This blog post does not have a happy ending. If you are already having a relatively bad day, especially with the winter weather the way it is, think about two things: Christmas is just around the corner, and you can stop reading this blog post right now.
It’s strange when you read an article that reflects so powerfully your own feelings about a critical topic. The following article that recently appeared in the New Yorker, is one of the best pieces of writing I have ever read. I am admittedly biased because I so strongly agree with the author [Malcolm Gladwell, MG]. But MG manages to skate the fine line between expressing his legitimate rage and telling his story in a coherent and even somewhat dispassionate way.
The New Yorker article summarizes over 50 years of experience in the field of cancer therapy. I will not even try to summarize the article, as I would surely do it injustice. What I will say is that it is hard to believe, after reading such an article, that we have made any headway in the field of medicine. Pride, greed, selfishness, small mindedness – there was a part of me that wanted to believe that these were all relatively new sins being committed by the medical community. After reading this article, and truthfully, based on my own 25 year experience in the medical field, it turns out that modern medicine suffers from age old human failings. The fact that medicine has advanced as far as it has, seems almost despite physicians, not because of them.
MG describes how a very small group of individuals managed to achieve success [relative to the time] with chemotherapy in treating various cancers. MG then goes on to describe how these discoveries were ignored by the top level medical journals of the time, and literally laughed at by “colleagues”. To put this into a modern perspective, imagine a small clinic in France trying to publish a paper that demonstrates how they cure HIV. The physicians in the clinic are relatively small players in the field of infectious diseases, and are not well known in the international medical community. But painstakingly, these French physicians ran a series of clinical studies that proved by the strictest of standards that their cocktail of medications, works. Imagine now that these physicians have submitted their article to multiple journals, but have repeatedly received a negative response, all because the reviewers of the article are themselves “expert” in the field and secondly, these experts “just can’t believe” that these results are true.
Believe? What part of science includes an element of belief? Of course, there are theories and certain axioms that every field of study is based on. But as I recently heard in an excellent documentary on the discovery of the Higgs boson, theories are cheap and everyone can have his own. But until you can prove it – it’s not science.
Sadly, physicians are very strongly driven by custom, tradition, oral law and fear. Medicine continues to be an old boys’ club. Break with tradition and you threaten your own standing in the club. If you are an independent physician with enough work to pay your rent, then you are free to say what you want. But if you are looking for grant money from the NIH and also looking to be published in major journals like JAMA and the New England Journal, you better not stray that far from the accepted doctrine. If you yourself are considered the leading person in your field, obviously, you have much more leeway. But there are very few people like this and they also are worried about losing their standing within their community.
MG perfectly depicts how so much of medicine still is based on command. Doctors, despite their extensive study, will often find themselves in situations where they are told by their seniors to do something. Sometimes, the younger doctors will challenge the knowledge and even the authority of the seniors. But as described in the article, there are those moments when your senior tells you to “do it”, and you do, despite your own knowledge base and opinion.
I remember what is probably one of the most horrifying experiences I had as a young resident. I was told to perform a procedure that I had only done once or twice before and definitely did not feel comfortable with. I literally begged one of my seniors to come and show me how he does it. My senior refused. The procedure failed and it is only by an act of G-d that I did not seriously harm the patient. The next day, in tears, I spoke to another senior and described the event. He also refused to take the time to show me hands-on how to perform the procedure. But fortunately, his oral description of the correct approach was detailed enough and effective enough that I never failed on the procedure after that point. Needless to say, this is something you would expect to read in a novel by Mary Shelley. But it wasn’t a story. It was real. And it was the first time that I said to myself that, if this is medicine, I made a horrible mistake by choosing to become a doctor. That night haunts me, unfortunately along with many others, until today. That is why this article in the New Yorker struck so close to home.
I could tell stories for days about the many failings in medicine and doctors, but I am trying to focus on a few poignant anecdotes that should make your skin crawl. I will share one more.
Many years ago, a family member was suffering from [and eventually succumbed to] cancer. Her care was being provided by physicians at, arguably, the top center for cancer research in the world. As her treatment progressed, her physical status dramatically declined. At this time, I had already been a practicing physician for quite some time, and in my own research, came across the use of anabolic steroids [yes, the kind that bodybuilders use] in increasing the health of cancer patients.
For multiple reasons, cancer and its treatments eat away at our healthy tissues. Anabolic steroids have the ability to reverse, to some extent, this tendency. Anabolic steroids have been used with HIV patients to great success [of course, individual response can vary]. I asked the treating physician if it would be appropriate to give anabolic steroids to my family member.
I expected that he would take a look at the references I found, or search his own library. Instead, he literally laid back in his seat, as if this was a casual discussion about politics, waved his finger around his ear to indicate that he was “searching his internal rolodex” to see if he could remember any literature that supported my suggestion. I was flabbergasted. The hubris was stifling. Admittedly, modern search tools were still not close to what they are today. But my suggestion definitely merited something more than a passing thought. He straightened up and declared that my suggestion was baseless. That was it.
If I had had private access to anabolic steroids [which are a controlled substance in the United States], I simply would have prescribed them myself. But I didn’t have such access, and I will never know if they could have helped my family member. I wasn’t trying to prove that I was right, and I wasn’t trying to prove that the expert was wrong. I just wanted to use my medical knowledge to help someone I love. And all that I merited was a passing thought.
The New Yorker article ends with the retirement of the physician in chief of the same hospital, my loved one was treated at. MG describes the sum total of the frustration that this maverick physician experienced at the end of his career, with the comment “the problem with [the physician in chief] is that he wants to cure cancer”. I have met doctors who were truly devoted to the welfare of their patients above all else. The vast majority of the small number of these physicians ended their careers in a similar fashion.
If you have muddled through this blog post until now, I will share with you significant hope for a better future.
For my 513th time, I will say that we live in magical times. Every day, it is possible to read about medical miracles, that are coalescing into a foundational change in the practice of medicine. There is a perfect storm forming which will bring a whole new age of healthcare to the world. I consider myself ultimately fortunate to have seen the beginning of this revolution. And I would be utmost thankful to G-d if he allows me to see the equivalent of the medical world’s splitting of the Red Sea, which is when we will effectively be able to cure every disease.
These days, a senior physician cannot make a statement without, at the very least, the medical students recording it and then immediately checking its veracity on multiple websites. It is no longer unusual for a medical student to ask, nervously, how the professor’s statement jibes with a paper that was published a week earlier in the New England Journal of Medicine. Professors can no longer declare the truth to be so just because it comes from their mouths.
Even more encouraging is a whole wave of new technologies that democratize research and the practice of medicine. In a very recent keynote speech from a conference appropriately called “Exponential Medicine”, the speaker described how, with nothing more than a credit card, a researcher could outsource the various components of the actual hands-on performance of various studies, and prove a theory. This new system of tools is so effective that high school students are doing work which was until a few years ago, PhD level research. Of course, as more and more data from both successful and failed studies is posted online, brilliant young people will be making discoveries that would previously have required entire university-based labs.
What is effectively happening is that the domain of the physician, professor and researcher is being dismantled. Those things that made research only possible within the walls of a university, are now being replaced by online services, which are open to all, independent of their title. Private business no longer has to wait by the door of the university lab, hoping that a marketable discovery will exit. Today, it is possible to sift through a seemingly endless list of companies, all of which are led by brilliant individuals, that are looking to radically change the world of medicine. It has never been so true that one only needs to build a better mousetrap so that the world should beat a path to one’s door.
With all of the people who carry a supercomputer in their pocket in the form of a mobile phone, it is now possible to reach out and find the necessary groups of people who are willing to partake in a given clinical study. The information is easily collected, stored and analyzed. And when the results are positive, all of this knowledge can be transformed into a profitable company within a very short period of time.
My wife, both supermodel and brilliant lawyer, tells me that many people study law without ever intending to practice as a lawyer. Legal studies are extremely helpful in various fields of business. The equivalent will soon happen in medicine. People will study medicine and even do a full residency without ever intending to practice in the field. Instead, they will do an MD/PhD type program which gives them the necessary skills to analyze the data that comes from their own or others’ research. The same doctors may specialize in fields that are very new or just coming into existence, such as medical informatics and biotechnology. This is hardly the medicine that Marcus Welby practiced.
When asked why he robs banks, Willie Sutton responded “because that’s where the money is”. Soon, medical research and even practice will fundamentally change because the public, who has the money, will demand a new model. The patient who leaves a doctor’s office dissatisfied with the care, despite the reputation of the physician, will easily search out another doctor who is kinder, more patient and who has access to all of the same information that the experts have. And in order not to starve, the self-important experts will have to change their attitudes or appropriately go extinct.
We are living in a time when patients don’t have to settle for the ridiculous and ancient mindsets of their doctors. I have seen horrible things done in the name of medicine. I hope soon to see wondrous things done in the name of caring for people.
Thanks for listening