EP. 35: ON MORAL INJURY IN MEDICINE

WITH DANIELLE OFRI

Nov 1

WITH DANIELLE OFRI, MD, PHD

An acclaimed physician writer shares how storytelling helps us make sense of suffering and what we can do about moral injury in medicine.

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Episode Summary

As one of the most prolific and acclaimed physician writers today, Dr. Danielle Ofri is the author of seven books on the intricacies of modern medical practice and the doctor-patient relationship. Her other writings have appeared in The New York Times, The Atlantic, The New Yorker, in addition to various leading medical journals. She is also the co-founder and editor-in-chief of the Bellevue Literary Review, a literary journal that publishes works focusing on the human body, illness, and health. In her writings, Dr. Ofri uses vivid narratives to shed light on the highs and lows of being a doctor. In this episode, she joins us to share her path to medicine, how doctors can mitigate the moral injury they experience in their work, and how storytelling can comfort us in times of suffering.

Danielle Ofri is one of the foremost voices in the medical world today, speaking passionately about the doctor–patient relationship and bringing humanity back to healthcare. She has written seven books about life in medicine and her writings have appeared in The New Yorker, the New York Times, The Atlantic, and leading newspapers across the United States.
Dr. Ofri’s essays have been selected twice for inclusion in the Best American Essays series and also for Best American Science Writing. She received the McGovern Award from the American Medical Writers Association for preeminent contributions to medical communication, and the National Humanism Award from the Gold Foundation. Dr. Ofri is editor-in-chief and a founder of the Bellevue Literary Review, a nonprofit literary arts organization that explores the intersection of healthcare and the arts. She was also an editor of the medical textbook The Bellevue Guide to Outpatient Medicine: An Evidence-Based Guide to Primary Care, which won a best medical textbook award.
Dr. Ofri received her PhD in pharmacology from NYU School of Medicine, where she worked with Eric J. Simon, PhD, to study the biochemistry and signal transduction of opiate receptors. She is a fellow of the American College of Physicians and a recipient of an honorary doctorate of humane letters from Curry College in Boston.
In this episode, you will hear about:
• How Dr. Ofri was initially drawn to internal medicine through the patient stories she encountered - 1:54
• A discussion of the tension between the business and art of medicine - 6:07
• Dr. Ofri’s advice on how clinicians can combat the moral corrosion that broken medical systems can induce - 11:29
• How Dr. Ofri’s medical residency during the AIDS epidemic led to her passion for writing - 16:33
• Dr. Ofri’s writing process - 23:30
• A discussion of the moral philosophy of medicine and why doctors do what they do - 27:09
• Dr. Ofri reflections on how her writing has impacted her clinical practice - 31:47
• The wisdom that physicians who encounter suffering every day can share with a world experiencing collective grief from the COVID-19 pandemic - 34:38
• A discussion of the emotional toll on clinicians of delivering bad news and confronting grief, and an exploration of guilt and shame - 42:25
• Dr. Ofri’s advice to clinicians on how to stay connected to meaning in medicine - 48:44
Henry Bair: [00:00:01] Hi, I'm Henry Bair.
Tyler Johnson: [00:00:03] And I'm Tyler Johnson.
Henry Bair: [00:00:04] And you're listening to the Doctor's Art, a podcast that explores meaning in medicine. Throughout our medical training and career, we have pondered what makes medicine meaningful. Can a stronger understanding of this meaning create better doctors? How can we build health care institutions that nurture the doctor patient connection? What can we learn about the human condition from accompanying our patients in times of suffering?
Tyler Johnson: [00:00:27] In seeking answers to these questions, we meet with deep thinkers working across health care, from doctors and nurses to patients and health care executives. Those who have collected a career's worth of hard earned wisdom probing the moral heart that beats at the core of medicine. We will hear stories that are by turns heartbreaking, amusing, inspiring, challenging and enlightening. We welcome anyone curious about why doctors do what they do. Join us as we think out loud about what illness and healing can teach us about some of life's biggest questions.
Henry Bair: [00:01:03] As one of the most prolific and acclaimed physician writers today. Dr. Danielle Ofri is the author of seven books on the intricacies of modern medical practice and the doctor patient relationship. Her other writings have appeared in The New York Times, The Atlantic, The New Yorker and various leading medical journals. In addition, she is the co founder and editor in chief of the Bellevue Literary Review. In her work, Dr. Ofri often uses vivid narratives to shed light on the highs and lows of being a doctor. In this episode, she joins us to share her path to medicine and to writing, how doctors can mitigate the moral injury they experience in their work, and how storytelling can help comfort us in moments of suffering. Dr. Ofri, thank you so much for joining us and welcome to the show.
Danielle Ofri: [00:01:51] Thank you. It's really a pleasure to be here.
Henry Bair: [00:01:54] You have led such an incredible career in narrative medicine, and we're going to get to all of that. But first, can you take us all the way back to the start and tell us what drew you into a medical career?
Danielle Ofri: [00:02:06] It's interesting because nobody in my family is a doctor. Everyone's a teacher. And when I grew up, I always wanted to be a vet because I love my dog. But then in high school, it seemed that everyone who likes science was going to be a doctor. So I just followed along. And the truth is, I had no idea, honestly, what it is that doctors did. But that's what you were supposed to do. So that's what I said I was going to do. But I ended up going to undergraduate in Canada at McGill a little bit by happenstance because it had a late application deadline and I was a bit tardy in that department, but I did not know I was getting myself into a British educational system where it's 100% science with no arts at all. And so you weren't just a pre-med, you had to be a physiology major or biochemistry or microbiology, very specified. So I found myself as a physiology major, and that's where it seemed that everyone who likes science was going to be a scientist. Medicine was just for technicians, and I really had never thought about a scientific career, but that's where this path was leading. And then I found out about the joint MD PhD program, which seemed the perfect solution to my dilemma. And so I did the MD PhD program because I figured I'll do both things and I'll figure out at the other end which one it is that I like. And the icing on the cake was that they would cover my tuition for that. So it was a great deal. And so I went and did the MD PhD program.
Danielle Ofri: [00:03:31] I had a really wonderful time. I love doing my PhD. I did opiate receptor signal transduction work at a kind of biochemistry lab, and I thought I was going to be a neurologist, but I'd be a bench scientist, do a clinic one day a week in neurology because I was doing neuroscience. So I did a one year medical internship in preparation for neurology, and I completely fell in love with general medicine and I fell in love with the patient stories. And I even remember the patient who was Mr. Feliciano, not quite his real name, but he was a gentleman admitted for endocarditis -infection of the heart valves- which required multiple weeks of antibiotics, and he didn't have insurance to get home antibiotics. So he was in the hospital for a very long time, and it fell to me as the intern to go every day, you know, do his vitals, do an EKG, check his heart. And each day he told me a little bit more about himself. And I got to know him really well over the course of, I don't know, six or eight weeks. And I became fascinated with the depth of how you would come to know a patient, especially when they're presenting sort of persona. In this case, he was a bit of a drug user. He was a bit on the edge of society, and yet he had such a rich and wonderful personality and story that I got to know as I spent time with him. And that's what really kind of sucked me toward clinical medicine. And of course, I ended up in the end doing primary care, which is exactly that.
Tyler Johnson: [00:04:57] You know, we have had multiple discussions on this show with doctors from many different parts of medicine and people who are not doctors as well, who have talked about the centrality of what you're mentioning, which is the stories that really make up the heart of medicine. And yet, at the same time, we just last week had a doctor on who specializes in the way that medical technology is transforming the medical landscape. And I think if you speak to many doctors now, they say, oh, sure, what I would love is to have 20 or 30 minutes every single day over the course of 6 to 8 weeks to go and get to meet this patient and get to know their story and all the rest of it. But what I actually have instead is 10 minutes that's been scheduled by the HMO that I work for to see the patient discuss all of their medical problems, get their prescriptions written, and hopefully start the node. You know, I hardly even have time to say the names of the medicines that they're taking, let alone hear anything substantive about their story. So I guess, how do you think about the tension between the demands of the business of medicine within which almost all medical professionals work and this ideal of wishing that we could have infinite or close to infinite time to get to know patients and their substantive stories?
Danielle Ofri: [00:06:29] Well, let's start by saying that the tension is real. But I'd also say that it's not our fault. And honestly, nor is that our responsibility to fix this. I mean, this is a systemic issue. This is not a problem- I think of those, you know, callous doctors who don't care about their patients, and of course, there are a few out there, but mostly, as you say, most physicians and I'll expand that to nurses and and all medical professionals, really want to take care of their patients and they don't want to be taking care of the electronic medical record or other data entry points that we have to do. But because our health system is defined by a business model and by private enterprise, we now have another priority in the health care system, and that is money. And of course, I'm going to be realistic. We can't function without money and of course we need to fund our hospitals, keep the lights on, pay our staff and all of these things. But I think we can see by now how it's really shifted into a business that prioritizes exactly, as you say, you know, getting through patients like an assembly line. And that's really to the detriment of our patients. You know, if you look at malpractice data, nearly every malpractice case can be traced to a communication error. And there are a couple, you know, they amputated the wrong leg, you know, cut and dried kind of things.
Danielle Ofri: [00:07:51] But most of them will come down to some kind of communication, whether from the doctor to the patient, doctor to the team, something interpretation of data. It's almost always about communication. And so when we think about ways to solve this particular problem, the malpractice crisis and medical errors, if we don't think about the time to communicate, we're really selling ourselves short. Because you're right, it's impossible to do real medicine, especially primary care in 10 minutes. I think the estimate is that it would take about 7 hours to do the entirety of the accepted primary care for every single patient. So we're always cutting corners. And when you ask committed people to cut corners, that's morally corrosive. And I think if we were maybe less ethical, we wouldn't care as much. But I think most people in medicine, again, there's a small minority who are we won't count those, but most people are in it for the right reasons and want to do the right thing for their patient. But we're forcing them to cut corners. So when you have 10 minutes and you must cover all these things, where are you going to cut your They're not going to give you the medicines. You're not going to ask about their mental health and social circumstances. You're not going to ask about the recent spouse who died.
Danielle Ofri: [00:09:03] You're going to forget a couple of screening things. You try and do one or two big things or the things you're required to Oh, you must do the asthma action plan. So you'll do that because you're required to do that, but you'll leave out the suspicion of an eating disorder. So we're going to cut corners. And when you care about what you do, cutting corners is is painful. And so I, I always hesitate to talk about the burnout of doctors and the burnout of nurses. That's part of it. But that's really the short end of the stick, because it's really a moral erosion in the way you're being forced to practice medicine or do whatever it is that you do in a way that's less good than you know you can do then you know you should do and that you know that your patient deserves. So I always hate when people say, Oh, well, let's have a wellness module, let's, you know, have yoga classes. Well, I don't want a yoga class. I love a yoga class, but I could use an assistant. That's what I could use, you know, or more time with my patients or I don't want a wellness module. I want to dismantle some of the craziness of our system. But I think I've probably answered your question maybe far too long.
Tyler Johnson: [00:10:07] You remind me at the end that when I was in residency, so this is for reference, right? I'm working 80 to 90 hours a week. I was spending every fourth day. I was on 33 zero our call in the hospital taking care of patients, and I loved it. But nonetheless, once a year we would have to watch these video modules. On the importance to your mental and physical health of uninterrupted sleep. And I was just like, what? Like there was some cGMP requirement that you be educated about the importance of sleep. But I was like, Yeah, but I'm working 30 hour shifts every four. Like, what good does it do me to know how important sleep is if I can't get any of it?
Danielle Ofri: [00:10:50] You know, I've often suggested that those who are making the policies, they ought to be practicing medicine, you know, one day a week, come to clinic once a week, you'll see what it's like, be on the wards, you know, one month out of the year. And when I feel like anyone in administration who has an MD or in after their name should practice clinical medicine for some portion of their time. And if you don't have an MD and then work the front desk and answer the phones one morning a month and then go ahead and make your policy. But you have to see how it actually lays out before you hand down, oh, some wellness module or some new administrative.
Tyler Johnson: [00:11:29] But let me together with that, I just want to ask you, because I imagine that many of our listeners hear you talk about that moral corrosion and hear you talk about the fact that the point of responsibility for the frustration that they feel in their day jobs is not really on them. Right. It's somewhere else. But still, I know that I imagine that many of them then hear that and think, well, yeah, I feel like I'm experiencing that moral corrosion. I feel like I'm it's like parts of me are eroding off of myself. Right. But then what? Right. Like, if you are the person who's caught up in that system, like, obviously it would be great to sort of jump ship and go to some other system, but and maybe some people can figure out a way to do that. But for many people, you know, some people go to concierge medicine or whatever, probably for that exact reason. But for many people who are operating within a system and don't really have the option or don't feel like it's ethically acceptable to just jump ship and go to a different system. Do you have any any thoughts about how to try to lessen the sense of moral corrosion, given that the system is what it is?
Danielle Ofri: [00:12:39] Well, I would answer that on two levels. One is the individual and one is the collective level. So just to start the individual level, you know, it really is unfair to ask the individual clinician to sort of shoulder the responsibility for fixing this very broken system. But there are two ways that I find gets the attention of the higher ups when you see a problem. And that is a defined that in terms of either patient safety or patient satisfaction, they're not really interested in, you know, doctor and nurse wellness other than just having to check the box. But medical errors, that counts for a lot. That's a big money. It's big reputation issues and also patient satisfaction because that's now tied to reimbursement. And so they care a lot about what the patients think of their medical care. And now sometimes they respond to patient satisfaction by getting a fancy coffee machine or a valet parking. But ask any patient, would you rather have the fancy coffee machine or more time with your doctor? Hands down, they want to spend more time with their doctor. I mean, do you want graham crackers in the waiting room or do you want the nurse to come as soon as you call her when you're on the wards? So it's pretty obvious where patient satisfaction comes from. So when I see a problem that is making me crazy, instead of saying, Hey administrator, I'm really miserable, I file a patient safety report and say this issue actually endangers patients.
Danielle Ofri: [00:14:01] And here's why. When I'm given 500, maybe I'm exaggerating a bit. But the patient safety, the medication safety alerts, I did one. I think it's the record in our hospital, 274 medication alerts for a patient on 18 medications and a complicated dose of warfarin Coumadin, which is a blood thinner that has a million drug interactions and they're on some crazy 988 milligram schedule and all. It comes in fours and five pills. So they had, you know, probably 24 prescriptions and everyone generates a ton of medication interaction alerts, which of course are important, but a lot of them are not. And it's so close your mind, you're missing the important ones. So I file a patient safety report saying that this endangers the patient because I'm going to miss the important ones. And when you file that report, the higher ups must follow up on that. That's a requirement. And so I put it in those terms or a patient satisfaction or and I have the patient, I say go to the patient advocate office and make a complaint about this problem. And so that's one way to to get attention. I think on an individual level, it's a little bit of a pain in the neck to keep filing patient safety reports.
Danielle Ofri: [00:15:11] But, you know, someone does have to follow up on those. The other way to think about this is collective and clearly much harder. But I think about the credibility and the voice that we gained throughout the pandemic. You know, back in the beginning, back in March of 2020, that 7:00 PM cheer, you know, that was the greatest thing, whether I was hearing it coming home from work or participating when I wasn't on it was the most inspiring time of the recognition of what people in health care are doing. And I think it's one of the first times that that the greater public really had a sense of the commitment that people put in when they go into health care. And I think that we gained a fair bit of moral authority from that experience, and we should use that. And, you know, trying to speak up as a group is obviously harder. But we do have our collective organizations, our professional organizations, and to really insist that they be speaking up for some of these things as well, that it's not just about, you know, reimbursement and getting the best deal for physicians, but what's right for patient safety and to really push the envelope on that.
Henry Bair: [00:16:20] You know, I don't think I've heard of advice for addressing the systemic issues contributing to our moral erosion through the lens of patient safety and satisfaction, especially when bringing it up to hospital administrators.
Henry Bair: [00:16:33] Switching gears a little bit now, many of our past clinician guests have mentioned having something they do that helps them stay connected to their mission in medicine. This is often an artistic or other allegedly pursuit. We know that for you, writing plays a large role in that regard. Can you share with us your journey in writing?
Danielle Ofri: [00:16:53] You know, when I attended medical school, went to residency, as I mentioned, I did the MD PhD program, so that was about a ten year block of time by the time I did both degrees. My internal medicine training was a long slog and it happened to coincide with the height of the AIDS epidemic, which similar to COVID, was a very brutal time. A lot of death and destruction, a lot of emotional exhaustion, a lot of death on our hands. And our patients at that time were, of course, mostly our own age, and their deaths were quite exquisitely brutal and it was very draining. And I remember thinking that some of these times with our patients in this situation were incredibly intimate and and intense. And I recognized that it's unlikely that I would ever be this close to patients ever again. That as you go along in your training, you're sort of further and further away than you are as the medical student and the intern when you spend hours and hours with each patient. And I recognize that the singularity of these experiences and I thought I should write these down, but who at time, you know, we were so busy and, you know, a patient would die in the bed, gets filled 10 minutes later. But I also think it wasn't just time. I think that it felt too close to the emotional bone at the moment. But after those ten years, I decided to take off some time, which was not looked upon quite so kindly, but by the powers that be.
Danielle Ofri: [00:18:21] You know, so on this academic track, you know, you're MD, PhD, you do residency, you become a chief resident, you have fellowship, you go into academic medicine. But I was really tired from this. I also had, when I was an intern, a very close childhood friend of mine, died of a sudden cardiac arrest from a rare heart condition. And that was really a turning point for me of of seeing that happened. And I suddenly began thinking, what am I racing for? I mean, I've been on this academic track since I was four years old, right? I even skipped a grade in high school to get there faster due to degrees. You know, I'm like, What am I racing for? And then I heard from a colleague one year ahead of me that she was going to do locum tenens, which is temp work for doctors. I'd never heard of that. But apparently outside the big cities there's a huge doctor shortage all over America and all these small towns. And you could work, you know, for eight weeks at a time. I thought, that is perfect, that is what I want. But every one of my supervisors says, That's a terrible idea. You'll forget all your skills. You'll never get back into academic medicine. And that is a quote from a faculty member who remains on staff, whose name I shall not mention. You'll lose all your connections. You lose all your ties. But then I spoke to a social worker who's not in the medical world. She said, you know, I think they're jealous.
Danielle Ofri: [00:19:40] And when she said that, I thought, You know what? That's it. I'm out of here. And I left. I canceled my New England Journal of Medicine subscription. I got some novels. I got a laptop, and I took off for 18 months. And I would work for for eight weeks in some small town in the middle of nowhere. And then after that, I would travel mostly in South America. Central America, where because I wanted to learn Spanish, most of my patients were from there. And then when the money ran out, I'd call collect from Oaxaca, like, Well, what do you got? And I'd end up in some other small town. And it was during this time, and I have to say, you know, there wasn't a lot to do. I live in Manhattan, so to go to a small town, there's really nothing to do. But that gave me the space to think. And that's when I began to write down the stories of the patients I'd taken care of. And I wasn't trying to write a book or write anything or do any allusive closure, a word that I shy away from. But I felt that I had to put the story somewhere, because if the stories stayed kind of up and alive and open, it's really hard to function because every one of them was emotionally wrenching. And you can't live your life right in the middle of the wound. You have to put it somewhere. I mean, you don't want to put it away completely and ignore it.
Danielle Ofri: [00:20:54] And I think when we do that, you know, those those emotions and those experiences come back to haunt us often in inappropriate ways. And when you see, you know, the screaming surgeon and the attendings yelling at the medical student, I often think this person never process all those experiences of their training. So it was a place to to put them somewhere where they're still alive but not actively bleeding. And so I began writing these stories in these small towns when I was traveling. And when I got back to Bellevue, I always wanted to work at Bellevue, which I love and remain to remain there to this day. There was a hiring freeze due to a financial crisis, kind of like now, and there's only a part time position open. And I had never considered working part time. It was 60%. But I you know, I had loans to pay off. And so I took it. And so on. One of those afternoons off, I picked up a writing brochure off the street on Second Avenue from one of those little yellow boxes and start taking a writing class. And that's the first time I began to work on stories. With a more eye toward craft of how to work these stories, nonfiction stories, and began sending them out to literary journals, really tiny ones. Honestly, circulation is less than your medical school class, I'm sure. But as they kept going, I started taking one on one classes. And then I remember a friend teacher told me that she was reading one of my stories and she missed her subway stop.
Danielle Ofri: [00:22:15] She said, Oh, that means it's time to get an agent. So I worked on getting an agent. And it's interesting experience sending you a work out. You know, the the rejection time was so fast. I imagine, like, the mail carrier was hand the manuscript and they would hand the rejection the same like mail transaction. But I got an agent and we we sent my essay collection out and it was turned down by, I don't know, 15 of New York City's finest publishing houses. I mean, really rejections, like, Oh, I think she should go write a novel first and then do this, like, write a novel. Why don't I have time for that? But I kept kept at it. And then finally, one of my pieces appeared in a journal and I got a call from Beacon Press, a publishing house in Boston. I was attending an awards, and the editor really liked my work and said, Do you have a book length manuscript? I said, As a matter of fact, I do. And I committed my one act of theft, and that is I borrowed a pre-paid FedEx label from my chair's office because I couldn't get to FedEx before it closed because I was on the wards. It was so busy, so don't tell them. But I mailed my manuscript to to Beacon Press and they accept it. And we've been together ever since. So it wasn't partly the planned thing, but that's really how it how it turned out.
Tyler Johnson: [00:23:30] I just love that it was one thing when you quit your job and your training, but when we knew that we you were really serious about taking time off was when you canceled your New England Journal subscription. That's when it really got serious. So I'm I'm curious if you can talk to us a little bit about I mean, you've mentioned this implicitly in your description of how you started writing, but but why do you write or what's it like for you to write or what is the relationship between the encounters that you have when you're on the wards or in your clinic and the process of getting those down onto the paper?
Danielle Ofri: [00:24:11] Well, those are three very different questions, and it also varied over time. So when I wrote my first book, I was really at that point looking back over experiences that took place over a decade. And so by the time that book finally came out, it was many, many years. And that book came to be titled Singular Intimacies: Becoming a Doctor at Bellevue. And my all my friends thought it was about French lingerie, but it was really about the seemingly intimate connection that a doctor and a patient have. And so by the time that came out, so many of those patients, many were deceased or sort of long gone. It was often ten, 15 years had transpired between then the event happened and when I wrote about it. So that was really kind of mining the memory, And the first two books were like that. Then the later books were little more in real time, which changed a bit of how I wrote, you know, For my first books I couldn't really go back and get informed consent from my patients for those I could track down, but most of them were not trackable. Writing more in real time. You obviously need permission from a patient and there's HIPAA and privacy regulations. But the most important thing is I always ask myself is what is the point of writing this particular piece? Does it have a larger drive and motive beyond just, Oh, this is a cool story, because then you risk exploiting the patient's story because don't forget the patient comes to you for their medical care and not for your writing career.
Danielle Ofri: [00:25:40] So I really do have to separate that. And the medical care absolutely comes first, second, third, fourth and fifth. So often, sometimes I'll use a patient in a vague outline where they wouldn't recognize themselves. But you know, a common scenario, it doesn't have to be so specific. And I'm always trying to find something that matters. So, for example, of a real time patient, early in the Trump administration, when the Muslim ban was passed and all the anti-immigrant rhetoric. So most of my patients are immigrants and many undocumented. And so the level of anxiety and fear was huge and it was palpable. And patients blood pressures went up and anxiety and need for anti-anxiety medications. And a lot of my patients struggled with the fact that maybe they and their older children were undocumented, but their younger children who are born here were documented. And would some of them be deported and some not very terrifying. And so I decided to write an article about that, and I asked a patient if I could use his story, and he emphatically said yes because he had no other way to make his story known to you. He was terrified of coming out of the shadows. He himself was not documented, and he worried that if he said something that could be used against him. But if I could say something without using his name or identifying characteristics, I could bring that out. So he was really grateful and I felt this was a way to bring a story to light that my patients were experiencing but themselves couldn't bring forward.
Tyler Johnson: [00:27:09] Let me switch gears a little bit before I get to this question. I want to make one thing really, really clear first, which is we as the co-host of this podcast, completely agree with you that there are systemic factors that certainly set the stage for physician burnout and moral injury and all of the things that you were talking about, which, you know, maybe we can influence them through collective action or whatever, but at least on a day to day, moment to moment basis are outside of our our ability to to change at least directly. At the same time, though, we also feel like through the course of many of the interviews that we have had, that one thing that we've kind of put our finger on that we feel like is important is that there may be, because of the moral injury and the systemic factors. But whatever the reason that there is also this prevailing sense among many physicians that we've just kind of lost touch with the deeper narrative or the more foundational reasons that we went into medicine in the first place, right? That there is this because on one level, of course, medicine is about making people feel better. But most doctors, at least at some point in their training or career, have a connection to a deeper sense of medicine as a almost like a metaphysical or spiritual practice. And so I'm wondering if you can talk to us a little bit about if you have that kind of a sense what does that sort of moral philosophy of medicine look like for you? What does medicine on that deeper level mean to you?
Danielle Ofri: [00:28:49] I think you put your finger on it and that is that helping our patients feel better and that is very broadly defined. You know, most of the things our patients have are not curable. We live in the age of chronic illness and there are very few wins like appendicitis or pneumonia that are easy cures. Most of our patients have whatever illnesses they have for their life, and many, if not most, are progressive. So we don't necessarily make them feel better by curing them. And so I think we have to rethink what it means to make patient feel better and to notice even the small wins. I mean, even, you know, re timing when you give the patient their Lasix or diuretic so they can go out in the morning and do their shopping and not have to rush for a bathroom and dose it in the afternoon. I mean, a tiny thing like that can have an incredible impact on a patient's life. And we we often forget that very small things can really matter. And beside the practical side, I think the other part that gives the deeper meaning is it really is this honor to be with our patients in this most vulnerable moment of feeling sick, of feeling frightened, of facing their death. And my kids always say, how can you deal with like people dying and all the blood? And and you're right, it's not necessarily pleasurable would be the wrong word, but meaningful that when you can make someone's passage to death less fraught and, you know, and more dignified and less painful and more supported, you've done the most amazing thing in the world.
Danielle Ofri: [00:30:29] I mean, I can't imagine what would feel better, more gratifying. I mean, earning more money that wouldn't even register on the gratification scale, but being able to be with a patient at the end or helping them through a difficult decision, you know, not just making the diagnosis of cancer, but whether to do a treatment, how we do the treatment. And those kind of decisions are so fundamentally human. And and that's where I think we have this special role. And I'm not a Luddite. I love electronics or technology, but you can't really substitute, you know, technology for that. I think it's the difference between being smart and being wise. You know, up to date in our various medical databases make us really smart. And thank goodness, could I remember the 20 kinds of vasculitis? Never that was gone, you know, years ago. And thank goodness I can look it up. But helping a patient decide how to do the treatment, whether the treatments are worth it in their life scheme and their, you know, philosophy, what they're willing to tolerate. That's the part of using the wisdom of medicine. And that feels like there's something really special that we have that makes it all the other stuff worthwhile.
Henry Bair: [00:31:47] Dr. Ofri, you have describe the many ways in which your clinical career has influenced your writing. But I'm wondering, how has your writing influenced your clinical career in turn?
Danielle Ofri: [00:31:58] Well, I'll start out by writing in medicine. That is a church state separation. They do not overlap, and I will never tell my patients that I'm a writer or anything like that. I mean, sometimes they'll find out and mention it to me, but most of my patients have no idea, and I keep it that way. And I never want to look at a patient thing. Huh? That's a great story. So I really kind of put down that wall. But you are right that the things we do as writers can make us better physicians. There was a wonderful piece that Abraham Verghese wrote many years ago, I think, in the Annals of Internal Medicine, called What Doctors Can Learn from Novelists. And, you know, if you're racing to catch a plane, you want to grab a book at the airport bookstore and you grab a book and you look at the first page, really quickly decide if you want it or not. In one paragraph, you will know if it's a great work of literary fiction or literary nonfiction or like a genre romance. You can tell two lines and and it's because in the genre romance detective, which can be a lot of fun, not just in them at all, but the characters aren't really developed, you know, they're often a standard kind of character. But in the literary work, we capture the individuality of the character by minutely describing how they look, how they appear, how they move in the world, what their voice is like.
Danielle Ofri: [00:33:19] And I don't mean just how they speak, but the way they use language. And that eye for detail is really what makes a good doctor. Great, right? A good doctor sees a patient and instantly knows something's wrong with the patient even opening their mouth. If you know a patient for a long time, you know, the way they move through this world and the way they speak, you know, when something's wrong. So developing that careful eye for detail is something we do a lot in writing, and I think it helps us become better doctors. And the other way I think it influences us is that, you know, I often think about it and not, I would say in the moment, but whenever a patient walks into your office or into your ward or you're in the room with them, you know, you're part of their story. You're a character in their story, whether you like it or not. You are part of that story. And and what you do as a character, the things you do, has an effect on the arc of the narrative. And so I often think about that we're part of this patient's story and that we have to respect that, that no matter how sort of removed and reserve we want to be, we are intimately a character in their story and have to respect how our actions affect our patient and their story.
Tyler Johnson: [00:34:38] One of the things that I have spent a lot of time thinking about over the last couple of years, to some degree, you can make the argument that the reason that the pandemic was so hard for everybody was because there was just so much suffering and death, right. In a way, in at least a concentration that is unusual for the world to experience simultaneously. But I also think that one other aspect of what made it so emotionally taxing for all of us is not even necessarily the additional degree of suffering. Because although it's true that COVID became a major killer of people of all ages, it's also true that there are major killers like that that stock people every day. Right. Cancer and heart disease and influenza for that matter, and whatever else. And so in a sense, I feel like what the pandemic really did is that partly because we were all just sort of stuck at home and endlessly scrolling whatever your preferred Twitter or TikTok or the evening news or whatever, it was just that the suffering was all right in front of us, right? Whether it was the death toll from COVID or whether it was the murder of George Floyd, or whether, like whatever the thing was, racial injustice, things that had been there for eons. Right. But like, the stuff was sort of right in front of our faces in a way that we couldn't escape it.
Tyler Johnson: [00:35:57] And I feel like that has caused this kind of societal reckoning with suffering. That is unusual because oftentimes as a society, we're good at sort of putting suffering out of our minds. But as doctors, we can't do that, right, Doctors. I mean, that's in large part what doctors do is to confront suffering with their patients. And as you mentioned earlier, yes, sometimes it's the earache in the eight year old that you can fix, or it's the pneumonia and the 60 year old that you can give antibiotics for or the cancer that you can remove by surgery. But much more often it's the diabetes that's never going away or the metastatic cancer that can't be cured or the operation that can happen because the person is too old or too frail or what have you. Right? There's just their suffering riddled throughout the entire experience. And so I guess as we watch the world grapple with suffering in a way that I think is is historically unusual, what do you think that as a doctor and a writer, what wisdom do you have to share -or do doctors more broadly have to share- with the world about how to encounter this degree of suffering and still allow life to thrive and to be meaningful and to find some sort of metaphysical purpose, even when things are so hard?
Danielle Ofri: [00:37:19] When you mention the ways that our patients suffer with chronic diseases. You know, I would add to that a lot of the suffering our patients have are things that are not medical. And one of the biggest frustrations I think, for trainees is when the is suffering for things that have to do with economics or immigration or spouses cheating on them, or a child with drug addiction or shoes that don't fit or having to work three jobs that that really do cause the suffering. And we know if we could solve some of those and I'll add food insecurity, housing and security, the many, many things that that come into it. And so in the way that our society now had to reckon with suffering that they can't necessarily control. We do that all the time and we love it. We can solve a problem with a great medicine or a great technology, but we're always dealing with suffering that's even beyond medicine. And when I talk to my students about what do you do when the patient's suffering, something that you that is not even medical, you know, it has to do with I have a patient whose daughter in her home country has cancer and she can't travel back because of she doesn't have papers and she wouldn't be able to return, so she's not able to go home. And that is the most suffering. And she couldn't give two hoots about the diabetes, hypertension and the cholesterol that I keep talking about.
Danielle Ofri: [00:38:39] And so every visit we have to start with talking about her daughter back home, that is the most important thing. And then we can get to the other stuff because that's the most important source of her suffering. And so the lesson that I try to give to my trainees is that a lot of what we do as physicians is to bear witness. We can solve a lot or even most of what our patients suffer with, but we can bear witness, and sometimes we're the only ones who will listen to the story of, you know, how they came to America, the struggles they had in their on their home country, the things they're dealing with at home, in their house, with their family, with their community, with with racial injustice. We may be the only ones who will listen to that. And you can say, well, you know, it's kind of like light hearted. You don't actually do anything. But listening is really important. And I think patients have the chance to unburden just some of what they're carrying and you can hold that with them. And so when I look at our society suddenly being faced with suffering that you can't solve, right? There's a war in Ukraine, there's a war in Yemen. You watch all the suffering.
Danielle Ofri: [00:39:45] It's painful. You, the individual can't change the suffering of children in Yemen. And so it's very hard. But sometimes if you allow yourself to kind of bear the witness of that, to take the time to read about one person's story and again, you're not solving it and maybe you make the donation to that. But it is important that you sort of hold that a little bit, that you take a little bit of that, and then it influences how you make your way in the world. Do you then have a little bit of extra attention for someone also suffering on the street or on the bus or in your family that maybe you didn't notice before? And so I try to keep kind of my eyes focus in two places. There's the larger world of all these big things that I want to be aware of. I can't necessarily change them sometimes overwhelming, but I can't shut the newspaper completely. But then the other eye is is more intimate. What can I notice a little more carefully about my own family or that distant uncle who I normally don't have much patience for, You know? And I think about what is that person suffering from? Maybe I can be this much more generous with my empathy to recognize that maybe what comes across as harshness might actually be some form of suffering. It's not easy because it's easy to get flattened and overwhelmed, and there are times we need to take breaks from that.
Danielle Ofri: [00:41:06] And I strongly believe that there's a role for the arts in that, because what the suffering makes us confront is that there's very little black and white and that most of what people suffer with are shades of gray and nuances, which incidentally, is very similar to how we do diagnosis. Most illnesses aren't clear cut. Oh, this is juvenile rheumatoid arthritis. No, it's complicated. It's nuanced and ambiguous. And we have to live with an ambiguity which is profoundly frustrating for us as physicians and for us as citizens of the world. But what has the I think, the best approach to living with ambiguity? I think it is the arts that great works of literature, music and fine art really revel in the ambiguous in in the parts that aren't so clear. That's what makes great art. Fascinating, right? So much more interesting to see complex art as opposed to simplistic art. That's why we like great works of literature and that when we read a flier, it doesn't really last with us. So I do think that that the arts have a great way for us to engage with ambiguity and understand how difficult it is and give us a place to rest those ambiguous. Feelings with someone else, an artist who has grappled with those same feelings.
Henry Bair: [00:42:25] One of the worst moments during my clinical training occurred during my inpatient medicine clerkship. It was one of my first clerkships and I was on my first week. A patient came in with what she thought was bronchitis, and our workup showed that it was, in fact, most likely metastatic lung cancer. She had masses in her lungs and liver and brain, and the fluid around her lungs had cancer cells present. The patient didn't know this diagnosis yet, and I was at this point quite interested in serious illness conversations, despite not having much real world experience. I decided to volunteer myself to lead that discussion and my team allowed me to do so. The conversation went pretty much as poorly as it could have. The patient responded, quite antagonistic to what I said, which of course is understandable in hindsight. After all, I was the architect of probably the worst day of her life. This experience is forever seared in my memory because of how she described what I made her feel to my team. She used words like hurt and unsafe. This felt like not only an indictment of a wrongdoing on my part, but an indictment of a wrongness and career choice. I had come to medicine to offer comfort, and instead I had done the exact opposite. It was around the time that I read your book, What Doctors Feel, and that book helped me in making sense of the guilt and shame I felt. So that book has a special place in my heart. It's clear that you've thought deeply about the struggles clinicians have with difficult emotions, often in the course of daily work. Can you tell us more about why you wrote that book and what advice you have for trainees about managing these difficult emotional challenges?
Danielle Ofri: [00:44:13] Well, first of all, I wanted to thank you for sharing that incredibly difficult moment, and I hope you found some peace with that. I suspect that her reaction may have conflated two things. One is your skill in doing that, and one is this horrific news. And I think for the patient, those may seem like one and the same thing. And why wouldn't they? I know for for her, that's the worst news ever. And so I hope that you've absolved yourself of some of the guilt, that some of the pain is just from the reality of the situation. I mean, one thing we do in medicine is we give patients bad news and we make them feel awful. Not intentionally, but we share bad news. Telling someone HIV diagnosis. You know that I've done that a lot and it's never pleasant. And the same with cancer and many other terrible things. We tell patients What we, I think then try to do is to be with them in that awful moment and not shy away. I think the average person would want to shy away and of course we would too. Who wants to be there in the worst moment? But staying there and spending the time sometimes can be difficult on the in-patient situation where, you know, people come and go pretty quickly and maybe different when we have long term relationships with patients. But those sort of emotions is really why I wrote the book, What Doctors Feel, because I had so many of them. And I also had a pretty horrific medical error that I committed right in the middle of internship. And early on as a doctor where I almost killed a patient.
Danielle Ofri: [00:45:50] I've had more than one of those. And you're right, I thought, Oh my gosh, I have picked the wrong career. Let me go work for a pharmaceutical company or someplace at a desk where I can't cause harm. You know, one thing Now I think about the difference between guilt and shame is so important. And I didn't really. They all just were bad feelings. But I recognize as I read more about it, that they're really two different things. And guilt is about the thing you've done and that pushes you to make amends. So if you maybe didn't present in the most empathetic way, there might be better ways to do that. And then there's places to learn that and people to learn that from. But shame is about who we are. And I remember in in the error that I had, one of the many errors that I made. But, you know, guilty was I felt plenty guilty, but it was the shame that was paralyzing that made me want to run and hide under a rock and never come out because we feel like we have failed. It's not just that we made a mistake, but we are the mistake and we have no business being in this field. Now, if you step back and think about it, if every doctor or nurse who made a medical error quit, well, that would be an adverse outcome for patients because there would be nobody left. You know, that's that's just the reality. Now, of course, we want to work to be the best clinicians we can and keep up our knowledge and try hard not to make mistakes and do things as right as possible.
Danielle Ofri: [00:47:19] But we'll never be perfect. And because that's because we're human and right, we could have our patients be taken care of by by our computers even that wouldn't be perfect. But maybe it would be better than us. Who knows? But it would miss a lot of the nuance. You imagine a computer trying to give a patient diagnosis of cancer. I mean, that just wouldn't play very well because we don't know how the patients will react. And we have to be able to be agile emotionally to support our patients as they grapple with the difficult diagnosis. And as I spoke to medical students and residents and practicing clinicians, I realized that everyone was thinking about this, but nobody wanted to talk about it. You always want to be strong. That strong medical student that's strong in turn. You never want to be that weak. One who, you know, goes off and into the corner somewhere and being strong. What does that mean? It means you put on this facade of getting everything right and we're so primed to want to be right and smart about everything. And then if you don't know the answer, just make it up or make you act as if you know it. Well, that's crazy. Shouldn't we be comfortable saying, Oh, I don't know, and quote, looking stupid on rounds because we're honest and rather than jeopardize our patients with our lack of knowledge, but go look it up. And so everyone seemed to be feeling this, but nobody wanted to talk about it. And that's really how that book came to be.
Tyler Johnson: [00:48:44] I resonate with Henry and with you in the sense that I know that the times when I have had those moments where even if I didn't make a even if I couldn't put my finger on an error that had been made. But just when things don't go to plan, right, you think the patient is getting better and then suddenly they take a turn for the worse or there's a problem that you had been so focused on this big problem and then this other one sort of sneaks in from the side of your view. And that's the thing that actually causes the most injury or whatever. Any time there is a negative thing that you don't anticipate, you you feel it, right? I mean, you feel it in your soul. And I know that that was the hardest part of becoming an attending for me was that when I felt like, okay, now the buck stops with me and I would wake up at 3:00 in the morning sometimes and think, Oh my gosh, if I had just ordered this test on this patient one day earlier, then X, Y, Z, right? In a way that was totally actually made no sense and was completely unfair.
Tyler Johnson: [00:49:46] But it just feels so real and so heavy. Right. And I think that's the flip side of the what it feels like when you are able to do real good on behalf of a patient is the flip side of it. It can be can be really heavy. So I think you've been so generous with your time, Danielle, and we know that it's almost gone to wrap up. We always like to ask. So in the midst of societal and technological and logistical and financial and all of the other changes that have, you know, have been overtaking medicine and will continue to over the decades to come for people who are just at the beginning of their medical career. Right. Somebody who's just going to go onto the wards for the first time in medical school or somebody who's just getting ready to start their internship and and they're having to do that, be down in the trenches in the midst of all of these many cross-currents of change. What is your advice for that person about how to stay in touch with the humanity that is medicine's beating heart in the midst of all of that change?
Danielle Ofri: [00:50:55] You know, one thing I like to think about is we are so fortunate to be able to be with patients at this most difficult time for them, and that we also have tools that we can also help patients feel better with our medications, our technology, or our attuned listening and support. So we both have the ability and the opportunity and the ability to help patients feel better. Imagine instead of that, you could be in a windowless conference room sitting with spreadsheets, moving widgets from point A to point B, which is what a lot of people in the world do. I mean, shoot me now. I would never survive in that. And thank goodness we get the the the pleasure and the gratification and the challenge of being with real people in the midst of real situations. It's not always beautiful or easy, but it's certainly alive. And you have the ability to move the needle for a patient, even one degree. And even if you were the lowliest medical student or the orderly without any skills, you do have things to offer and one of them is to listen. So often the patients have no one to talk to or to tell what's going on. And of course, often the medical students, the one who comes up with the right answer because they're the one who spent the hour listening to the patient in the middle of a long afternoon.
Danielle Ofri: [00:52:16] So being with the patient, even just saying, hey, how are you doing? You know, is there anything that we miss, anything that we forgot can be an amazing thing for a patient or go to the patient, say, hey, you know, a lot of us are still learning, but you're an expert in a manner of speaking. What is something that that we could learn, that I could learn to make me a better doctor, or that we could learn to all be better doctors and nurses and see what patients wisdom can be. It's often very surprising. So there are many things you can do. And don't underestimate your power in helping patients feel better from whatever angle you have. And the second thing I would say is keep your ears open. There's so much to learn and listen for from your patients, from your supervisors. As you watch the world around you, you know, you'll end up identifying who are the people I want to be like and who are the ones I really don't want to be like. And that will help you identify what are the aspects about medicine that are meaningful for you, and that could be different from one student to the next.
Danielle Ofri: [00:53:22] But you'll find those mentors and they may not just be other physicians. You watch how the radiology technician really helps that patient get onto the CT scanner bed with with a sense of gentleness that, you know, isn't this part of the job? But boy, does that make the patient feel secure and comfortable and look how their pulse goes down and relaxes. So there are things you can pick up all around you. There's so many teachers out there at every level. And don't just think about the doctors and the residents around you. And I guess the last thing is make sure you find 5 minutes for whatever's meaningful for you, whether it's reading a book or playing your instrument or listening to music or doing art. You know, if you if you read the new journal Medicine or Harrison's textbook of internal medicine, 5 minutes less, you will not kill any patients. I promise you you will not. But if you spend 5 minutes feeding your soul a little bit with whatever gives it meaning, you will be a better clinician for your patient.
Henry Bair: [00:54:28] Thank you for sharing your story with us, Dr. Ofri. I've been following your works for a few years now, so this is a true privilege. Before we conclude, though, I do have to ask about one thing. So I play the cello. In fact, during my college applications, I had applied to music schools simultaneously. I know that you play the cello and have written about the cello, and I would love to hear what pieces you've been working on lately.
Danielle Ofri: [00:54:52] Well, it's interesting. I just had my lesson this weekend. My teacher spends the summer in Italy, so we had a summer break. So it was a horrific lesson of all the things that went wrong. So what am I working on? So we've been working our way through the Bach Cello Suites, and I am on the prelude of Suite number five, which if you know the suites, that prelude is like very intimidating. It's five times as long as any other one. Bach was really going off the deep end. So there's that. And then I just started the Brahms Sonata. Number two, the F major, which is also very intimidating. I'm listening to Jacqueline Dupree play it at speed and thinking I will never get there. I did an article on Dr. Orchestras and I spoke to a gentleman. He played the double bass and he said just for the opportunity to touch the hem of that greatness, that's all I want and that's what I think. I'll never play like Jacqueline Dupree, but I can aspire to touch her hem, and that is all I want.
Henry Bair: [00:56:25] Thank you so much. That was wonderful. I loved it.
Tyler Johnson: [00:56:28] I love listening to music and I have no idea what any of the pieces that you referenced were. But I'm sure they're very, very beautiful. And I. But I do hear you about wanting to touch that kind of beauty. I'm. I'm with you there.
Danielle Ofri: [00:56:42] Well, go. Go. Listen to those pieces that are really worth your time.
Tyler Johnson: [00:56:45] I will do that. Thank you so much for giving us so generously of your time. We really appreciate it.
Henry Bair: [00:57:04] Thank you for joining our conversation on this week's episode of The Doctor's Art. You can find program, notes and transcripts of all episodes at the Doctors Art. If you enjoyed the episode, please subscribe, rate and review our show available for free on Spotify, Apple Podcasts, or wherever you get your podcasts.
Tyler Johnson: [00:57:22] We also encourage you to share the podcast with any friends or colleagues who you think might enjoy the program. And if you know of a doctor, patient or anyone working in health care who would love to explore meaning in medicine with us on the show. Feel free to leave a suggestion in the comments.
Henry Bair: [00:57:37] I'm Henry Bair.
Tyler Johnson: [00:57:37] And I'm Tyler Johnson. We hope you can join us next time. Until then, be well.