and when they try to squeeze costs, doctors are
the easiest targets because insurance companies, hospitals, and
pharmaceutical companies are so powerful. That’s why we’ve
seen in the past five years that all of the increases in healthcare
spending have gone into insurance company profits, hospital
systems, or pharmaceutical companies; whereas physician
reimbursement has dropped a little more each year, while
overhead expenses continue to rise dramatically.

For example, because of the out-of-control legal system and

escalating jury awards, medical malpractice rates have soared to
such unaffordable levels that doctors are moving from certain
states or going out of business. I believe that if we do not
immediately tackle this problem on a national level, the high-
quality healthcare we have all come to take for granted will be in
jeopardy. There are so many pressures – I wish we could just
focus on caring for patients – it really would be better for
everyone involved. But those days are over.

In any industry, power shifts occur with time. In professional

sports at one point the owners have control, then all of a sudden
the athletes have the power. In movies and entertainment the big
studios were very powerful at one point, and then the power
shifted to the talent – the actors, actresses, and unions. Every
industry goes through this, and things will change – it’s just a
matter of riding things out. I believe many physicians felt we
were immune to these types of changes. Things should improve
over time, but I think things will get worse for physicians before
they get better.

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I think we will see more of a challenge, where more and more

people are trying to get profit from and take control of what we
as physicians do and take a little more power from the
physicians. Even though physicians earn maybe only 15 to 17
percent of the healthcare dollar, we actually control 80 percent of
it with our pens and with our recommendations, so through what
we order, how we write prescriptions, what tests we send people
for, and when we put patients in the hospital, we really still
control the healthcare spending, and we need to be more
accountable for it. That is an area where physicians need to step
up and assume more responsibility, both fiscally and from a
leadership perspective. That would be an important first step in
regaining control of an out-of-control situation. Government
pressure would decrease, and the role of managed care would be
questioned and decrease. I don’t think it will happen in the next
five years, but I hope that in the next 10 years we will find ways
to be more efficient with the limited resources we have.

In private practice right now, in my office, not a day goes by

when my decision-making ability is not questioned or stepped on
receptively by someone – usually someone without training in
my specialty. I will want to prescribe a drug or other remedy,
and they don’t cover it, or I need pre-authorization – it really is
very frustrating. I am not saying that some degree of it is not
warranted, because we as a profession, as doctors, have not been
able to be accountable and police ourselves – it’s not something
we were ever taught to do or expected to do in our training. We
were just trained to take care of patients and be knowledgeable
about patients; we never really knew the economic side or the
business side of it. That is changing, but for now someone else is

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stepping in to do it, though I believe it is not always in the best

interest of the patient. I hope we can step up and be more
accountable and look at our own colleagues and say, “You’re
doing too much of this; the success rates aren’t there.” We need
to look at outcomes, be able to really measure quality, and
reward quality.

I hope that a decade from now we will know who the better
doctors are and be able to reward them. I also hope we will find
the problem ones who are running up the costs by not doing
what’s right, or making the wrong decisions, and try to educate
them and make them better. If they can’t get better, then maybe
they shouldn’t be doing it. I take a rather hard stand on the issue,
but I would love to see quality rewarded, and no one really does
that now.

It’s easy to talk about quality – but much harder to accurately

measure it. For a decade I worked part time with the largest
healthcare insurer in the world, and I spent a lot of time thinking
about how you measure quality in my own specialty. It’s not that
sophisticated yet; it’s still primitive, but I have many ideas, using
emerging technology to really measure and improve quality, as
well as reduce medical error. With information systems,
physicians are getting better at collecting their data and
becoming more critical of their data. This is one of the positive
results of the revolution we’re going through right now; maybe
we’ll be more accountable, and maybe we’ll be better at using
information systems and monitoring what we’re doing, and
really looking at those best practices and rewarding them.

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The way things are going, we are spending almost a trillion

dollars on healthcare annually, and with inflation we can’t keep
doing that. There is tremendous waste in the system, and I’ll be
the first to admit that there is some unnecessary surgery,
unnecessary care, and unnecessary duplication of services just
because we’re not all on the same page. I believe this is changing
now in a positive direction. I am convinced that computers,
handhelds, and the Internet will play a huge role in the next
decade. They will become an integral part of the patient
encounter, like the stethoscope or prescription pad. Physicians do
embrace technology, but have not yet found effective ways to
bring it to the patient’s bedside or into the office setting to
improve patient care. Our workflow is so different from those of
other businesses that it has been a major challenge to incorporate
this technology. I hope to do some very creative things with my
Web site, drnick.com, which is dedicated to “keeping you
healthy in body, mind, and spirit” – again, finding creative ways
to improve people’s health.

Magic Bullet Fantasies

One thing I would do, if I could snap my fingers and create

whatever wonderful drug I would like, is create an immunization
to give to children that would prevent them from having any
disease or problem until they are well into adulthood. I have a
big soft spot for a child with an illness; it just touches me. I think
it’s unfair. I question everything when I see kids suffering from
unbelievable things like cancers or heart disease at young ages.
It’s unfair for them and impossible for their parents. Instead of a

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drug that would cure diseases, I would create that immunization

so that children could enjoy their youth without having to deal
with those awful issues.

For the second drug I would create, instead of a specific drug for
one particular ailment like cancer or heart disease, I would create
one that would slow down the aging process, because if we can
do that, science will do the rest. I firmly believe we’re on the
verge of a lot of great things in terms of maintaining and
repairing the human frame, so if we just keep people from falling
apart at a certain age, we could do a lot. People may be living
longer, but they are not necessarily living stronger.
Unfortunately, we become confined, less active, and less
independent. No one wants to live long if they’re not going to do
well. Dr. Ernst Wynder once said that it should be the function of
medicine to have people die young as late as possible. It’s not
enough just to make people live more years if those years are not
quality years. It’s also been said that we live too short and die
too long. If there were a pill that would slow down or halt the
aging process, science would catch up and find the other pills or
interventions for cancer, heart disease, and other diseases. Also,
in my own field, I would create a new drug that would reverse
arthritis and joint wear.

The Challenges of Being a Doctor

Many challenges face physicians today. From a management or

business standpoint, the current environment we’re working in is
a major challenge with managed care, the government, and just

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about everybody else trying to tell you, the physician, what to

do. It’s funny that the insurance companies want to be doctors,
and they want the doctors to assume the financial risks for the
care of the patients. That was managed care’s founding tenet –
you get paid a certain amount; you take care of a population; and
if you spend more caring for those individuals, you lose the
money. I think it’s very odd that they want us to be the actuaries
and the insurance companies, and they want to tell us what to do
from a medical standpoint.

I don’t think this arrangement is in the best interest of the

patient. I’d like to see it go back the other way, where doctors
are accountable, but they make the medical calls, and the
insurance companies use every ounce of business knowledge and
all of their information technology to write fiscally sound
policies and help monitor the quality and outcomes of the care
rendered with the goal of constantly improving the care
delivered.

If you leave an academic position or a salaried, large-group,

managed-care type of environment to start a private practice, you
need to be both smart and patient. You can’t build a private
practice overnight; you really have to put time into it. It is
especially tricky these days, where you see that the big insurers
have consolidated, and so have the hospitals and even many
medical practices. I don’t think it’s a guarantee that doctors by
themselves are going to do well – it’s just a scarier field out there
alone. I’m not sure I would wholeheartedly recommend it now,
unless you’re very unhappy in your group setting, and you have
a loyal group of patients and some funding for your private

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 Inside The Minds

practice. Most doctors coming out of medical school are in

tremendous debt. The residents I work with are $150,000 to
$200,000 in debt, some of them even more. Depending on what
city you go to, particularly as a specialist, you may face
extremely high malpractice rates your first year. It’s pretty scary
because you’ll probably have to take out even more loans and
possibly put up some collateral, and it’s not guaranteed that
you’ll make it. Now that’s not true of every area in the country,
but these are things doctors never had to think about before.

You used to be able to go wherever you’d like – in the city, in

the country, in an academic setting – and if you were good and
willing to work hard, you would do well. That’s not a given
anymore. I’ve seen it in my area, Philadelphia – one of the
national hotbeds for malpractice suits – even very top-notch
doctors are leaving. The economics are squeezing them; they
can’t get malpractice insurance, or they can’t make their
overhead, and I’m talking about the best of the best. I don’t think
we’ve ever seen this problem in medicine before. It’s a reality
that doctors will have to face until things improve.

Another challenge for patient care that I find personally in my

specialty is that you can’t fix or cure everything. Most of us
really want to do that, and I think the general public each year
has higher and higher expectations of what medicine can do for
them. They want to put the ball in our court and have us solve all
their health-related problems. I always find that to be a volley
back and forth, where I try to pass the ball back to the patient.
People can do so much for themselves, and one big challenge is
how to get people to take responsibility for their own health and

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healthcare, to take better care of themselves, and to get more

interested in prevention. All too often patients are in the mindset
of “If it breaks, fix it,” or “If I get sick, you make me better.” We
could do much better – from insurance companies to the medical
profession, to the government – at putting the onus back on the
individual. There are many good reasons for that; the trillion
dollars we’re spending for healthcare is rising dramatically –
double-digit inflation for healthcare spending – yet only about
1 percent of those dollars actually goes to prevention.

At the turn of the last century, back in 1900, we were living only
to age 46, and the three leading causes of death were basically
out of our control – almost like getting hit by lightning.
Pneumonia was the number-one cause; tuberculosis and
gastrointestinal disorders were up there, too. These things just
came out of the blue, and if you were unlucky, you died. Now
we’re living to almost 80, and the three leading causes of death
have direct links to lifestyle: heart disease, cancer, and stroke.
Some experts say that significant percentages – 50 percent to 60
percent of death and premature death in our country – are
lifestyle-related. Yet we have not shifted to a prevention
strategy.

We will never cure healthcare spending if we keep paying for a

disease after it happens, because treating the disease will only
get more expensive. The new procedures, the new technology,
the new drugs – none of them are cheaper than the old ones, as
you can probably see with pharmaceutical companies or
instrument companies or devices we put into people getting more
and more expensive. With baby boomers aging – getting back to

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“boomeritis” – we have a huge demographic who are starting to

hit their 60s, and when they start getting into more serious health
problems, I think we’ll see an unprecedented strain on healthcare
resources. If you think the elderly consume a lot of resources
now, wait until these baby boomers start getting sick, because
even with their minor ailments, they are showing an
unprecedented ability to consume healthcare resources. When
they really get sick – I’m not talking about a sore knee, but heart
disease, cancer, and serious diseases – there will be a tremendous
strain on the system.

One of these days we have to turn around and say, “It’s lifestyles
that are driving this, so how do we give people incentives to take
better care of themselves?” How do you reward those who do,
and how do you at least question those people who seem to not
care at all and then want someone else to pay for it – whether by
drinking and driving, not wearing a seatbelt, smoking, or
unhealthy diets? At some point patients and people need to
become more responsible. That’s how we’ll have a healthier
population.

It’s unusual for an orthopedic surgeon to be writing about this,

given that they usually say, “Call me when the bone’s broken,”
but I really have spent my whole life trying to work out this
problem. Somehow my mind got opened to all this. I think one
of the things that helped me out was that I had a background in
martial arts and an interest in Eastern philosophy. In old China
they paid the physician as long as the patient was well, and when
the patient got sick, they’d stop paying. There was a huge focus
on prevention.

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With the Eisenhower Foundation I was a special ambassador to

China on a sports medicine exchange during the early 1980s. I
got to spend a month there to see firsthand the use of many
alternative techniques that hadn’t hit here yet – whether it was
barefoot doctors, acupuncturists, or moxibustion. It’s a wholly
different approach to healing, and having the martial arts
background going into that – I spent a lot of time not just doing
martial arts but learning about their philosophy and reading
Eastern thought – probably helped open my mind a bit. Also my
physician-executive background and experience with a large
health insurer allowed me to think more about populations rather
than individuals in terms of healthcare. It’s a much broader view
of what’s great about our healthcare system, and also its
shortfalls. Making a decision that potentially affects millions of
people, instead of just one, is a mind-opening and mind-altering
experience.

My work as a Special Advisor to The President’s Council on

Physical Fitness and Sports during the first Bush administration
also broadened my perspective. Our chairman, Arnold
Schwarzenegger, was a tremendous leader with a track record for
getting things done. Our charge was to improve the health of all
Americans. I gained tremendous perspective on what it takes to
substantially change health habits and health behaviors across a
wide and varied population. All of these types of experiences
shifted my perspective and influenced me dramatically.

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The Golden Rules of Being a Doctor

Primum Non Nocere: First, do no harm. I think that’s a golden

rule that fits into everything you do. You put the patient first.
Though it’s hard because you’re pressed for time, you have to
remember that each patient is first a person, and they are often
intimidated when they are interacting with you, the physician.
They may not hear or remember everything you tell them – you
must check with them frequently.

Making the diagnosis and knowing what to do or what to

recommend is the easy part, often accomplished in minutes or
less. The real challenge, and where time must be spent, is pealing
away the layers to expose their true concerns and questions and
determining what treatment best fits their mindset and situation,
rather than your preferences. Also, your expectations and
definition of success with treatment or interventions may differ
widely from your patient’s. It’s about reaching people and
ultimately trying to have a positive impact on their lives.

The best litmus test is to imagine a loved one in the patient’s

place, with another physician. What quality and quantity of
interaction would satisfy you? To me, the technical expertise and
knowledge are givens; you have to have that to be the best. But
other qualities, such as caring and communication, become very
important in terms of being a truly effective doctor.

A commitment to excellence and caring drives me, and if I try to

instill anything into doctors, it’s that they need to have that
commitment, not just to the patients, but also to nurses and the

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people around them. You are only as good as the teams you
build and nourish. You can’t do it all alone; you have to find
ways to work effectively with the people around you.

The true leaders I have encountered, in all walks of life,

accomplish great things by bringing out the best in others,
pointing them in the right direction, and keeping them loyal and
motivated. In healthcare this can be a major challenge. In the OR
it’s rather easy if they give you the same team every time, or the
same group of people to work with, and if they sincerely like
you, they will perform for you. But it gets harder and harder at a
big hospital or university. You have to depend on everyone, from
the laboratory to the floor nurses to the administration. When it
gets to that point, it’s difficult to predictably control all that.
That’s where true leaders emerge to make a difference. It’s easier
to arrive at a destination when you are all on the same map with
common goals. If your compass is set to “putting the patient
first” and “doing no harm,” you will never go off course.

Dr. Nicholas DiNubile is an orthopedic surgeon specializing in

sports medicine in private practice in Havertown, Pennsylvania.
He is also Clinical Assistant Professor of the Department of
Orthopaedic Surgery at the Hospital of the University of
Pennsylvania. Dr. DiNubile served as special advisor and
medical consultant to The President’s Council on Physical
Fitness and Sports during the first Bush administration, with
Arnold Schwarzenegger as Chairman. Additionally, Dr.
DiNubile serves as Orthopaedic Consultant to the Philadelphia
76ers basketball team and the Pennsylvania Ballet.

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 Inside The Minds

Dr. DiNubile graduated from Saint Joseph’s University, where

he was president of the student body, and received his medical
degree from Temple University School of Medicine. He
completed his internship in surgery and his orthopedic residency
at The Hospital of the University of Pennsylvania, where he also
did basic science and clinical research in the preservation and
storage of articular cartilage.

Dr. DiNubile is a spokesperson for the American Academy of

Orthopaedic Surgeons (AAOS) and the American Orthopaedic
Society for Sports Medicine (AOSSM). He has been chosen one
of the “Best Doctors in America” and featured on Good
Morning America, CNN, and National Public Radio, and in The
New York Times, The Wall Street Journal, The Washington Post,
Newsweek, and numerous other publications.

Dr. DiNubile’s work has been recognized by several

organizations, including the AAOS and AOSSM, for which he is
the national representative to the U.S. Department of Health and
Human Services’ “Healthy People 2000 & 2010” projects. In
1993 he was the recipient of the prestigious Healthy American
Fitness Leaders (HAFL) award, given to individuals who have,
through their work, improved the health of our nation. Dr.
DiNubile has also been a member of the editorial advisory board
for The Physician and Sportsmedicine, Muscle & Fitness, Shape,
Men’s Fitness, and The American Journal of Medicine & Sports.

As Associate Medical Director and Chairman of Aetna U.S.

Healthcare’s Orthopaedic Surgery Specialty Advisory
Committee, Dr. DiNubile helped set national policy for one of

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the largest healthcare companies in the world. He is a member

of the American Academy of Orthopaedic Surgeons, American
Orthopaedic Society for Sports Medicine, Arthroscopy
Association of North America, American College of Sports
Medicine, American College of Physician Executives, and
National American Fitness Leaders.

Dr. DiNubile serves as National Medical Advisor for Arnold

Schwarzenegger’s Inner-City Games, and Chairman of the
Inner-City Games in Philadelphia. From 1993 through 1995 he
also served as the medical consultant and editorial advisor to
“Ask Arnold,” Arnold Schwarzenegger’s syndicated column in
USA Weekend magazine.

Dr. DiNubile is the author of The Exercise Prescription and was

on the review panel for The Surgeon General’s Report on
Physical Activity and Health. He was also editor of Exercise is
Medicine, a series in The Physician and Sportsmedicine. Dr.
DiNubile lectures and consults nationally on topics of sports
medicine, health, and fitness, as well as a variety of healthcare
issues.

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business intelligence from newly published books, articles, speeches, journals,
magazines, web sites and over 30,000 other business intelligence sources (from every
major business publisher in the world) that match your business intelligence profile (the
one page questionnaire you fill out describing the type of information you are seeking
that is in the business reply envelope). Each 8-10 page report looks like a personalized
research report and features sections on the most important new books, articles, and
speeches to read, one-sentence descriptions of each, approximate reading times and page
counts, and information on the author and publication sources - so you can decide what
you should read and how to spend your time most efficiently.
$99 a Year for 4 Reports/Year (Reports arrive within two weeks of start of each quarter.)
To Order, Please Call 1-866-Aspatore (277-2867) Or Fill in Order
Form & Business Intelligence Profile (in Envelope) & Mail or Fax
 For Businesses
A) Access to All Publications by Aspatore
Receive print or electronic access to hundreds of books and articles already published by
Aspatore, with new publications added every month, creating the ultimate reference
library for quick access C-Level business intelligence. This collection will enable you or
anyone on your team to get up to speed quickly on a topic, increasing your chances to
close more business, identify new areas for business and speak more intelligently with
current and prospective clients. Aspatore publishes approximately 40-60 new books
every year, in addition to hundreds of articles, briefings, essays and other publications.
Simply subscribe to the entire library or books and other publications published only on
your area of interest, or make your electronic library available to customers as a resource
for them as well.
Titles in Your Industry Only
i. Electronic access to publications in your company’s specialty area (Select from:
Technology, Legal, Entrepreneurial/Venture Capital, Marketing/Advertising/PR,
Management/ Consulting) (Via Password Protected Web Site) - Company employees
can access the publications, as often as they like, and printing of the material is
permitted. For examples of titles that would be made available immediately, see
sample titles page.
Pricing - $999 a month (Based on 1 Yr), $899 a month (Based on 2 Yrs), $799 a month
(Based on 5 Yrs), Price includes up to 25 user seats(individuals that can access the
web site), Each additional seat is $25 a month
Access to All Titles
ii) Electronic access (Via Password Protected Web Site) to receive every publication
published by Aspatore a year. Approximately 60-70 books a year in addition to 50+
books on the sample books page (on the following pages) made available immediately.
Anyone in your company can access the publications, as often as they like, and
printing of the material is permitted.
Pricing - $1999 a month (Based on 1 Yr), $1899 a month (Based on 2 Yrs), $1799 a
month (Based on 5 Yrs), Price includes up to 25 user seats, Each additional seat is $35
a month
Access to All Titles With Additional Navigation
iii) Same as ii, however all publications are arranged by different divisions of your
company, each with its own web site, and information can be made available to
external customers/clients as well.
Pricing - $2999 a month (Based on 1 Yr), $2899 a month (Based on 2 Yrs), $2799 a
month (Based on 5 Yrs), Price includes up to 75 overall user seats and up to 10 different
web sites, Each additional seat is $45 a month

iv) Print Publications (All Future Publications by Aspatore, Sent as They are Published)-
$1,490 a Year

v) Print Books-Build Your Own Corporate Library (65 Best Sellers Already Published by
Aspatore) - $1,089 (A savings of 45%)

To Order, Please Call 1-866-Aspatore (277-2867) Or Fill in Order

Form & Business Intelligence Profile (in Envelope) & Mail or Fax
B) Your Own Company Book Every Quarter
Receive 4 quarterly books, each with content from all new books, essays and other
publications by Aspatore during the quarter that fits your area of specialty. The content is
from over 100 publications (books, essays, journals, briefs) published every quarter on
various industries, positions, and topics, available to you months before the general
public. Each custom book ranges between 180-280 pages and is based on your
company’s Business Intelligence Profile. Up to 50 pages of text can be added in each
book, enabling you to customize the book for particular practice groups, teams, new hires
or even clients. Put your company name on the front cover and give your books a title
(ABC Technology, Technology Reference Library), if you like.
Please call 1-866-Aspatore (277-2867) or visit www.Aspatore.com for pricing

C) PIA (Personal Intelligence Agent) – Custom

Company Reading Lists
Corporate PIA Reports present your entire company, or a division/group within a
company, with information on exactly where to find additional business intelligence from
newly published books, articles, speeches, journals, magazines, web sites and over
30,000 other business intelligence sources (from every major business publisher in the
world) that match your business intelligence. Each 8-10 page report features sections on
the most important new books, articles, and speeches to read, one-sentence descriptions
of each, approximate reading times and page counts, and information on the author and
publication sources - so you can decide what you should read and how to spend your time
most efficiently.
For 1 Report For Entire Company, $499 a Year for 4 Quarterly Reports, Copies Permitted
(Reports arrive within two weeks of start of each quarter.)
For Multiple Reports For Same Company, Please call 1-866-Aspatore (277-2867)

D) License Content Published by Aspatore

Our content saves marketing, communications and public relations teams valuable time.
For information on licensing content published by Aspatore for a corporate intranet,
extranet, newsletter, direct mail, book or in any other way, please email
[email protected].

E) Bulk Orders of Books & Chapter Excerpts

For information on bulk purchases of books or chapter excerpts (specific chapters within
a book, bound as their own mini-book), please email [email protected]. For orders
over 100 books or chapter excerpts, company logos and additional text can be added to
the book. Use for sales and marketing, direct mail and trade show work.

To Order, Please Call 1-866-Aspatore (277-2867) Or Fill in Order

Form & Business Intelligence Profile (in Envelope) & Mail or Fax
 Business Intelligence Profile
Please fill in answers on the page in the envelope or call and
answer the questions over the phone.
Your Business Intelligence Profile is Based On:
1. The amount of time you have to spend on reading and analyzing
business intelligence every quarter
2. Information you are looking for on your area of specialization and/or
industry
3. Your preferred type of business media (books, speeches, magazines,
newspapers, Web sites, journals, white papers)
4. Business information most relevant to you (e.g., articles on your
industry in a particular periodical)

Sample Questions
Please fill in answers on the page in the envelope or call and
answer the questions over the phone.
A: What industries should your PIA report/custom book cover (such
as auto, technology, venture capital, real estate, advertising, etc.)?
B: What area of specialty should your PIA report/custom book
cover (such as technology, marketing, management, legal, financial,
business development)?
C: What level are you at in your career (entry level, manager, VP,
CFO, COO, CTO, CMO CEO, etc.) ?
D: What is your preferred source for business intelligence (books,
magazines, newspapers, journals, web sites, speeches, interviews)?
E: Are there any particular publications your PIA report should
specifically cover (such as The Wall Street Journal, Business Week,
books published by Aspatore, etc.)?
F: How many hours do you spend reading business intelligence
(books, articles, speeches, interviews) every week? Every month?
G: How many books are you comfortable reading every quarter?
H: Are there any key terms or concepts you are looking to stay on
top of (such as nanotechnology, business-to-business marketing,
online privacy, etc.)?
I: Is there any other information your PIA should know in order to
better customize your quarterly report?

To Order, Please Call 1-866-Aspatore (277-2867) Or Fill in Order

Form & Business Intelligence Profile (in Envelope) & Mail or Fax
 Praise for Aspatore
"What C-Level executives read to keep their edge and make pivotal
business decisions. Timeless classics for indispensable knowledge." -
Richard Costello, Manager-Corporate Marketing, General Electric
"True insight from the doers in the industry, as opposed to the critics on
the sideline." - Steve Hanson, CEO, On Semiconductor
"Unlike any other business books…captures the essence, the deep-down
thinking processes, of people who make things happen." - Martin
Cooper, CEO, Arraycomm
"The only useful way to get so many good minds speaking on a complex
topic." - Scott Bradner, Senior Technical Consultant, Harvard University
"Easy, insightful reading that can't be found anywhere else." - Domenick
Esposito, Vice Chairman, BDO Seidman
"A rare peek behind the curtains and into the minds of the industry's
best." - Brandon Baum, Partner, Cooley Godward
"Intensely personal, practical advice from seasoned dealmakers." - Mary
Ann Jorgenson, Business Chair, Squire, Sanders & Dempsey
"Become an expert yourself by learning from experts." Jennifer
Openshaw, Founder, Women's Financial Network, Inc.
"Real advice from real experts that improves your game immediately." -
Dan Woods, CTO, Capital Thinking
"Get real cutting edge industry insight from executives who are on the
front lines." - Bob Gemmell, CEO, Digital Wireless
"An unprecedented collection of best practices and insight..." - Mike
Toma, CTO, eLabor
"Must have information for business executives." - Alex Wilmerding,
Principal, Boston Capital Ventures
"An important read for those who want to gain insight....lifetimes of
knowledge and understanding..." - Anthony Russo, Ph.D., CEO, Noonan
Russo Communications
"A tremendous treasure trove of knowledge...perfect for the novice or the
seasoned veteran."- Thomas Amberg, CEO, Cushman Amberg Comm.
"A wealth of real world experience from the industry leaders you can use
in your own business." - Doug Cavit, CTO, McAfee.com

To Order, Please Call 1-866-Aspatore (277-2867) Or Fill in Order

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 Sample Books
(Also Available Individually At Your Local Bookstore)
MANAGEMENT/CONSULTING
Empower Profits –The Secrets to Cutting Costs & Making Money in ANY Economy
Building an Empire-The 10 Most Important Concepts to Focus a Business on the Way to
Dominating the Business World
Leading CEOs-CEOs Reveal the Secrets to Leadership & Profiting in Any Economy
Leading Consultants - Industry Leaders Share Their Knowledge on the Art of Consulting
Recession Profiteers- How to Profit in a Recession & Wipe Out the Competition
Managing & Profiting in a Down Economy – Leading CEOs Reveal the Secrets to Increased
Profits and Success in a Turbulent Economy
Leading Women-What It Takes to Succeed & Have It All in the 21st Century
Management & Leadership-How to Get There, Stay There, and Empower Others
Human Resources & Building a Winning Team-Retaining Employees & Leadership
Become a CEO-The Golden Rules to Rising the Ranks of Leadership
Leading Deal Makers-Leveraging Your Position and the Art of Deal Making
The Art of Deal Making-The Secrets to the Deal Making Process
Management Consulting Brainstormers – Question Blocks & Idea Worksheets

TECHNOLOGY
Leading CTOs-Leading CTOs Reveal the Secrets to the Art, Science & Future of Technology
Software Product Management-Managing Software Development from Idea to Development
to Marketing to Sales
The Wireless Industry-Leading CEOs Share Their Knowledge on The Future of the Wireless
Revolution
Know What the CTO Knows - The Tricks of the Trade and Ways for Anyone to Understand
the Language of the Techies
Web 2.0 – The Future of the Internet and Technology Economy
The Semiconductor Industry-Leading CEOs Share Their Knowledge on the Future of
Semiconductors
Techie Talk- The Tricks of the Trade and Ways to Develop, Implement and Capitalize on the
Best Technologies in the World
Technology Brainstormers – Question Blocks & Idea Development Worksheets

VENTURE CAPITAL/ENTREPRENEURIAL
Term Sheets & Valuations-A Detailed Look at the Intricacies of Term Sheets & Valuations
Deal Terms- The Finer Points of Deal Structures, Valuations, Term Sheets, Stock Options and
Getting Deals Done
Leading Deal Makers-Leveraging Your Position and the Art of Deal Making
The Art of Deal Making-The Secrets to the Deal Making Process
Hunting Venture Capital-Understanding the VC Process and Capturing an Investment
The Golden Rules of Venture Capitalists –Valuing Companies, Identifying Opportunities,
Detecting Trends, Term Sheets and Valuations
Entrepreneurial Momentum- Gaining Traction for Businesses of All Sizes to Take the Step to
the Next Level
The Entrepreneurial Problem Solver- Entrepreneurial Strategies for Identifying Opportunities
in the Marketplace
Entrepreneurial Brainstormers – Question Blocks & Idea Development Worksheets

To Order, Please Call 1-866-Aspatore (277-2867) Or Fill in Order

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 LEGAL
Privacy Matters – Leading Privacy Visionaries Share Their Knowledge on How Privacy on the
Internet Will Affect Everyone
Leading Lawyers – Legal Visionaries Share Their Knowledge on the Future Legal Issues That
Will Shape Our World
Leading Labor Lawyers-Labor Chairs Reveal the Secrets to the Art & Science of Labor Law
Leading Litigators-Litigation Chairs Revel the Secrets to the Art & Science of Litigation
Leading IP Lawyers-IP Chairs Reveal the Secrets to the Art & Science of IP Law
Leading Patent Lawyers –The & Science of Patent Law
Internet Lawyers-Important Answers to Issues For Every Entrepreneur, Lawyer & Anyone
With a Web Site
Legal Brainstormers – Question Blocks & Idea Development Worksheets

FINANCIAL
Textbook Finance - The Fundamentals We Should All Know (And Remember) About Finance
Know What the CFO Knows - Leading CFOs Reveal What the Rest of Us Should Know
About the Financial Side of Companies
Leading Accountants-The Golden Rules of Accounting & the Future of the Accounting
Industry and Profession
Leading Investment Bankers-Leading I-Bankers Reveal the Secrets to the Art & Science of
Investment Banking
The Financial Services Industry-The Future of the Financial Services Industry & Professions

MARKETING/ADVERTISING/PR
Leading Marketers-Leading Chief Marketing Officers Reveal the Secrets to Building a Billion
Dollar Brand
Emphatic Marketing-Getting the World to Notice and Use Your Company
Leading Advertisers-Advertising CEOs Reveal the Tricks of the Advertising Profession
The Art of PR-Leading PR CEOs Reveal the Secrets to the Public Relations Profession
The Art of Building a Brand –The Secrets to Building Brands
The Golden Rules of Marketing – Leading Marketers Reveal the Secrets to Marketing,
Advertising and Building Successful Brands
PR Visionaries-The Golden Rules of PR
Textbook Marketing - The Fundamentals We Should All Know (And Remember) About
Marketing
Know What the VP of Marketing Knows –What Everyone Should Know About Marketing,
For the Rest of Us Not in Marketing
Marketing Brainstormers – Question Blocks & Idea Development Worksheets
Guerrilla Marketing-The Best of Guerrilla Marketing-Big Marketing Ideas For a Small Budget
The Art of Sales - The Secrets for Anyone to Become a Rainmaker and Why Everyone in a
Company Should be a Salesperson
The Art of Customer Service –The Secrets to Lifetime Customers, Clients and Employees
Through Impeccable Customer Service
GENERAL INTEREST
ExecRecs- Executive Recommendations For The Best Products, Services & Intelligence
Executives Use to Excel
The Business Translator-Business Words, Phrases & Customs in Over 90 Languages
Well Read-The Reference for Must Read Business Books & More...
Business Travel Bible (BTB) – Must Have Information for Business Travelers
Business Grammar, Style & Usage-Rules for Articulate and Polished Business Writing and
Speaking
To Order, Please Call 1-866-Aspatore (277-2867) Or Fill in Order
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 Inside The Minds:
THE ART & SCIENCE OF BEING A DOCTOR
Dedications & Acknowledgements

Dr. W. Randolph Chitwood, Jr.

Dedicated to my grandfather, Dr. Edmund Madison Chitwood,
and my father, Dr. Walter Randolph Chitwood, Sr., both
deceased; acknowledgment to Louise Chut, writer.

Dr. Michael J. Baime

Dedicated to three generations of love and caring: Gloria,
Regina, Edwin, and Ian.

Dr. Rosalind Kaplan

I would like to dedicate this chapter to my husband, Dr.
Lawrence Kaplan, my true role model and my source of strength.

Dr. Martha S. Grayson, M.D.

I would like to thank my mother, Julie Grayson, my brother, Dr.
Paul Grayson, and my friend Dr. Myrtho Montes for their
invaluable assistance with the manuscript.

Dr. Nicholas A. DiNubile

I dedicate this to those who helped make me a caring doctor –
Connie, Alfred, and Linda – and to those who give me purpose
and keep me striving for excellence every day – Emily, Dylan,
and Marybeth.