On Becoming a Healer

The two doctors charged for their roles in the events leading up to actor Matthew Perry’s death were both involved in a “side hustle”: selling ketamine at a big mark-up to make extra money, above what they earned through legitimate practice. One was an internist-pediatrician and the other an emergency medicine physician.

Their cynicism was starkly evident in a text one sent the other about jacking up the price: “I wonder how much this moron will pay. Let’s find out.” It’s easy to write off these doctors as just bad apples; regrettable examples of how difficult it is to prevent a small number of unethical people from making it through medical school and residency.

But what about the profit-making that occurs when thousands of physicians perform procedures, including surgeries, for which there is strong evidence of NO benefit from randomized controlled trials, but with all the risks of pain and complications during recovery and over the long term?

From a patient’s perspective is there really a difference between being subjected to predictable harm when you know your doctor is a drug dealer versus these practices within the mainstream of medicine where patients assume their physicians are acting in their best interests?

Which is the greater betrayal?

There are a lot of videos on YouTube that feature typically young physicians explaining why they decided to leave the profession after years of dedication and hard work. For some it appears that they were so successful at building a social media presence and related businesses, that they quit medicine. Others seem to just want to share their experience in the hope it might help others. They describe how a sense of exhaustion, dreading work each day and discovering that it wasn’t what they imagined when they dreamed of becoming a doctor drove them away. What they have to say feels quite convincing, and thousands of comments affirm them.

At the same time, there is something missing. They rarely talk about their relationships with patients or how medicine, no matter how corrupted it is by profit seeking, really is a special and unique profession that is worth fighting for. We reflect on what to make of this blind spot, trying very hard not to sound preachy.

The National Institute on Drug Abuse defines addiction as a “chronic disease” occurring in the brain – Many believe this definition can help to reduce stigma. But, is it helpful in the care of individual patients? In this episode we discuss what we gain and what we lose when we speak of people with addiction as having “diseased brains.”

The view of addiction as a chronic disease has traction, supported first by mid 20th-century alcoholism research, and then by a flood of brain imaging and neurophysiologic studies. Functional MRIs highlight changes in the brain, whether the addiction is to a substance like alcohol or opioids, or to a behavior such as gambling or disordered eating. Many authorities suggest that the “brain disease” designation is not only correct on scientific grounds, but that it also advances a social priority: to blunt stigmatizing concepts of addiction as a weakness or moral failing.

However, many neuroscientists disagree with the brain disease model. Without disputing the brain science, they note that all learned behaviors change the brain, not just addiction. Also, people who reduce or stop use often report they chose to make that change because of new opportunities or intolerable consequences. The brain disease argument invites a second criticism: arguably, it lets unfettered capitalism off the hook – predatory industries spend billions to get people addicted. Calling it a disease of an organ conveniently focuses attention away from a predatory system.

Why does this debate matter for clinicians and patients? Saul interviews co-host, Stefan Kertesz, who is a primary care doctor and a board-certified addiction medicine specialist. Together we consider how addiction is a part of the human condition, which includes how we learn, how we relate to the environment in which we live, and how we are shaped by experiences.

Nearly everyone has habits that are problematic to varying degrees. How we think about addiction can shape our approach to patient care across a wide range of clinical interactions.

For years, when physicians order tests to assess lung function, or blood work to determine kidney function, or look up guidelines for managing high blood pressure the results have been adjusted for race. This practice has been based on studies that seemed to indicate that the same result means different things if the patient is Black vs white. So, for instance, an “uncorrected’ creatinine of 1.6 was thought to be less concerning in a Black than white patient as Blacks were thought to have greater muscle mass (not true). These correction factors masked underlying environmental and social stressors disproportionately affecting Black Americans. Regrettably they also contributed to delays in care for chronic conditions, as Black patients had to be sicker than white patients to trigger therapeutic interventions – further exacerbating disparities. We talk with two physicians who lead an anti-racism equity committee based in a Chicago VA hospital to understand the history and science that led to these “corrections,” and how they have successfully been removing them through education and advocacy across their organization and nationally. Their activism is especially meaningful because of its immediate, tangible, benefit for affected patients. The views expressed in this episode are those of the participants and do not necessarily reflect the position or policy of the Department of Veterans Affairs or the United States government.

In this second of a two-episode series on medical student mistreatment, we discuss its impact on burnout with a colleague who is working to change the culture of medical education and practice through research and leadership.