EP. 55: ADVENTURES THROUGH THE HUMAN BODY

Mar 29

WITH JONATHAN REISMAN, MD

An emergency physician, writer, and explorer shares what he has learned about medicine and health from having practiced in the world’s most remote places.

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Episode Summary

From Tanzania to India, from Tibet to Antarctica, Dr. Jonathan Reisman, our guest in this episode, has practiced medicine in truly diverse regions of the world. Dr. Reisman's talents and passions are unparalleled in their variety; he is, among many things, an emergency physician, naturalist, food writer, travel writer, and wilderness survival expert. He is the author of The Unseen Body, an exploration of the human anatomy through all of its miraculous, mundane, bizarre, and surprising parts, presented through the eyes of a lifelong adventurer. Over the course of our conversation, Dr. Reisman shares his experiences traveling through the most remote areas of the world, what his voyages have taught him about health and illness, the impact of emerging digital technologies on the doctor-patient relationship, and much more.

Jonathan Reisman, MD, is a physician, author, and adventurer. His interests include anatomy, food, travel, nature, wilderness and prehistoric crafts. He has practiced medicine in some of the world's most remote places, including Antarctica, Arctic Alaska, the Russian Arctic, the Himalayas of Nepal, rural Appalachia, the urban slums of Kolkata, India, and on Pine Ridge Reservation in South Dakota. He is co-creator of the anatomy-based dinner series Anatomy Eats, which explores human anatomy through cuisines from around the world using offal, internal organs and other unusual body parts. He runs a non-profit dedicated to improving healthcare and education in India. His first book The Unseen Body is currently being translated into 6 languages.
Born and raised in New Jersey, Jonathan studied mathematics and philosophy at New York University. After graduating, he lived and traveled in Russia on and off for 2 years while conducting research on the Russian timber industry. He spent five months traveling on the Kamchatka Peninsula among indigenous reindeer herders, and then returned to the US to attend Robert Wood Johnson Medical School in New Jersey. Jonathan did his residency in both internal medicine and pediatrics at Massachusetts General Hospital (MGH). He lives in Philadelphia with his wife and children.
In this episode, you will hear about:
• How a love of the natural world led young Dr. Reisman to travel abroad and ultimately to the medical profession - 2:04
• Dr. Reisman’s early adventures studying sociology in the Russian Far East - 5:30
• The parallels between exploring the natural world and the human body - 9:26
• The puzzle-solving aspects of medicine and the impact of emerging technologies and artificial intelligence - 12:18
• Dr. Reisman’s reflects on his time practicing medicine in India, Tanzania, Nepal, and Antarctica, and the importance of the physical exam in these settings - 21:15
• The strengths and limitations of the physical exam, especially as they relate to the clinician-patient relationship - 31:53
• How artificial intelligence will complement human physicians in the future - 36:38
• What Dr. Reisman believes is critical to the future of medical education - 46:12
• Dr. Reisman’s advice to young clinicians on how to keep their curiosity alive - 55:10
Henry Bair: [00:00:01] Hi, I'm Henry Bair.
Tyler Johnson: [00:00:02] 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 healthcare 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 healthcare, 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] From Tanzania to India, from Tibet to Antarctica. Our guest in this episode, Dr. Jonathan Reisman, has practiced medicine in truly diverse regions of the world. Dr. Reisman's talents and passions are unparalleled in their variety. He is, among many things, an emergency physician, naturalist, food writer, travel writer and wilderness survival expert. He is the author of The Unseen Body, an exploration of the human anatomy in all of its miraculous, mundane, repulsive and surprising glory, presented through the eyes of a lifelong adventurer. In this episode, Dr. Reisman shares his experiences traveling through the most remote areas of the world, what his travels have taught him about health and illness, the impact of emerging digital technologies on the doctor patient relationship and much more. Jonathan, thank you so much for taking the time to join us and welcome to the show.
Jonathan Reisman: [00:02:01] Thank you so much for having me.
Henry Bair: [00:02:04] Yeah, so to kick us off and I know this is not a straightforward story, but can you share a little bit about what first drew you to a medical career?
Jonathan Reisman: [00:02:14] Sure. So I did not want to be a doctor through high school. Through college. I finished college without doing any of the sciences that would be required to go to medical school. But then I was out of school for a few years and traveled pretty extensively, lived abroad. And I guess then it started occurring to me that perhaps being a doctor would be a career that I liked, partly due to the ability to travel and to sort of serve people, to be useful to people, no matter where you go in the country or the world. Especially helping the downtrodden was attractive. I love traveling and the thought of traveling in the context of doing some medical work related project or just helping people in whatever locality I was in was was definitely attractive. Another thing was I have a lot of hobbies like crafts using like using my hands. And I thought that being a doctor would be a great combination of two things I liked one using my hands and the other using my brain to problem solve, almost like a detective observing on a detailed level, putting together clues and sort of figuring out a mystery. It turned out I was right. You know, depending on your specialty, you use your hands more or your brain more or less, which I ended up in emergency medicine, which I think is a great combination of those two. But if you ask my mother, who was sort of telling me to be a doctor from the time I was small, she would probably say that eventually I just realized she was correct.
Tyler Johnson: [00:03:43] You could grow up to be a doctor, a physician, or someone who helps people get better from being sick. Right. Any of those were fine choices, right?
Jonathan Reisman: [00:03:50] Those are the only three choices, however.
Henry Bair: [00:03:52] Yeah. So I'd like to dig into your lifelong love of adventure and exploration. You know, we typically think of being an explorer as a dream that kids have, a fantasy vocation that is all but unrealistic in the real world. And yet you were able to, for all intents and purposes, become a professional explorer. Can you tell us how that happened? How did you initially get into traveling?
Jonathan Reisman: [00:04:18] Sure I did not travel much before the end of college and really got the travel bug after that. I did get the bug while in college of being interested in the natural world and learned to, as I write in the book, identify wild edible plants and some wild edible mushrooms and just got fascinated with understanding all sorts of species and how they interact and how they comprise an ecosystem and sort of how that works on a higher level. And that that fed into the travel because when you travel, you end up in sort of different climates, different ecosystems with different natural worlds. You end up interacting with cultures who raise different animals, eat different plants, have different forests surrounding their villages, etcetera. So I think the love of nature and wanting to see all the varieties of nature across the earth played into the travel. But my first big travel was a few months after finishing college. I ended up going to Russia for six months and interning at a social research center based in Saint Petersburg. The way that came about was while I was in college. I took summer school classes in environmental science, and my professor was a Russian researcher who studied basically the social aspects of the environmental movement in Russia since the end of the Soviet Union.
Jonathan Reisman: [00:05:35] I think it was a sort of a science requirement that had to be checked off for most other students. And I was actually fascinated with the class, perhaps the only student who was actually interested. And so I ended up helping this professor with some of her grant applications, editing the English and some of her papers that she was writing based on her research. And then she invited me to be kind of an intern at her center in Saint Petersburg. And then over the next two years, that led to four different trips to Russia. And basically after the last one, when I was in the Kamchatka peninsula of the Russian far east, it was kind of there that I decided I wanted to go to medical school. I was sort of doing sociology research and I had been to a few sociology conferences and realized that academic sociology was not for me. So I wanted something a bit more hands on.
Henry Bair: [00:06:22] Kamchatka that would be like in the wilderness, right? You were living pretty like far in remotely, remote places.
Jonathan Reisman: [00:06:28] Yeah. Kamchatka is on the very far east of Russia, right across from Alaska, basically. And it's known in Russia. It's known as Siberia's Siberia because it's so far away from the major urban centers of western Russia. There is a city there, Petropavlovsk-kamchatsky, and there are some towns, quote unquote, but there are tons of villages. I mean, it's basically the size of California with about 300,000 people, and most of them are in one city. So it's very remote and very wild and really quenched the the desire for wild nature and for seeing a new kind of ecosystem and understanding new plants and animals. And also the native cultures that lived have lived there for a long time and still live there, plus the sort of recent history of the Soviet Union and then the post-Soviet period. So it was very fascinating in every way. And yeah.
Tyler Johnson: [00:07:20] So if it was that that wild and that remote, can you you must have a story of a close scrape with some sort of animal or some adventurous situation. Can you, can you tell us one?
Jonathan Reisman: [00:07:32] Sure. One trip I went on, I was in the A town in the center of Kamchatka called Ezo, where there's a lot of it's a big tourist attraction because there's a lot of geysers and hot springs. And the town actually has a very large swimming pool that's totally fed by this naturally hot water. So it's a heated swimming pool that just comes sort of from the ground. While I was there, I was sort of just traveling. And when you're traveling, you sort of follow your nose and anything that sounds interesting, you go investigate it. And a family, a couple and their child were heading out of town on horseback to their hunting cabin, which was a few days travel away. So I said, can I come and, you know, contributed food for the trip and other things and ended up joining them on my own horse. And we traveled kind of through these roadless mountains for about three days camping to get to their cabin. Learned a lot about how you navigate through the mountains and how you find the right mountain pass to go through. And I talk about there's a story about that in the in my book.
Jonathan Reisman: [00:08:31] And we definitely surprise. We saw three different bears on that trip. I think one was so far away across a huge valley that I could not even believe. The native guide, the husband of the couple had seen it through his binoculars. It was like a brown dot. And he gave me the binoculars, said There's a bear. And I saw it. I said, Really? Is that a bear? And he yelled as loud as he could. And it echoed through the valley. And I saw that brown dot lift up its head. And so I sort of I saw how familiar these two people were with the land and they were so familiar with it, even though it was a complete wilderness to me and all of the animals and plants living on it. And that was really special. And something something that I was seeking out and truly found was to see a different way of life and different way of interacting with the natural world. So that trip was really amazing. Another time we did surprise a bear and it just ran away instantly, which is usually how the large majority of bear encounters end.
Henry Bair: [00:09:26] You've written about how your international travels eventually guided you towards medicine and in fact shaped your approach to medical school. Can you tell us more about what those parallels were? The parallels between your explorations of the natural world and of the human body?
Jonathan Reisman: [00:09:43] So I think a lot of that travel just sort of focused me on what I was interested in and the research I was there to do wasn't that interesting in the end. I sort of loved being there and interacting with people, hearing their stories, learning about their culture and history. But I think being being more practical and again, using my hands was something that really attracted me. I think the book reflects that. The way I explain it is the sort of mindset that I brought to medical school "the Traveler's mindset," "the Nature Explorer type mindset," the desire to be interested in in everything. Be interested in how things work, where things come from, how different people do things differently, how different parts of the earth function differently, etcetera. I think I brought that same sort of fascination to medical school. And so once I started learning about the body, I similarly followed my nose or just got interested in different aspects and it led me down some interesting paths and gave me some good stories that ended up in the book. For instance, in Anatomy Lab, when we were dissecting our cadavers, one of the professors talked about always like to mention which cuts of meat correspond to which muscles in the cadaver we were exploring. And that really struck me. And I thought, oh, that's really interesting. I want to learn more about muscles and how they become meat and which muscles are which. And so I found a slaughterhouse an hour away from where I was going to med school less than an hour and and just called and said, can I come on the next slaughtering day and learn about things? And they were hesitant.
Jonathan Reisman: [00:11:18] But once I convinced them that I was not a Greenpeace activist, they said, okay, sure. And then I ended up writing about that for an article in the New York Times, and then it ended up in my book as well. So that's sort of, I think, that sort of "follow your nose, interested in everything, want to dive deeper into the zany questions of how does anatomy and the way the human body is built and correspondingly how the bodies of animals are built" relates to just about everything, you know, whether it's food or different cultures, plants, prehistoric crafts. That was another one of my hobbies that I got interested in college. I learned how to tan hides and make tools out of stone and bone and antler just because I was super fascinated with like, how did people in the ancient world live? Where did they get their materials from? How did they make a knife to cut things? You know, before there was metal? These sorts of questions I just found fascinating and ended up exploring them before medical school and then after medical school, they sort of provided a context for how I explored topics that arose when I was studying the human body.
Tyler Johnson: [00:12:18] And I'm curious, you mentioned early on that one of the reasons that you one of the things that drew you to medicine was this idea that you would get to be a puzzle solver or a detective. Have you found that to be born out? Can you talk a little bit about sort of how to look at medicine as a as a puzzle solving field?
Jonathan Reisman: [00:12:40] I think when I made that decision, I didn't fully know what I guess making a diagnosis was like, for instance. But I knew there was some cerebral activity going on. You know, you had to think you had to know a lot and you had to process things and come to a conclusion. That was probably it, but found that, yes, I do think medicine has a tremendous aspect of being a detective and problem solving, a combination of using, you know, a combination of having a lot of knowledge in your head, a lot of experience with these body parts and the human organism, etcetera. And then also observing very astutely using your all your senses, really everything from sight, you know, touch hearing. Of course, when you're doing a physical exam, even smell definitely comes in handy. Not taste, thankfully anymore, but maybe in the past. But I think that, you know, a naturalist also has an incredibly vast knowledge of all the species in a natural setting and then observes really astutely and can sort of see details that the average person might not see. And I think that's true of a traveler, too. You know, travel writers especially use when you travel, you see more. And when you're a writer, you look at things differently more deeply.
Jonathan Reisman: [00:13:54] You notice details that the average person might not notice because you got to write about it. So I think the same is true in medicine. So observation and knowledge go together. When I was doing my rotations as a third year medical student, I did find that internal medicine was the most sort of detective like work and sort of the broadest experience. You know, you're taking clues from every body part, from tests of every bodily fluid, every kind of imaging technology. You know, you're sort of a generalist. And I was always sort of interested in everything. So the idea of sort of knowing everything, which I think interests internists perhaps come the closest to, was really fascinating. And I thought I wanted to go into internal medicine. And then after my third year, I took a year off, spent a bunch of time in India, and one of the experiences there was treating a lot of children with a variety of vitamin deficiencies and other conditions that I had read about but would likely never see in the US. And that got me really interested in children as well. So I ended up doing med PEDs and studying both internal medicine and pediatrics.
Tyler Johnson: [00:15:02] I'm curious, do you fear that some of the observational aspect of medicine and even some of the puzzle solving aspect of medicine is at some point going to become a relic of the past? That the reason that I ask this is because so I'm a medical oncologist and we are rightly very concerned about infection risk and especially during the pandemic. And so during the first really year and a half of COVID, we very aggressively moved, as I think most doctors did, to a virtual only format whenever possible. Right. And almost all of the visits that we did for a long time were video visits. Then starting about a year ago, we started to try to pivot back to having more normal in-person visits. But because Medicare still pays for virtual visits, those are still an option. And one thing that we've found, to my surprise, is that most of our patients just don't want to come to the doctor's office because it's, you know, I mean, we have people who come from far away. So I totally get it right. Who wants to drive for four hours? If you can just hop on a zoom chat or whatever. And then in some cases, in many cases, Medicare will even pay for telephone visits as if it were a doctor's visit.
Tyler Johnson: [00:16:14] And so all of this is just to say that it's not that it's impossible to observe things. And in fact, you can even observe some things over a Zoom visit that you can't observe otherwise. Right. About their home environment and all that kind of stuff. But I have to admit that for me personally, it just it really feels like it's hollowed out a lot of what made medicine medicine, right? Like, I feel like I sort of take care of ghosts. There are these kind of video avatars that I like see on the screen, and I have this idea that they have cancer. But, you know, I mean, you can't really do I mean, you can do some aspects. I know of a physical exam, but it's just not the same. Right. You you can't feel their pulse. You can't listen to their lungs. You can't I mean, you can't do any of that stuff. And then by the same token, I sort of feel like, of course, the big thing in the news right now is Chatgpt. Right? And then there's this whole I don't know if you guys saw, but there was this really frightening New York Times article this morning about where the author had a an extended chat with the Bing Chat Bot, the part of the new Bing chat bot that's powered by Bing GPT, and by the end of the chat the chat bot was professing its love for the New York Times writer and then was not allowing the writer to talk about other things, like it wanted him to come back and talk about the chat bot and like confess his love and leave his marriage.
Tyler Johnson: [00:17:30] This is all true. It's a really frightening article. Anyway, all of this is just to say that I also wonder with generative, artificial intelligence and all that other stuff, if a lot of the diagnostic puzzle work is eventually going to be some bot saying, Well, this is what the person obviously has and the doctor just saying, Oh yeah, that's right, here's your antibiotic. Anyway, so you know, maybe I'm just being a Luddite, but I just I fear that because I agree with you that like, that stuff feels like the sort of romantic heart of medicine. But I wonder if some of it is going to go by the wayside.
Jonathan Reisman: [00:18:00] Yeah, I think that's a very important question. And as technology advances, it will probably become harder and harder, not only like AI, but just better, you know, better imaging, definitely supplant some of the physical exam, does supplant all of it. No, I think also different areas of medicine might be different. For instance, in emergency medicine or urgent care, let's say I often joke that telemedicine is just a more efficient way of getting azithromycin to people who don't need it. Um, and I think like some things you can't do over telemedicine, but I guess some things you can is the thing. And I also think as every aspect of life becomes so much more convenient and easy, you know, you can do almost everything without leaving your home from shopping to ordering groceries and so much else. I feel like every time I have to actually get up and go to the post office, I'm slightly outraged that I actually have to even leave my house to to do that. It seems like in this day and age when you don't have to get out of your chair, we should be able to to do almost anything. I do think there's a place for that. Like my daughter had a rash and, you know, getting I mean, I'm a doctor, but I wanted someone else to look at it. Her doctor messaging system, they said, Oh, why don't you make an appointment? And, you know, the the first one is seven days away.
Jonathan Reisman: [00:19:17] And I said, Well, can I just send you a picture? And they were a little resistant. So I do think that there is some there has to be some movement towards making things more convenient for people. And I hope that would also cut costs just because it's very difficult. You know, people have to take a day off from work, pull their child out of school, drive for a while, park, be frustrated in the waiting room and all sorts of other things that I think are people are less and less tolerant of. Not that that might not be a good thing, but they are definitely less and less tolerant of it. Another interesting thing, actually, my wife is a professor of bioethics at University of Pennsylvania, and we lived down the street from UPenn. But she's studying a lot of do it yourself and direct to consumer things. You can do almost any blood test on yourself from home just by ordering it, and they send you a kit. So she she's been ordering these kits just to experiment, see what they're like, see what the consumer experience is like. And she ordered a kit for thyroid studies. And so it came with a little finger prick set. And you don't need a prescription for these. These companies just sort of have a doctor that signs off on everyone automatically.
Jonathan Reisman: [00:20:22] And I think we're heading that way, for better or worse. But one one other story I'll tell is my wife had a rash of last year. To me it looked like petechiae, which was concerning that she might have low platelets. And I was actually concerned, you know, as a doctor, you know, a little too much. And so I was convinced for about two days that she had leukemia. She doesn't, thank God. So I said, call your doctor. I want you to get a blood cell count, get a blood test. And so she emailed her doctor and they said, oh, yeah, we'll get you in the next appointments ten days from now. And I was thinking, I'm not waiting that long. So she actually ordered a blood test through the Internet and it was an automatic. You order it and then you go to Lab Quest or, you know, one of the normal lab places. It's not a do it yourself, but you can order it yourself. She got a CBC that same day for 25 bucks. She went to the local lab. Quest or quest or lab core had it done and we had the results. They were all normal. And so I think there's going to be a lot more movement in that direction. And for better or worse, doctors are going to have to adapt and have to make it more convenient and easier for people.
Tyler Johnson: [00:21:24] I'm imagining the start up that the three of us are going to put out there, which is going to be at home testing for doctors to prove that they don't have diseases that they already really know they don't have, like heart failure and leukemia. But, you know, we can sell it to every medical student when they're going through their, like, lymphoma block And they think they have swollen lymph nodes or whatever.
Jonathan Reisman: [00:21:44] Yes, I had a lot of diseases during medical school that ended up not not being diseases.
Henry Bair: [00:21:51] Yeah, I like that, Jonathan, you talked about yes, these technologies are going to be a fixture of most many of our lives, certainly in the United States. But I think the perspective that you bring that's really fascinating is, you know, for example, you talked about your time in India, seeing things that you don't see here. You have that international perspective. And it just it's true that it just looks very, very different. Medicine looks very different depending on where you are. And I'd like to explore that a little bit more. Can you tell us after medical school, what are some of the places internationally that you've worked in and what are some of the most impactful and eye opening ones?
Jonathan Reisman: [00:22:34] As a medical student in India was probably the most eye opening. Shadowed in a public, a large public hospital in Mumbai, India, called Kem Hospital, where I often say that my pathology textbook came to life because I saw just about every disease that I learned about and would probably never see practicing medicine for an entire career in the US. And then, as I mentioned before, I worked in Calcutta for a medical charity and ended up doing a screening for about 70 children who lived at an orphanage just at their request and found all these vitamin deficiencies and other chronic illnesses. And that was very eye opening to during residency and after residency. I did some global health research studying newborn resuscitation, especially through the The Helping Babies Breathe program, which tries to train people in resource poor settings to better resuscitate newborns who are not breathing and vigorous kind of right after birth. And so I did some work in India and in Tanzania on some projects related to that, which was also very eye opening. I think whenever you do global health, it's often very frustrating because you think you can have a big impact. And then when you get to some of these locations, you realize all the reasons that it's very difficult to make these changes. And if it was easy, they probably would have been changed already. And there's tons of issues. I mean, money is just one, but there's so much money going into a lot of these projects. Yet still due to geography or culture, resources, other limitations, it's just so difficult to make huge impacts like you think you're going to think. And that was also very eye opening in a different way.
Henry Bair: [00:24:14] So how have your travels around the world and your work across vastly different cultures informed your perspectives on medicine and health?
Jonathan Reisman: [00:24:23] Practicing medicine in different cultures and in different geographies is always very eye opening and enlightening, not only because it shows you new diseases that you might not have experienced. When I went to India, I saw a lot of diseases that used to be around in the US but are no longer due to, you know, more hygienic conditions perhaps, or just due to reasons we don't always understand. For instance, leprosy disappeared in the US before we really had good treatment for it. Why did it? I've read that it's not actually clear why it disappeared. And then you also see climate related stuff. So in India I saw malaria and dengue and other other sort of tropical diseases that I also wouldn't see just because I don't practice in a tropical region and typhus, typhoid, etcetera. I think learning seeing new diseases is always very eye opening. I think also in India, seeing in the public hospitals where you have to pay for every test or every bag of IV fluid out of pocket. And many people can't afford it like the doctors, for instance, do rely on physical exam much more. And I was totally blown away by how good they were at doing these physical exam on their patients.
Jonathan Reisman: [00:25:32] I think some factors there involve that people often don't seek out medical care until it's very advanced because they can't afford the health care. So they keep working until they're so sick that they just can't get up and go to work that day and then they seek care. So I think the disease is being very advanced helps. And actually, I think the overall lower weights help to a lot of people in India. Not only the poor are much skinnier than Americans and you can just hear and feel and see everything much better. I remember a very skinny man with thalassemia that was totally untreated. You could see his spleen and liver moving with respirations moving down and up at each time he breathed. Just because they were so big and because he was so skinny, partly from being poor, partly from having advanced disease that was probably making him waste away. So I think all those give you a different perspective on the practice of medicine in the US and really made me want to sort of perfect the art of physical exam. Though as I mentioned, I do recognize, you know, the place for imaging and I'm sure that will only increase.
Henry Bair: [00:26:37] Were there any patients or diseases you encountered that were particularly surprising to you?
Jonathan Reisman: [00:26:43] I would say just that I saw a surprising amount. Surprising diseases in surprising places, I would say. For instance, I was working at high altitude in Nepal and there was a monk, a lady who lived in a cave sort of up the hill from our clinic, and she had lived there for about 35 years. I write about her in the book as well, and the Brain chapter, and I was really shocked to find that she has hypertension and Type two diabetes and comes to the clinic every few months to just get things checked and to refill her medicines. She takes medicine. I think that was just surprising because people would imagine a monk living in the high mountains on a very ascetic diet would be the picture of health. But no, she had I still can't explain actually why she had these sort of very common chronic diseases of modernity. But but she did. And so you sort of see disease everywhere you go. It can be surprising.
Tyler Johnson: [00:27:39] You mentioned this a little bit, but I, I know during residency I went and practiced at an HIV and TB clinic in South Africa for a while. And it was revealing to me precisely because, as you mentioned, you were so much more reliant on history and physical exam because any kind of diagnostic test that you wanted to run, like if you wanted to do blood tests, you had to send them to an outside place and then they get the blood run and then you'd have to get the results back sometime later. And if you wanted to get really the only kind of imaging that they had, I think they had a sort of an old fashioned ultrasound probe and then they had a place where they could do chest x-rays, and that was about it, right? If you wanted to get a CT scan, it was like a three hour drive into a hospital in the city. And then, I mean, it was just a totally, totally different world, I guess. I wonder when you have practiced in other places that don't have the same ready availability of all of the stuff that we take for granted here so often, do you find that the practice of medicine in those places is richer? Is it just different? Does it feel more? I mean, I feel like it's tempting to paint a sort of romantic picture that, you know, that's what medicine used to be like or something. But I'm curious what your experience that way has been.
Jonathan Reisman: [00:28:56] Yes, definitely. I think it definitely changes the way that you practice what you have access to. And that includes not only diagnostics and imaging technology, but also consultants. So working in rural America or some of the other places I've worked, like Arctic Alaska, I worked in a hospital there. We did have a CT scanner there actually, and 24 hour ultrasound, but there were no specialists of any kind, even general surgeons. And the same was true on I worked on Pine Ridge Reservation in South Dakota. We had no MRI, but every other kind of imaging technology that an ER doctor would need. And now I work in rural Pennsylvania where we do have MRIs, but still no specialists. And I think the less technology you work with- So I also worked on some cruise ships where there was no technology of any kind. You know, there's finger stick sugars and even an EKG machine, but not so much more than that. And I think you do actually, when practicing that kind of medicine, which could be called "wilderness medicine", I think that you end up being more reliant on your physical exam skills. And I think it's really helpful because you end up trusting your physical exam skills more When you listen to a patient's lungs in the middle of nowhere, you have to really like, do you really hear something or not? You know, you can't just be like, Well, I think I hear this. Let's just get an x-ray and and figure it out, which is probably how even I do it in the E.R. Like, I think I heard this, but we'll get an x-ray. I mean, what you hear is all there is.
Jonathan Reisman: [00:30:22] And so if you aren't sure or you don't take the listening act seriously, which I think a lot of doctors do, even in my all E.R. is modern hospitals. You know, you listen, but maybe you don't take it as seriously or convince yourself as assuredly that you're hearing what you're hearing because you know, you're just going to get some imaging study or do a blood test. And I think it does boil down to the sort of essence of medicine in a way. Not to romanticize, but I think it actually does. You have to rely on your history. You have to hone those physical exam skills and you have to then make a diagnosis or a presumptive diagnosis based on what you see and hear without the usual confirmation. So I had a patient in in Antarctica. I was a doctor on a ship with 160 passengers from Japan. A man became confused and had a low grade temperature. When I felt his pulse, it was very fast and very irregular. And so usually I think I would be like, well, let's get an EKG, put him on the monitor. Maybe it's AFib, but after feeling his pulse, I was like, He has rapid AFib done. And so you come to diagnoses more firmly and have to start acting on them sooner without the. Well, let's confirm. Let's see. What could it be? You have to make a diagnosis and act on it whether you are sure or not. So I think that mindset is very different from a modern hospital, and I think it does hone a lot of your your decision making and your certainty and your physical exam skills.
Henry Bair: [00:31:53] There is another piece of this when we talk about the physical exam. Dr. Abraham Verghese has probably done more than any other physician in advocating the idea that the physician's touch still matters in our digital age. When we had Dr. Verghese on the show all the way back in episode 11, he told us somewhat unexpectedly that he was supportive of this shift towards telemedicine because by and large, this is better and preferable for many patients. He mentioned another point that is quite relevant here, Jonathan. Earlier you mentioned how physicians in the US can often be unsure of their physical exam techniques or will hedge when it comes to their exam findings. What Dr. Verghese points out is that patients can tell when you're not doing a thorough or proper job of it. And what is the point of having your patient drive four hours to your clinic, wait an hour in the waiting area only to have you spend five minutes on a half hearted cursory exam before you announce that. "Oh, we'll just wait for the labs and imaging to tell us what's going on." It makes a difference to the patients. I think this is a point that really shouldn't be overlooked, and I like that for this and many other reasons. There is true value in honing these physical exam and history taking skills.
Jonathan Reisman: [00:33:14] Yeah, I think there's definitely value. It's hard though, when I think by by automatically our skills are being degraded over time as there's more imaging available and things like that. And it's almost unavoidable. I mean, I wish it weren't, but it does seem to be like that compared to those doctors in the Indian Hospital in Mumbai who were characterizing every valvular lesion of these patients with rheumatic heart disease and echoes were often proving them right in the patients who could afford the echocardiogram. At the same time, I think it's important for doctors to admit that a lot of the physical exam stuff that we do is not useful and a lot of it is as an act, a ritual really that we're going through that doesn't actually add anything or change management in any way. And I think people in the future, if they're given the option of driving hours to their doctor's office versus having a much better than it is now, I help them without them having to leave their house. I think they're going to choose the latter. And so I think it's important for doctors to or in the health care system in general to adapt and to figure out the best way to deliver care, hopefully the highest quality. I mean, if there's great studies that show having a human versus an AI and driving to the office improves outcomes, great. I think a lot of people would choose that. I'm not positive it will. I guess we'll see.
Tyler Johnson: [00:34:37] Yeah. I mean, I think I can see two sides of the coin because on the one hand, I totally agree with you. So I teach a lot in the medical school, including a lot of the courses on on aspects of the physical exam. And it's so often the case that a student totally appropriately will say, why are we doing this? Or what is the normal and what is the abnormal? Or if this is not the way that I expect, then what does that mean? And so often the answer to those questions, you either have to be evasive or squishy or just admit that actually there is no meaningful answer to the questions, right? Like the liver span. Actually, you're not going to do anything differently if the liver span is a little bit bigger than you think it is, because I don't even think it's reliable the way that we percuss the liver span anyway. Right. Because you're only percussing one dimension of a like six sided object, right? Or whatever. Like, I mean, and there are so many things like that. And so, which is to your point, I try to be really precise and detailed when I teach the physical exam. When you get to one of those things where it really does matter, right? Like especially a lot of the aspects of the neurological exam, like you can pretty much know if a person is having a stroke pretty quickly, if you know how to look for it the right way.
Tyler Johnson: [00:35:47] Right. And that part of your physical exam is really, really important, whereas a lot of the other things are kind of plus minus. But having said that, even acknowledging all of the limitations of the physical exam, the thing that I really worry about is that that aspect of the ritual I think really matters, right? Like even if it were nothing other than a ritual. And actually, Dr. Verghese has written pretty extensively about the fact that if you think about the traditional elements of a physical exam in medicine, it really is kind of like a religious ritual, right? You put on like a special kind of a almost like a priestly vestment, right, with your white coat. And then you have a special, almost religious artifact in your stethoscope. And then there's this way of, like, you enter the room in a particular way and you do these particular motions and then you, you know, anyway, there's a lot of elements that are similar between the two things.
Tyler Johnson: [00:36:38] And that part, I think, really actually matters because I was really struck a couple of weeks ago. We had a young woman who we had been taking care of in our clinic for a long time who got admitted to the hospital, and the team in the hospital called me to come over and see her and said that she was really, really upset with us. And that kind of surprised me because we had had a really good relationship and had known her for a really, you know, a really long time. And when I went over to the hospital to talk to her about what was why she I mean, both about why she was in the hospital and also why she was upset with us. She told us that she was really frustrated because the visit before that, we had had a really difficult conversation. She had a CT scan that showed a really discouraging result and that was going to lead to some questions about how much more chemo was going to make sense and what was her overall prognosis and other things. But the point of this is that that happened. We had that conversation in the context of a video visit, and she had always wanted her video, her visits to be video visits. So I hadn't really thought about it. But then it occurred to me only when she told me how much is lost. Like there is a difference having that kind of a conversation in person, right? Even though you can have the same exchange of information and the same, you know, the sort of result can be the same. It's just very different having it in person than having it on a video.
Jonathan Reisman: [00:38:01] Right. And I definitely think it's important to parse the aspects of medicine that are that do require face to face contact, the sort of more human sides of things and those aspects of the physical exam that you need to actually do. For instance, like is someone wheezing, Right? No CAT scan of any kind will tell you if they're wheezing or not. And so that's while most other lung pathologies will be found out on, let's say, a contrast chest CT, wheezing won't. So that's something you have to listen to. But I guess medicine I like. One thing I often think about is how medicine combines these two aspects. One is very technical and robotic and mathematical and logical deductive, and that could be probably done better by some future AI and some do it yourself blood draw the blood at home kind of thing than a human. But then there's that other side that does require that is the opposite of that, that sort of human and intimate and requires seeing the person being in the same room, touching them sometimes in the context of a physical exam. But I do think there is a lot of medicine that is that robotic technical side. And so it's important for us to sort of separate those out and not romanticize the technical because one day computers really will do it much better than us. So but there is that other aspect that is super important that probably computers will never be able to do.
Henry Bair: [00:39:29] Yeah, it's interesting. Here at Stanford, there are so many efforts to create digital tools that can support or even replace a lot of the diagnostic process. And there's just there are ethicists who point out that at some point when they do get better than humans at doing it, it will be unethical for us to not use those tools. You know, if you can get better outcomes, results with those tools. So it's it's definitely something very interesting to think about.
Jonathan Reisman: [00:39:57] Yeah. And even like algorithms, I feel like algorithm, I follow algorithms all day, every day. Algorithms are sort of like the first step towards taking the reasoning out of the human brain and putting it into something that probably does it more consistently and better.
Tyler Johnson: [00:40:13] Well, and it's so interesting, too, right? Because I remember I mean, it's been a long time since I graduated from residency, so I haven't heard these debates in a long time. But I know when I was in residency, one of the big debates was when is it appropriate to put cardiac stents into a partially-clogged coronary artery? Right. So there are some cases if a person is having an acute heart attack, that they clearly need one and they need it right now. And then there are other cases, if it's a 20%, quote unquote, blockage, that they don't need it. But there are a lot of these kind of, you know, semi chronic conditions where and again, I don't know any of the details of the literature now, but my understanding is that there's this very complicated literature where there are some studies that seem to suggest that they help, at least symptomatically and some that suggest they don't really make a big difference in the overall picture. But the thing that's so interesting about those is that right now, I think that most people, even if they don't even if they couldn't articulate it kind of like that in that area of ambiguity, they have a person to come to them and say, "well, you could argue this and you could argue this, but I think for you the best decision would be ABC, X, Y, Z," right? Like that, "I think for you" is somehow comforting, assuming that you, you know, trust the doctor that you're seeing.
Tyler Johnson: [00:41:28] And so it's so interesting to think about, well, what if that decision was just made by a bot, right? That that calculated in all of the results of all of the studies and the exact three dimensional architecture of your coronary artery and the blood flow and the cost effectiveness. And anyway, you know, 9000 other factors that a human could never do with as much rigor and just printed out a thing that either said deploy the stent or don't deploy the stent, like in theory, that would probably at some future time be a lot quote unquote better. And yet I wonder whether people will ever really sign off on that or will they always want the person saying, I think that in your case, you know, X, Y, Z? It's an interesting question.
Jonathan Reisman: [00:42:13] Right. And I think the operative detail there is we don't have enough data to know for sure. And there's also, you know, when I'm having those discussions with people about, you know, let's say, to start antibiotics for their be UTI or wait for the culture, I often will start by saying something like, well, you know, there are some people who just want to treat it, be a super aggressive and treat it even if there's a tiny chance of there there being an infection. There's other people who want to avoid medications if they're not necessary. And I don't think it would be dangerous for you to wait a day or two for the culture. There are some people who only want to take it if it's absolutely necessary and prefer to wait. So what kind of person are you? That sort of conversation It's hard to imagine a bot having with people because even if there was more data, I do certainly think that some people, you know, might be deathly afraid of undergoing any procedure, no matter what the data shows. Sure, you have to take all these things into account, and I do think that is part of the the human side. It would also be really nice if we had a lot more data on these things that we're doing kind of million times a day across the country and spending billions on. I really feel like America needs a randomized trial industrial complex to really figure out what the heck we're doing that helps and what we're doing that doesn't help.
Henry Bair: [00:43:27] Yeah, it's, you know, as a medical student, we rotate through different hospitals. We rotate through county hospitals, a private HMO, and then Stanford Hospital, like an academic institution. And the way that the same specialty is done in the three three institutions are so different. And often the rationale behind these practices don't extend much beyond well, this is just the guidelines that we inherited. Basically, these are just institutional historical ways that things are done. And yeah, there's I have no idea if one way is genuinely better than another way.
Jonathan Reisman: [00:44:02] It can be very confusing for medical students and patients alike and doctors who perhaps go from one institution to another where it's done very differently. Although interestingly, a lot of the ultimate decisions to put the stent or not fall on the bot known as "will health care pay for it?" So we're we're sort of already having some of those decisions made by an external force that is not the doctor's brain.
Tyler Johnson: [00:44:25] Well, and actually, it's so interesting because in oncology. So some places like Kaiser, right, which is this big managed health care organization in California and surrounding states, if you go to an oncologist at Kaiser, they actually have oh, I can't remember the name that they have a formal name for them, but they have this system where your oncologist basically just plugs in your diagnosis, your staging and some other pathological details. And then a computer says, okay, the acceptable regimens for chemotherapy or whatever that you can prescribe to this patient are A, B and C. End of story. Right. And since Kaiser is also the payer, because it's an enclosed system, that's just the way it is, Right. There's no real appeal to be made. There's no, like explanation to make to somebody. So they just have to choose one. And the truth is that those algorithms, to your point, are based on NCCN guidelines and the best available data and all the rest of it. And yet I have talked to patients who say that they really don't like that because then they feel like their doctor is providing them with cookie cutter medicine or cookbook medicine or, you know, something that they're just following an algorithm, right? And they want doctors who are, I don't know, more independent or free thinking, which on the one hand kind of intuitively makes sense to me and on the other hand, makes absolutely no sense. Right. Because what you want a doctor who's going to ignore the best available evidence or ignore, you know, NCCN guidelines or whatever? It really is sort of a it's a funny quirk of how we work as humans that we would think about it that way.
Jonathan Reisman: [00:45:57] I would love to see a randomized trial where people get the same recommendations from a computer and from a human talking to them, you know, but the same exact recommendation and see which experience they like better. That would be interesting.
Tyler Johnson: [00:46:10] Yeah, totally.
Henry Bair: [00:46:12] Yeah. Jonathan, you've had so many interesting experiences seeing the ways that different cultures practice medicine and approach health. We've spent some time talking about the flaws in current medical training, for example, in how the physical exam is taught. So in light of your international experiences, in light of your awareness of the history of medicine, and in light of our conversation just now about the emergence of AI tools, let me ask you, what should the future of medical education look like?
Jonathan Reisman: [00:46:45] But I do think some good things I see in medical education is, for instance, you see people of every undergraduate kind of with a degree in every undergraduate subject. In medicine, it's right. It's not only people who studied science or people who studied anatomy. There's English majors, there's philosophers, you know, philosophy degree havers and stuff like that. So I do think that I think that's changed from from many decades ago. But I think it's good because it's putting more of an emphasis on that human side of medicine, which will probably become more prominent as the technical side gets better and better and less needs an error prone human brain to get in the way. But also think, for instance, there's been a lot of growth of literature, medicine and literature, medical humanities courses and things like that that are sort of built into the education. And I think that's a good step toward the same end of producing well-rounded, simply human physicians who can deliver news and deliver or even recommendations thought of or concluded upon by a computer. I think that will be more and more important. Again, as the technical side of things improves and we're less needed on that side. I think medical education is very good. For instance, I work with a charity in India that is trying to their whole reason for being is to try to get more teaching on how to read medical literature and evaluate studies and how to search the literature into Indian medical schools, which is not a big part at all of it, or at least wasn't when I was there ten years ago or so.
Jonathan Reisman: [00:48:22] But and still, it's a pretty meager part, and I think that is really important as well. An important aspect of American medical education that I think has improved. There's a lot more data around these days to train on. So I think people are learning that evaluating the data is super important until computers can do it for us and they're not even close. So so I mean, certainly I think American medical education is great. Not to mention people get to travel abroad. A lot of medical students from America get to travel abroad, see medicine practice in a different context, whether socioeconomic, geographic, climatic, etcetera. All these different contexts are super informative and interesting. I definitely think working in the middle of nowhere with minimal technology and consultants is a great medical education and certainly has helped me hone and refine some of the skills that I still use in hospitals, even when there is a lot of technology available. But I suppose there's always room for improvement. But I do think that American doctors probably need to get ready for big changes that are coming, and I'm not sure what the best way that for that to happen is.
Tyler Johnson: [00:49:32] Well, the one thing that strikes me about that, that I've thought for a number of years but now seems particularly antiquated, is that I mean, Henry can tell me if this is different in your perspective now as someone who's just going through medical school, but I know that when I came into the first two years of medical school, having been a liberal arts major in college, I was stunned by the fact that all we did was memorize a bunch of stuff. I mean, it was just, you know, there was no synthesis, there was no analysis, there was no comparative I mean, there was just none of that. It was just memorizing reams and reams and reams of information, which is so ironic because that is the single least important thing that a doctor needs now, right? You don't need to have virtually anything memorized because it's all available on Google or Up to Date or whatever. And as computers become increasingly more integrated into what we do, it's going to become even more useless to have a bunch of facts memorized. Right. And so I don't it seems like there should be a pivot there that at least. But, you know, and step one and step two are still largely memorization tests. Not entirely, especially step two is at least a little bit of analysis and synthesis. But it does still seem a very strange thing to emphasize so heavily in the first two years.
Henry Bair: [00:50:50] Yeah, so that is still most of medical school. It is still memorization. And of course, like some some degree of memorization is absolutely necessary. I would say that even as I comes and takes care of most of the straightforward cases, really, I think where future doctors will really show their worth and their skill is applying a thorough understanding of fundamental physiologic processes to solve edge cases, to solve vague, uncertain cases, to take into account the complex psychosocial environments of each patient. I think that is that amalgamation is really where medical education has to go. The reason I don't think that has happened yet is because that is so hard to assess. It's hard to teach and it's hard to assess. It's really easy to test whether someone knows A and B and C, right? Like how do you test synthesis skills? You know? So that's my take on it.
Jonathan Reisman: [00:51:36] Yeah, I think that's an important point. I do remember as a medical student, a lot of I was interested in kind of everything and a lot of my fellow students often could be heard saying, Oh, why do we need to know this? And. Guess I often felt like, you know, a lot of it you don't need to know. I mean, as a ER doctor, I feel like I could probably, you know, give all the foundational knowledge needed to someone in a year, let alone four years. But guess I always sort of wonder if people should still be exposed to all those details, you know, do we need to memorize the Krebs cycle? I mean, don't use it. Haven't it once in my career, although I did have to think through it when I had a patient with metabolic illness. But I guess I feel like being exposed to all that stuff is still good in some way, even if it's not even if it's not needed for your future career. And even if it is, like you said, Henry, very hard to test. Besides, just memorize this, okay? Do you remember it? Which is kind of how medical school works these days. I don't know what the the better way is. Yeah.
Tyler Johnson: [00:52:42] I often tell my my pre-clinical medical students that really what they're doing, I mean, they do it by virtue of memorizing a bunch of stuff. But what they're really doing in effect is they're learning to speak the language of medicine, right? It's like learning to speak a language before you move to a foreign country that you have to have some fluency. Otherwise you just can't get around, right? You just can't. You just don't know how to function there. And so I think that and I don't mean to suggest by any means that we don't need to understand basic facts. But I guess and I know to Henry's point that this is very difficult to test, but I just feel like the emphasis should be on the understanding and synthesis and less on the memorization, especially of minutia. But in any case.
Jonathan Reisman: [00:53:20] I certainly do agree with that. I mean, I use Up to Date constantly in my practice and algorithms, especially CHOP has some amazing pediatric algorithms that are just the only thing you need to practice pediatric emergency medicine. It's I feel like I often say if there's a machine that could just follow these algorithms, it would probably be a very decent pediatric emergency room doctor.
Tyler Johnson: [00:53:42] Well, and I've written that I feel like most doctors are already functionally cyborgs, right? Because Google and Up to Date is just an extension of our brain. Like I know that it's there and I know like, I can see the up to date article about it and I purposefully have not memorized it because I know that I just pull up the Up to Date article and go to that section or. Right. Like you're saying, you just go to that algorithm, which you know is arguably a wise way to manage your brain space and time efficiency.
Jonathan Reisman: [00:54:11] Yeah. And knowing how to look stuff up is a crucial skill, perhaps even more important than knowing it. So I think there needs to be a balance there.
Henry Bair: [00:54:20] Yeah. To that point, during the preclinical phase of my medical school training, we all had to take a required genetics class and for this class we did not have to memorize anything. To the credit of the instructors, I think they were trying to see how a subject so traditionally rooted in rote memorization could be taught in a way that better reflected how it works in the real world. So for our final exam, they gave us a bunch of databases and we basically had two hours to rummage as fast as we could through these databases to find the diagnoses or the genetic mutations that best fit a given patient case presented. Oddly one of my most stressful exams in medical school. But I suppose it mirrors much of how medicine works these days.
Henry Bair: [00:55:10] Jonathan, to close this out, I want to ask you one more thing. When I was reading your book, The Unseen Body, I was struck by how much it felt like I was reading a travelog as you take us through a journey through the universe that is the human body. I learned so much about the heart, throat, mucus, blood, urine, eyes and more that I previously didn't know. And through it all, I could sense your wonder, passion and curiosity emanating from the pages to the medical trainees who are listening out there. What advice do you have about maintaining that sense of curiosity, even when all the other aspects of this work threaten to stifle it?
Jonathan Reisman: [00:55:51] That's a good question, and I think I did actually envision the book almost like a field guide, you know, a field guide to plants, mushrooms, animals, whatever it is, trees. I sort of saw it as a combination of that and perhaps like a travel travelog where the terrain you're traveling over is the human body rather than a new country. So I'm glad that you saw the similarities there. You know, it's super important for doctors to take care of themselves. It's almost a truism at this point. But work life balance is super important. And I think one of the first thing that things that goes when a doctor is getting burnt out or perhaps not achieving the ideal work life balance or maybe even being pushed around by his, his or her employer, I think that even before your compassion goes, which does definitely exit pretty quickly, your fascination with the work is probably the first thing to go. And I think for me at least, the fascination with the body, how complex it is, how unbelievably kind of wonderful that it all works together and how fascinating was sort of what I saw from the first day of med school and just sort of carried me through and kept me interested in everything. And I think that honestly, work life balance and enjoying your work is probably the most important thing to maintain your fascination and every other aspect of life that you enjoy.
Jonathan Reisman: [00:57:13] You know, doctors historically have high suicide rates, and these days after the pandemic, I think there's more burnout or more risk of burnout than before. And so I think, you know, with kind of private equity and all this stuff changing the way health care is working, I think it's really important for doctors to take care of themselves if you know, if they want to continue taking care of patients. So I really think there's I think there has been more of a focus on that in recent years, hopefully in medical schools as well. I still see many of the people that I graduated medical school with overworked and sort of pushed around and not loving their job and thinking about doing something else. And and so I think I've been able to have a pretty good work life balance. And so I've been very happy with that. That does involve sort of not being in an academic setting, which can sometimes be a different kind of work, sometimes more more intense. But anyway, I think just taking care of yourself and finding a job that you love and making sure that you do things in life you love and don't get worked to death is very important for maintaining your fascination.
Henry Bair: [00:58:21] Yeah, Well. Well, with that, we want to thank you again, Jonathan, for taking the time to speak with us and for sharing your remarkable experiences and insights.
Jonathan Reisman: [00:58:29] Thanks so much. Thank you guys so much for having me.
Henry Bair: [00:58:34] 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 www.thedoctorsart.com. 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: [00:58:53] 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: [00:59:07] I'm Henry Bair.
Tyler Johnson: [00:59:08] And I'm Tyler Johnson. We hope you can join us next time. Until then, be well.