Medicine’s science has advanced. Medicine’s art has stalled. [PODCAST]

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“I was a bit nervous about how she would perceive my advice. She could find it inappropriate and report me for making personal remarks. But I believe she sensed the sincerity in my words and appeared invigorated, uplifted, and excited. She was smiling now and exclaimed, ‘Doctor, you will see now how I get my game on!’ She asked me when her next scans would be, and I told her, ‘First, you make an appointment at the hair salon, and I will schedule your next scans after that.’ We struck a deal, and her body language changed. She jumped out of her chair and walked out of the room like a woman on a mission. A mission to look good. A mission to not feel ugly.

I don’t know how much longer she has to live. She may have another two months or another two years. I will be ready to treat any symptom she gets from cancer, but I will also make sure that we do everything for her to feel beautiful. Just like she actually is.”

Farhan S. Imran is a hematology-oncology physician who blogs at Did I Ask?

He shares his story and discusses his KevinMD article, “After all the years of medical training, I learned how to treat ugly on my own.”

This episode is sponsored by Tradeoffs, available on your favorite podcast platform.

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Hosted by Kevin Pho, MD, The Podcast by KevinMD shares the stories of the many who intersect with our health care system but are rarely heard from.

Transcript

Kevin Pho: Hi, welcome to the show, where we share the stories of the many who intersect with our health care system but are rarely heard from. My name is Kevin Pho, founder and editor of KevinMD. On today’s show, we welcome back Farhan Imran. He’s a hematology-oncology physician, and he wrote the KevinMD article “After all the years of medical training, I learned how to treat ugly on my own.” Farhan, welcome back to the show.

Farhan S. Imran: Thank you, Kevin. I want to congratulate you on the success of your podcast, and thank you for having me back.

Kevin Pho: Well, thank you so much for writing and being on the show. The podcast, of course, would not be as successful without all the KevinMD guest authors on my site. So we’ll get into your article in a little bit, but for those who didn’t get a chance to listen to our first episode, that was more than a year ago, can you just briefly share your story and journey to where you are today?

Farhan S. Imran: Yeah, so I went to medical school in the northern part of Pakistan, in Peshawar, Pakistan. Khyber Medical College was my medical school. Then I’ve had most of my training in Rochester, New York, but I did my hematology and oncology fellowship at Georgetown University in Washington, D.C., and then decided to come back to Rochester. Here I have a hematology and medical oncology practice at the Lipson Cancer Center.

Kevin Pho: So we are speaking today in the middle of September, and we are 18-plus months into the pandemic. Give us a sense of what you’re seeing in the hematology-oncology clinic. Give us some sample cases that you typically see these days.

Farhan S. Imran: Initially, as we all know, when the COVID pandemic hit, it was a catastrophe. It was just such a big wave of fear and not knowing really what to do. Things drastically improved after the vaccinations came along and many people went ahead and got vaccinated, and that, by the way, was the topic of my previous podcast with you as well.

But what we are seeing currently is this sense of some calm among people who are already vaccinated. But as we all know, there is a percentage of the population, and it always has been, if you look at the history of vaccinations, who do not really trust the science, or trust the politics of it, or the myths of it, or based on their religious beliefs. And those people who are not getting vaccinated, there’s this big sense of anxiety among people who are vaccinated and who are unvaccinated.

As a physician, especially one who takes care of a very vulnerable population whose immune systems are very, very compromised, I do remain with a sense of anxiety, where I would consider that many people would think of getting vaccinated. My message is that they should trust us, and it is important for themselves and also for the loved ones that they are living with, because it’s not just about people themselves, but for the sick grandmother who’s at home going through chemotherapy. They don’t want to make her sick. So that’s what we are seeing currently, but I’m hopeful that we will be able to beat the pandemic, hopefully in the next few months or years.

Kevin Pho: All right, so let’s transition now into the KevinMD article that you wrote. It’s titled “After all the years of medical training, I learned how to treat ugly on my own.” Now, for those who didn’t get a chance to read your article, can you just walk my audience through it and share the story of why you decided to write it?

Farhan S. Imran: Yeah, so basically it was another routine day, but in the middle of the day, a patient said something to me which I had never encountered before, and I thought that it would be reasonable to write about it.

Basically, I walked in. This was a patient of mine about my mother’s age, a very nice, elegant woman, and she was diagnosed with small cell lung cancer, which, of course, everybody knows, the prognosis can be very challenging. I gave her the information that we would be able to do some treatments, but her prognosis might not be more than a year or two, which she accepted. She went through all the treatments in a very brave and dignified manner. She did very well. She responded so well to the treatments, including chemotherapy and a little radiation, that her cancer went into remission.

Here I was two years down the line, and she had already outlived the grim prognosis that I had initially given her. I looked at another set of scans, because we do these scans every three months, and the scans were again looking great. So I walked into the room very happy, triumphant, jubilant: OK, we’re going to share the good news and move on from there.

But when I walked in and I gave her the news, instead of being happy, she started crying, and it was not the kind of cry that you do when you are happy and relieved. It was a very upset crying. When I asked her, “Why are you crying? It’s good news,” she said, “Well, that’s all fine, but I feel so ugly.”

That’s when I almost froze in my chair for a few moments, because I felt like in all these years of training, during medical school and then residency and then fellowship and then in practice, I had never encountered this, and nobody ever trained me what to do or what to say when a patient says something like that. So initially, I responded by saying something routine, like, “Oh, no, you look perfectly fine to me.” But I could tell that that wasn’t doing anything for her.

I could also just write a referral to a therapist or a psychiatrist, but I felt like this is not full-blown depression, or even if it might be, and even if she goes to the therapist, why have we compartmentalized medicine so much that I would treat only her cancer and not take care of her feelings and how she feels in her personal life? I took it upon myself to talk to her. I actually looked at her, and I started talking to her about why she’s wearing a baseball cap to hide her hair, and why she used to be so well dressed when she initially came to me, and now she was not dressed very elegantly.

I felt worried about what if she misconstrues my advice, and whether it is appropriate to give such advice. But she took it with open hands, because I was giving it in a very genuine manner. Then she felt more reinvigorated, and in future appointments, I did see that she did feel much better. She was much more open talking to me about how her personal life is, and she was dressing up better and looking better. So I felt like that was more important than those scans and the overall survival and the p-values at that time, and I felt very good about that. So that is really what my article is about.

Kevin Pho: Now, it seems like medicine today is getting more siloed, right? Everyone is becoming more specialized, and people only practice in the hospital or only practice in the clinic, and sometimes that mentality translates into the exam room, where physicians are only comfortable talking about their specialty. Tell me what you think about that trend, about doctors becoming more specialized, leading to the scenario that you described in your story.

Farhan S. Imran: Right. Well, that’s a great question, and that’s exactly why I wrote that article. I would encourage all my colleagues to go back and read some of the medicine history books, how medicine was being practiced and documented, let’s say, 100 years ago or 300 years ago. If you read those books, there is the science of medicine, but there’s a lot of art of medicine. When somebody was writing progress notes at that time, they were talking about who the patient is and not just about the disease. They were talking: Is this a butcher or a meat seller? How many kids does this person have?

Then science progressed, and we all know that we have made tremendous achievements in the field of medical science in the last few decades. The science has progressed, but the art of medicine is lagging behind. In fact, it is going in reverse, to the point that I don’t recall, during any of my training, talking about these things. This is always in the background. The art of medicine has been moved into the background. We’re all talking about disease-specific symptoms, concerns, clinical trials, and statistics, and those are all very important, but we cannot let that overcome the art of medicine.

So that’s why it’s very, very important for each one of us to get to know our patients much better, really deep down on a personal level, and really not think of ourselves as, “OK, well, I’m the oncologist. The patient has diabetes or high blood pressure, send to the primary care or send to the endocrinologist.” I should at least, short of any medication adjustments, sit down with them and tell them, “What are you doing with your diet? How are you spending every day?” So we really need to break that up.

One other quick thing that I’m going to say is that there’s a lot of criticism of the EMRs, and I agree with a lot of that, but we also need to look at the positive side of the EMR. One positive side is that by the time any one of us is seeing a patient, all their symptoms and examinations have been documented so extensively, especially for hospitalized patients. Patients get annoyed when you go in: We are trained to ask the same history again and do the same exam again, and they get annoyed, they get upset.

So I tell my residents, “Start with the social history, and just sit down with the patients. You already have all that information from the EMR, so just ask a couple of medical questions, but then use that time to get to know the patient. And when you are presenting a case to me, start with the social history.” That simply means that we are getting to know the patients.

The reason I said medical training is because it is upon us as attending physicians to teach medical students and residents. If we’re not going to teach them to behave that way at the bedside, they’re not going to learn. They’re going to become more robotic, very siloed kind of physicians, and that will be a failure for the art of medicine: a success for the science of medicine, but a big failure.

Kevin Pho: Well, as you know, there are a lot of external pressures facing physicians today, not only in the hospital but in the exam room as well. There’s always a focus on productivity and revenue, and sometimes that’s in tension with getting to know the patient. So how do you reconcile that tension? How can we sit down and get to know patients when we’re under increasing time pressure?

Farhan S. Imran: Well, that is the most limiting factor. I myself can say that I’m very, very fortunate, because at the organization that I work at, we don’t have those pressures. I mean, it’s not like we’re not seeing many patients. But I feel that any physician, number one, who wants to do this has to have a will to practice that way. That’s how practicing becomes enjoyable.

Sit down with your administration team and talk to them and say, “Hey, I can see a lot of patients. We can bring a lot of revenue. But do you want me to give quality care, or are you only interested in income generation and RVU generation?” I feel like, as a physician, one should have the guts to practice your philosophy. If the philosophy is, “My philosophy is not just RVU generation, but it is also to give wholesome bedside care in a very nice manner, where you’re practicing cutting-edge scientific medicine but you’re also keeping up the art of medicine,” then if your organization is allowing you to do that, which all good organizations will, then keep up with that. Otherwise, one has to look elsewhere.

And also talk to the administrators, or whoever is keeping up with the finances of the program. The more quality care you give, the more people come to you, because they know who’s giving quality care and who’s treating the patient rather than the disease.

Most of the time, I also feel like we all come up with our own excuses. Every time I’m saying that I don’t have time to talk to the patient, I do have time. I just have not learned how to manage the time. That is where I was saying that rather than just sitting and talking to the patient, you can take care of them so much better, rather than typing in the computer and then just saying, “Oh, I don’t have any more time for you.” A lot of us have more time than we actually think.

Kevin Pho: We’re talking to Farhan Imran. He’s a hematology-oncology physician, and he wrote the KevinMD article “After all the years of medical training, I learned how to treat ugly on my own.” Farhan, what kind of tips can you give to clinicians? Perhaps you could wrap up with some take-home messages and advice to my physician audience.

Farhan S. Imran: My tip would be that medicine, if practiced on a daily basis, bland encounters, not getting to know the patients on a deeper level, can actually become very boring. A lot of people who you see also write a lot or talk a lot about going into other fields. They talk about burnout, and they talk about financial independence, meaning going into some other field, either along with medicine or leaving medicine.

So my tip really is to start enjoying your work and start enjoying your patients. These patients love us, and the more love and care you put in, the more they give back to you. The more we get involved and bogged down by the bureaucracy of it, by the financial piece of it, by the RVU generation, the more there will be burnout. But in a single day, if you’ve seen 10 patients or 20 patients, and even if two of them have turned around and said, “Doctor, thank you,” or, “Doctor, you made a big difference in my life,” that carries more weight than the additional few hundred RVUs that you’ve made at the end of the three months. So that’s what I would say.

The other thing is that if you’re fortunate enough to be in a teaching position and be a role model for your friends and residents, do not let them talk just about the science of medicine, but keep bringing up how they are reinvoking the art of medicine, because the responsibility is upon our shoulders to uphold the art of medicine that has been going on for centuries and centuries. That’s what I would want to say.

Kevin Pho: Farhan, thank you so much for sharing, again, your time and insight, and thanks again for being on the show.

Farhan S. Imran: Thank you, Kevin.

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