Podcast: Med Life with Dr. Horton — Dr. Victoria Sweet on slow medicine
Transcript
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Jillian Horton: I'm Dr. Jillian Horton, host of Med Life with Dr. Horton on CMAJ Podcasts. I'm a general internist and associate Chair of the Department of Internal Medicine and the director of the Alan Klass Health Humanities program at the Max Rady College of Medicine in Winnipeg, Manitoba. I also host insights, arts, medicine life at the National Art Center in Ottawa. My guest today is Dr. Victoria Sweet. Dr. Sweet is an associate clinical professor of medicine at the University of California in San Francisco. She's also a general internist and the author of two national bestsellers, God's Hotel, and Slow Medicine. She's a PhD in the history of medicine, and a Guggenheim fellow. I've reached her today at the studios at Stanford University in California. Dr. Sweet, thank you so much for joining me today.
Victoria Sweet: Well, thank you so much for having me.
Jillian Horton: So anyone who's read your books has a sense of the many forces that have shaped you. And I wonder if you could start by talking about your academic path and how it led you to internal medicine?
Victoria Sweet: Yes, I had a little bit of a wandering path, I would say, because I often point out that I'm not a natural born doctor. And I think it's important for understanding me and actually quite a number of other doctors, maybe yourself included, where I didn't start out wanting to be a doctor. And I wasn't one of those people who, when they're kids, they want to hear everything, and they want to volunteer in hospitals. And they watch all the doctor shows. I didn't want to have anything to do with the body at all. I was very much in my head. And I was trying to figure out what I was going to do when I graduated from college. And I discovered, sort of by happenstance, the writings of Carl Jung, the psychiatrist, and he really thrilled me. When I discovered his work, I was standing I can remember the moment I was standing, reading his memories, dreams and reflections in a bookstore. And I was just amazed by first of all, by the meaning that he expected from his own life, and the meaning he gave to his patient's lives. And also, by the way, he's set up his own life, you know, living by that lake in Zurich, and seeing well paying neurotic patients in the morning, and illuminating manuscripts in the afternoon, I thought that was a great balance to have. So I decided I was going to be a Jungian analyst. And that's how I got to medical school because at the time, you had to have an MD or a PhD, to become a Jungian analyst. That's how I got to medical school. And then in medical school, I realized that I really was much more taken by medicine than I thought I would be. I particularly liked, you know, what we call the workup the history of the patient, you know, taking the history because there was so much psychology to it, I realized, you know, I had to listen to what the patient said, and what they didn't say and how they said it. And then there was examining the patient. And I think the physical exam was what surprised me most about myself, I loved the physical exam, and I still do I find it such a powerful tool for diagnosis and it's sort of falling out of fashion, which is a pity. So that's kind of how I got, you know, to medicine, because after I discovered that I ended up as an internist. But that other side of me never completely went away.
Jillian Horton: So your first book, God's Hotel is about your work at San Francisco's Laguna Honda Hospital, where you work for 20 years. So could you talk for a little bit about how those years filled out your view of what is at the heart of the practice of medicine?
Victoria Sweet: It was an amazing experience. So you know, what actually happened is I I went, you know, I became an internist. I practiced for a number of years, before I got to Laguna Honda. And the longer I practiced medicine, the more impressed I was, by its modern, methodical, step by step way of approaching the body, but I was also more and more impressed by what it left out, which was, of course, anything that wasn't logical. So at some point, once I really had gotten, I thought medicine under my belt, I started looking around for other ways of looking at the body. You know, I looked at your Ayurvedic medicine, and Chinese medicine and I even thought about learning Chinese so I could understand that medicine from the inside. But I realized even if I did all that I would never understand this other part. This other way of looking at humans, bodies that I felt from my patients. But I didn't get it out of modern medicine it didn't explain so much. what I saw. There was that sort of discouraging moment I was trying to figure out what to do that I discovered another book. Speaking of books, in the library that changed my life. It was called Hildegard of Bingen's Medicine. And it turned out that Hildegard had been a 12th century nun, an abbess, a mystic, an artist, a theologian, but she'd also been a medical writer and a medical practitioner, and she'd written a book about her 12th century medicine. And I stood in the library reading this book, thinking, wow, this sounds so much like Chinese medicine, or Ayurvedic medicine, but it's from the west, maybe this was the missing piece that's been left out of the medicine that I've learned. So I decided at that moment, I was going to go back to school and get a PhD in history of medicine with Hildegard as my focus. But I didn't want to stop practicing medicine. I wanted to practice part time, and at the time, it was very difficult to find a part time position. And that's how I got to this really strange hospital in San Francisco, which was Laguna Honda hospital, because it was the only place that would let me practice medicine part time. And it was just an amazing place because I called the book God's Hotel because it was the Hotel Dieu, the almshouse of San Francisco, in fact, its original name was a San Francisco Almshouse. And in the United States, and I'm pretty sure also in Canada, we inherited the British system, which grew out of the medieval monastic system for taking care of the sick poor. It's kind of an interesting history, because in ancient Rome and Greece, nobody took care of the sick, poor, they just died. Literally people at the forum would step over lepers and dying people, there was no sense that there was a civic duty to take care of them. But in the Middle Ages, starting with monks in the monasteries this was a very profound vocation of the monks. They were supposed to care for the sick, poor, you know, it comes out of the Bible, the New Testament in Matthew 17, I think, he says, you know, whatever you do, for the least of these you do for me. So the monasteries, all of them had a hospice and an infirmary that took care of the monks but also took care of the sick poor. What happened was when Henry the Eighth, overturned the system and divorced himself from the Catholic Church, and dissolved all the monasteries, there was nobody left to care for the sick poor. So this was in around 1536, actually. And so it took about a generation for people to realize that there was something missing from their world. Somebody to take care of the sick, poor, and it reminds me a lot, at least in the States of what's happened when we took down the mental health institutions, the state mental asylums, right? It's been a generation, and in the United States, we're coming to realize, Oh my God, we need those institutions. We need somebody that takes care of the mentally ill. And so it took us a generation, it took them a generation. It wasn't until Elizabeth, around 40 years later, everybody kind of scratched their heads and going like, Oh my god, we've got all these sick poor wandering around in the old and the decrepit. And so at that moment, she passed the Elizabethan Poor Law, which said that all the counties had to take care of their sick poor, anybody who couldn't take care of themselves, it was the county's responsibility. So that was how we ended up with our county hospitals in our county Almshouse in the States. Because when we settled the States, every city and county had to have a way to take care of the sick poor, and mostly, they did it by having a county hospital to take care of the acutely ill, and a county Almshouse to take care of everybody else. And the Almshouse in French, of course, was the Hotel Dieu. It was God's Hotel. So that's the system we had in the States before we had health insurance. And there was one in just about every county, and then in the 1950s, all the almshouses and a lot of the hospitals began to be closed. The left didn't like them, because they were sort of a dickensian feeling of throwing the poor away. And the right didn't like them, because by this time, they'd been settled on all these great amount of real estate. So they kind of got together they closed them all except in San Francisco. So San Francisco's system, that old system still exists. We have a San Francisco General Hospital that anybody can go to. And we have a San Francisco Almshouse. That's the Laguna Honda hospital that I walked into 25 years ago. And it was an amazing place to practice because the Almshouse, typically, just to give you a sense of the place when I got there for my interview, there were 1178 patients located on 62 acres of land, right in the middle of the city, because it had been the outskirts of the city when in 1862, the county had given its charter, but then the city growed around it. So it's this gorgeous piece of land. The buildings were what we call in the States mission revival. So it looked like a 12th century monastery. It had cream colored walls, and a red tiled roof and bell tower and turrets. The patients were all on these long open Nightingale wards. So it was a walking history lesson. It was a live history lesson really, because it had continuous history since 1862. And in fact, as I became more and more aware of not just the patients who were so fascinating, but the place itself. I began to wander this immense place and discover just fascinating things that I didn't even get into my book. But I'll give you one little example. And then I'll get back to a little bit of the sense of the patients. But at one point I, I was thinking about the food. Because we had a huge kitchen and this kitchen had been designed in the last time the hospital had been rebuilt was 1926. So it had this incredible, it was just kick and I tracked down the head chef, who told me that he had menus from the 1880s because it had been continuous, we had this continuous tradition. And so in his old desk were menus from the 1900s and the 1880s. And so he showed me them and it amused me speaking of the Middle Ages, because they were medieval menus. What do I mean by that? So I'll tell you. So a typical menu would be in the morning the patients would get beef stew, and at about, for elevenses, they would have a homeopathic dose of liquor, brandy. And the homeopathic dose, we would not consider it a homeopathic dose, it was like four ounces of brandy.
Jillian Horton: Wow.
Victoria Sweet: And then they would get a dinner around noon or about you know two, and then they would have a supper, you know, tea and toast kind of thing. So the thing that made it remarkable as a doctor was that there were 1200 patients. The patients were three standard deviations from the mean, because anybody who ended up there were just, that one tenth of one percent of patients that fall through every crack in the world, really interesting patients. And best of all, from my point of view, was that we were over the hill to the poorhouse. And really, we were insulated in some ways from all of the insert, swear word here, stuff that was happening sort of outside of the place. You know, all of the efficiency and quality and all this stuff. We paid attention to that. But it was old fashioned, you know, we had paper charts, and a patient. Most of all, I had enough time with patients, I had the time to do that medical school physical. To call the patient's Docs, to talk to their family to get to know them to re examine them. They could stay for as long as they wanted. And so what it meant was that not only did I have patients that had every disease literally in Harrisons, literally. But I could get to know them, I could watch them heal, I could change things. And I saw about a quarter of my patients who'd been admitted there for long term care, went into getting healed and cured and go home. And that's a lot. Actually, it was a lot. So it was an amazing place to practice medicine. It's a bit of a long winded answer, but it's a little hard to explain otherwise,
Jillian Horton: You know, what I really find myself thinking about, as you tell that story is this concept that without any kind of an understanding of our history, and the various political and historical forces that bring us to a particular moment in time. And we teach very little history of medicine and the majority of our medical curriculums these days It's really hard to understand the heart of a place, or sort of the spirit of a particular place, how it came to be. And as a result, it's hard to understand how easily you can eviscerate it by beginning to manipulate some of those elements that you just talked about, or what their function might have been It sort of makes me think of, you know, just randomly removing organs and seeing what happens before you actually understand physiology. The other thing you just made me think about are efficiencies. You know, we live in this era where we cannot avoid talk about not just the financial efficiencies, but also the concept of course of efficiencies of practice. And I think sometimes that those two concepts get confused and to me personally, they are very different. Could you talk from your perspective about what efficiency of practice means to you?
Victoria Sweet: I find it much easier to talk about inefficiency. The word efficiency in my mind goes on it just blanks out, really. I don't think we can distinguish efficiency from finances because at least in the United States efficiency is a code word for doctors seeing more and more and more patients as quickly, as more quickly than humanly possible. And for administrators to be hired by the excess money that we make for them to, you know, try and see if they can get us to see even more patients. I don't think it is divorcable from the finances. I think it is code for the finances, so called efficiency. I mean, if I were going to really define what I thought would be efficient, it would be getting the right diagnosis, and the right treatment, with the patient being happy about the way things went, and the doctor being happy for the least amount of money. That's my definition of something really efficient. And none of that is in our efficiency measures. What could be less efficient than getting the wrong diagnosis? And the only way that that's cost effective, is if the person dies, immediately, but not otherwise. Because otherwise you're just chasing your tail for ever because you had the wrong diagnosis from the beginning. I just have a friend who just spent four years trying to get the right diagnosis for her abdominal pain. And she was in a very efficient system that put her hither and yon. They did every test then nobody ever put it all together. Nobody did it. It was impossible. And finally, she ended up getting a doc, hiring a doc, gave the doc all of her stuff, the doc thoroughly examined her, went through and figured out what it was after four years. That's not in any quality assurance measure in the United States. We have like 80 MIPS measures, 80 measures. Did you have tell your patient to attach their seatbelt? And did you give them their unnecessary shot of some kind? And did you put them on statins that they didn't need, excuse me, but I'm op-editing, I guess I would say. But the actual really important thing to a patient when they come in is the right diagnosis. There's not a single measure of that, or the right treatment.
Jillian Horton: I also am just reminded of your story, I forget the patient's exact name, but this one in slow medicine about the gentleman with the long history of headaches and psychiatric symptoms, and the amount of time that it took for you as an early trainee to go like a detective and sift through these charts one page after another. But finally, that needle in the haystack was there in plain sight. And there's another case where you just talk about, you know, really getting to the heart of what's best for the patient. And these decisions that require us to help people navigate a lot of complexities that it really takes time. And therefore, because of the amount of time that's required, this idea of things that take a lot of time not being efficient, has planted this kind of malignant seed in how we think things are supposed to unfold in the clinical encounter, right? I sometimes find myself thinking about it. And I think I mentioned this in a previous podcast with Dr. Sinski, that this comment in Rosenbaum's article in the New England Journal earlier this year, that efficiency is a value judgment, you know, I found that concept very liberating that, you know, my definition of efficiency might take just like yours, those five hours to go through every single chart. Because at the end, you save time and money and suffering that you can't even quantify. So, you tell a very compelling story in the opening pages of Slow Medicine, and it's about your father's stroke, and how the way that we interact with electronic health records can obscure our ability to actually grasp what's at the heart of a narrative. Could you share that story with our listeners?
Victoria Sweet: Yes, the thing about with my father was that he didn't have a stroke. But that stroke diagnosis, got in his electronic health record, and there was no way to get it out. And he continued to be treated as if he'd had one the entire hospitalization. So he was in his nineties, he was pretty vigorous. He was out having lunch with my mom, and he had a grand mal seizure. But it turned out he'd had grand mal seizures for about 10 years. So this was nothing new. But she was freaked out. They call the paramedics. The paramedics took them to our beautiful community hospital, where they saw you know, a 90 year old man who'd had a grand mal seizure, and they immediately assumed that he'd had a stroke. So that's what got written in the medical record. They gave him a CT scan, but the CT scan didn't show a new stroke. They hospitalized him for the treatment of a stroke, and they gave him all the treatments for stroke, despite the fact that I as an internist showed up, showed him his medical records. Talked to the docs, there was no way I could get him not treated for a stroke he didn't have and it got worse because they put a foley in him that he didn't need. And then he tried to get the foley out. So they tied his hands to the bedstead, and then when they tied his hands to the bedside, he got really agitated. Because there was nothing really wrong with him, except nobody would pay attention to him. So then they gave him antipsychotics. So pretty soon, within about two days, he was a dribbling demented old man who'd had a stroke, and there was no way I could get people to reverse that. It was absolutely maddening. We new hospitalists coming, and I didn't really exactly blame them. I mean, you know, in the efforts for efficiency, these guys would have like twelve fifteen in-patients to see in their shift, which you know, you do the math, it's 15 minutes. By the time you've opened the chart, and read, cut and pasted notes, all you do is continue everything. So my father was going to die so I, knowing how hospitals are, I told the doc that the family had decided he was going to be hospice. Seeing that now he was this old man with a terrible stroke. And we took him home, and I took everything out. And he was fine for the next couple of years.
Jillian Horton: I mean, it's such a, I mean, on one level, you know, the absurdity of it, of course, is amusing. But on the other level, it's one of the many frightening components to it, you just say, if this is, you know, your experience, and obviously, I've had experiences like this with family members, and so have probably many people listening in, and you say so if this is our experience, you know, from the outside looking back into a setting we're familiar with, what chance does the average person have who has no such connections or insight. And it's that power, too, isn't it that the minute something is written in a medical record, whatever it is, you can write that somebody might be from outer space, you know, and it will just get sort of mindlessly repeated over and over in every iteration.
Victoria Sweet: So I've gotten many, many, many letters and emails from people with very similar stories, right? I mean, it's amazingly common. What I've been told is that the way that these health records are set up is you literally can't get rid of the diagnosis, there actually is no way to do it. Because I think what happens is, if you came through the emergency room, and he got the diagnosis of a stroke, then the DRG for that gets into it. And it ends up being medical fraud if you didn't have a stroke. I mean, I don't know. But somebody explained to me that you actually can't get it out. So you talk about inefficient he shouldn't even have been admitted to the hospital. Oh, yeah, grand mal seizure, probably you know, your meds are low, check his levels of his seizure meds, give him a little bit more, keep them, watch them in the ER and send him home instead he was there for like two weeks.
Jillian Horton: And it comes back to doesn't it to that time element, right, that one phone call with a family member at the beginning? You know, in your case, a family member being a physician, you can answer every question correctly, if you invest that additional increment of time upfront. But really it becomes of course about where we're allocating this time, which I think is...
Dr. Victoria Sweet That's right, exactly.
Jillian Horton: ...a huge part of how you are framing the problem. In Slow Medicine, you talk at different points about the individual's latent capacity for healing, and you talk about the concept of Veritas. And you make the case that we often leave very little space for this healing and conventional medical interactions. So how would you personally find the balance between that concept and therapeutic nihilism?
Victoria Sweet: What a nice question. Of course, it automatically brings up one of probably your favorite quotes, but certainly one of my favorite quotes by Oliver Wendell Holme's grandfather, Oliver Holmes who was the doc who said, in the 1840s, he said: "If all the medicine we had was at the bottom of the sea, it would be all the better for humans and all the worst for the fishes." [laughs]
Jillian Horton: [laughs]
Victoria Sweet: I love that quote. So I make a distinction in my mind. I think there's a very huge distinction between the well and the sick, and the well, and the not well, and the getting sick, and then sick and then being super, super sick, and then recovering and then being in a recovery period. And back to well, again. That cycle, we don't differentiate, right? And there's a historical reason for that, actually, it's actually traditional that, you know, prevention is the essence of the cure, right? Ounce of prevention is worth a pound of cure, etc. So this idea that if we could prevent somebody from getting sick, that would be efficient. But that concept has taken over our entire system, again, allied with financial concerns, very much so. So I make a distinction between the well and the sick. I think people that are well should just stay away from doctors and keep doing what they're doing whatever it is. If you're well, you're well, it's when people that to me, I'm not a person who's a healthcare delivery person or healthcare provider. I'm just not, I learned to take care of sick people, prevent them from dying, give them what they needed to get on the road, right to getting better. That's what I'm good at. And that is a great place for our technology and our medicine. And that's what I want. If you know, when somebody has a heart attack or a stroke, if we can do something fantastic, we do it, jump in do all of it. But distinguish when they're starting to get better. And this is what I saw, I got to see at Laguna Honda a lot, because a lot of the patients we'd get after some, you know, three day, two week, two month ICU admission. A complete disaster, total flail, they wouldn't die. They'd come to us literally on twenty, twenty-five medications. And I took tremendous pleasure in gradually getting them off those medicines, and watching their little spark of life flicker. And then the little flame, and then it gets hotter and more vibrant until you know, they'd be back on nothing. That was my goal, or at least most of them, I could get down to three or four meds. And then if you look at the before how much prevention, we are talking about public health and prevention is where we put a tremendous amount of our energy and time. And I'm unimpressed with those results. If you actually look at not the relative risk kind of stuff, but how many people I harm or help. When I treat a hundred people, I give a hundred people a medicine for the rest of their life, and I prevent one heart attack. But I cause three cancers and four car accidents as they're going on their way to the doctor to pick up their meds. I'm unimpressed with that, which is heresy.
Jillian Horton: I love that point. You talk later in the book about our shifts in language. So for example, and you spoke about it just now, this movement to call ourselves healthcare providers. And there's one section I really love in Slow Medicine where you describe sustaining a hand injury one night when you're on call. And you have the experience of being cared for by peers and colleagues. And you talk about that moment of insight as being related to your understanding of archetypes. And I wonder if you see a connection between our shifts in language and our disconnect from useful aspects of archetypes that relate to the physician identity?
Victoria Sweet: Yes. Yes, I agree.
Jillian Horton: So that was a leading question. I think I'd be thrown into the courtroom for asking that.
Victoria Sweet: Yeah, that was a very leading question, it's great, you just took me into that space, which was really lovely to think about. So this is not an accident. This is deliberate rhetorical, conscious use of language. Let's call it Orwellian, since that seems to be a very brilliant attempt to change a way of looking at health and disease and illness and dying and death, and what you need when that's all going on. So this was not an accident, this actually happened in a specific time in a specific place in the States. Well, it was developing for a while in the sixties and seventies is complex. And there was a way in which the sort of consumer movement to take control of our paternalistic, which was paternalistic medicine, and many other things in the late sixties and early seventies. Which I think was an honorable desire, got co-opted by financial interests, who said, yeah, this would be great, because if we can turn this into healthcare, providing we can own it, and if it's doctors and patients, we can't. Because it was actually against the law, up until the early eighties, just to give you an example for non doctors to hire doctors, it was considered unethical. And the American Medical Association had a code of ethics. And it said that as a doctor, you cannot be employed by a non doctor. And the reason for that they're quite explicit. The moment that happened, your allegiance would be split between your employer who would clearly want you to make money or save money, and your patient. And that would be unethical. And the AMA actually got sued by the Federal Trade Commission to take that piece out of their code of ethics. And the AMA took it all the way to the Supreme Court and they lost. So at that moment, medicine was reclassified as a trade and as a commodity, which healthcare providers provided. And within six months, there were retail urgent care clinics popping up all over the country. Some of them run by fast food companies. So that the only way that financial interest could get control of, you know, in the United States like, well, these days, it's like sixteen, seventeen percent of the economy. And I think that is the essence of what's gone wrong to what I think a lot about how to reverse that. Because once you have this immense amount of money in the last couple of years, since I wrote Slow Medicine, what I've really been diving into is understanding how much money is involved? Well, we just have no idea who's involved, how they're involved. It's just enormous cornucopia of cash. And so in the United States anyway, that you have hedge funds, buying hospitals, taking out loans on hospitals, until they're completely bankrupt, and closing them and selling them for real estate. And going to the next one.
Jillian Horton: You know, you make me think of another parallel force, which actually seems relatively benign, in contrast to what you were just talking about. But it's this idea that has come to characterize conversations about the physician identity in medical education. And that idea is professionalism. And you know, one of the stories that also really stuck with me, in Slow Medicine is the story that you tell about your patient, Mr. Schumer. And so this was, of course, the patient who declined to follow the recommendation to go to the emerge. And yet, it was a nurse who drove to his house and insisted that he go to the emerge, and you talk about this concept. And I found this, both interesting and gratifying, actually, the idea of bullying a patient to make a critical decision. Now, I think, and I suspect you would, as well that we are convoluting, a lot of these things for learners today, because I'm sure that there are a sizable number of medical students and residents who would listen to that story or that word and say, well, it crosses a boundary or it's unprofessional, you can't go to somebody's house. And yet, as you so beautifully describe in the book, some of these kinds of interactions are so necessary to really fulfilling our deepest obligations to patients. So I wonder what you see, as some of the ways to backtrack on this teaching around this sort of sterile concept of professionalism, that still keeps the patient at the absolute center of the equation.
Victoria Sweet: Beautiful. There's so much to say to that question, Jill. I mean, that's just like, Whoa, I think the most useful thing is, the golden rule is to say to yourself, what would I want? If I were that patient, and knew what I knew, understood what I understood, that's the only way I think you can get down to what's the rightest. So that would be my summary. And to sort of back that up, I would say this, it was my nurse Kathy, and I get a kick out of the fact that I had so many nurse Kathy's and it took me a long time to realize that Kathy's were Kathy's because they were Kathleen's and they were Irish Colleens, and they had this whole tradition. They had an unbroken tradition of vocation of caring, of nursing, and probably doctrine. But of course, back then they weren't very often doctors. But they had this fundamental religious, fundamental spiritual approach to taking care and medicine is very different. Where we've been at is the secularization of medicine, and this strange misunderstanding, I think, of what the sick patient needs. And again, I distinguish between the well and the sick. I mean, I've watched my medical students over the years, you know, there's a physical exam course, which of course, I taught for a long, long time. And I watched them get more and more reluctant and more and more trained to not touch the patient. It was fascinating. Of course, they were uncomfortable, right? Where everybody's uncomfortable, you are crossing a boundary, but if you do not undress the patient and look at all their parts, and do their rectal exam and do their vaginal examine, examine their breasts and look at their teeth and stick your fingers every place, you're going to miss something. And that they will not thank you for. And so I think that there is this strange, they're taught by the well, often, you know, they're in their 20s. They've most likely never been sick. They most likely, their father, their parents are in their forties probably if they're 20. So they remember maybe their grandmother got sick, maybe. But they haven't had to grapple with anything. They haven't been sick. And so then they're taught by people that are 30. I watch them they walk in there, like they introduce themselves. They're so polite. They're so conscientious. They're wonderful, right? But wow, actually crossing that fundamental barrier into somebody else's body. It's not ladylike. It's not gentlemanly. It's not courteous, you're not supposed to do that. Asking them about, gee, I noticed your cross eyed, what's the scoop? They wouldn't say that. Right? Part of it's the way they're taught. Part of it is our society has become so virtual, why go there, but part of it is the sick and the well. That I think, once you yourself are incapacitated, as I was, at that moment, as a resident where I was just I'd gone from being a doctor to a patient. I'd slammed my hand in the door, I thought I'd amputated my finger I bleeding all over the place, I was incapacitated. And my friends, the intern who I hadn't liked very much picked me up, I had passed out. He picked me up and carried me to the emergency room. And then one of the doctors that I couldn't stand one of the ER doctors, he was always calling me up telling me to come down and see a patient that, you know what I mean, he was the one who sewed me up with such compassion and such expertise. So I just think there is the boundary about going to a patient's home about but and yet, you have to say to yourself, what would I want, if I put myself in that patient's shoes. They've come into my office, or they've just gone home, I know that this patient is going to die of their exploding abdominal aneurysm. And as a matter of fact, I was on the other side of that dichotomy in that particular story, right, I had picked up the abdominal aneurysm and that it had gotten bigger in two days. And I told the patient, look, you're going to die of this. And I explained it, I drew a picture. And I felt like that was it. That was what I supposed to do. It never occurred to me to drive to his house after he left. So I was on that other side. But I think I was wrong.
Jillian Horton: Well, that's the other thing I love about that story is that the role model was a non-clinician. To me, it just speaks to another teaching point that is so often missed in medical education is there a lot of other people around us doing the right thing? You know, we're building this fence called boundaries, but the nurses are often, you know, achieving a very different caliber and quality of emotional relationship that's palpable when you walk into a room. And there was just this piece in the New England Journal, I don't know if you saw it in the last few days about a clinician contemplating whether or not they should fulfill a patient's request to sing a song at the bedside in a palliative context. And you know, I mean, on one hand, like a beautiful reflection, but then the flip side, it actually made me so sad, you know, just thinking like, why is this even a, why have we made this into a moral question this nothing, of course, you do it and it's an in no way to disrespect the perspective of the doc who wrote it. It's an important trigger for conversations like this, but just there seems to be so many, you know, mountains that we have made out of these molehills, and meanwhile, you know, the city's on fire around us. So, I love so many of the ways that you just bring us back to that the presence, you know, and the emotional qualities. And so one more question just to close. If there's one final message that you want clinicians listening to this podcast to take away from your work, how would you summarize it now?
Victoria Sweet: I guess it would be that the essence of medicine is personal. It's person to person and face to face. And you have to somehow take the time to turn away from your computer and touch your patient. Look them in the eyes. Touch the part that hurts. Find that time to do that.
Jillian Horton: Well, what a wonderful note for us to end on. Dr. Sweet, thank you so much for being here with me today.
Victoria Sweet: It was wonderful talking to you. Very, very exciting. I am all jazzed up.
Jillian Horton: Dr. Victoria Sweet is an associate clinical professor of medicine at the University of California in San Francisco. She's also a general internist and the author of two national bestsellers, God's Hotel and Slow Medicine. She's a PhD in the history of medicine and a Guggenheim fellow. If you'd like to hear more podcasts in this series Med Life with Dr. Horton, you can find them as part of CMAJ Podcasts on SoundCloud, Apple podcasts, or wherever you find your podcasts. And don't forget to subscribe and leave us a rating. This podcast was made possible in part by the support of the Alan Klass Health Humanities program. I'm Dr. Jillian Horton. Thank you for listening.