Samuel Shem, 34 Years After 'The House of God'
What I've learned from speaking out against the brutality of medical training, in advocacy of quality connection -- and four additional "laws" for good doctors
By Samuel Shem
The Atlantic
Nov 28 2012
For better or worse, except in real danger, I don't seem to run on fear. Guilt, yes; fear, no.
It's a good thing, because my book The House of God enraged many among the older generation of doctors. I was maligned and disliked. The book was censored by medical school deans, who often kept me from speaking at their schools. None of it really bothered me, though. I was secure in the understanding that all I had done was tell the truth about medical training.
I took this pseudonym because I was just starting my psychiatric practice and wanted to protect my patients from knowing that their therapist had written such an irreverent novel. (They all found out, and didn't care -- but "Shem" had arrived, and refused to depart.) I also felt that real writers had no place in going out and publicizing their novels. I refused all invitations. And then one day I got a letter forwarded from my publisher, which included the line:
"I'm on call in a V.A. Hospital in Tulsa, and if weren't for your book I'd kill myself."
I realized that I could be helpful to doctors who were going through the brutality of training. And so I began what has turned out to be a 35-year odyssey of speaking out, around the world, about resisting the inhumanity of medical training. The title of my talk is almost always the same: "Staying Human in Health Care."
The theme of my speaking out is simple: the danger of isolation, the healing power of good connection. And any good connection is mutual.
I base a lot of my talks on what I've learned from The House of God. About how I've come to see it, and all my novels, as a "fiction of resistance," a way of resisting the injustices of a system.
It wasn't until years into my journey that I realized the importance of the fact that I and my fellow interns were products of the 1960s. We grew up in that unique lost period of American history -- beginning with FDR and ending with Reagan -- when we learned that if we saw an injustice, and got together and took action, we could bring about change. During my college years, we helped put the Civil Rights laws on the books and ended the Vietnam War. When we entered our internships we were a generation idealistic young docs. We soon were caught in the clash between the received wisdom of the medical system, and the call of the human heart. Our patients, and we, were being treated inhumanely. As Chuck the intern put it:
"How can we care for our patients, man, if nobody cares for us?"
If we decide to walk through suffering alone -- "stand tall, draw a line in the sand, tough it out" -- we will suffer more, and spread more suffering around.
And so we took action. The novel can be read as a model of nonviolent resistance. Big hospitals, like all large hierarchies, are "power-over" systems. The pressure comes down on the ones at the bottom, and they become isolated. Not only do they get isolated from each other, but each gets isolated from his or her authentic experience of the system itself. You start to think "I'm crazy," instead of "This is crazy." In The House one of the interns does go crazy, and another commits suicide.
The crucial question is how to find mutuality -- or "power-with" -- in a "power-over" system. Historically, the only threat to the dominant group -- whether of race, gender, class, sexual preference, ethnicity -- is the quality of the connection among the subordinate group.
***
In The House of God there were 13 "Laws." I would now add these four:
Law 14 : Connection comes first. This applies not only in medicine, but in any of your significant relationships. If you are connected, you can talk about anything, and deal with anything; if you're not connected, you can't talk about anything, or deal with anything. Isolation is deadly, connection heals.
One of the worries in how the new generation of doctors practice medicine is their use of computers. If you have a laptop or smart phone between you and your patient, you are much less likely to create a good, mutual connection. You will miss the subtle signs of the history, of the person. With a screen between you, there is no chance for mutuality, and the connection has qualities of distance, coolness, rank, authority, and even disinterest. The "smart" digital appendages can make you, in human-connection terms, a "dumb" doctor.
This, as more and more studies suggest, can lead -- hand in hand with the tyranny of algorithms and other "quality/efficiency/cost-containers" -- to more tests, more errors and medical mistakes, lower quality care, and higher costs to all.
Law 15 : Learn empathy. Put yourself in the other person's shoes, feelingly. When you find someone who shows empathy, follow, watch, and learn.
Law 16 : Speak up. If you see a wrong in the medical system, speak out and up. It is not only important to call attention the wrongs in the system, it is essential for your survival as a human being.
Law 17 : Learn your trade, in the world. Your patient is never only the patient, but the family, friends, community, history, the climate, where the water comes from and where the garbage goes. Your patient is the world.
Some have said that The House of God is cynical. And yet in rereading, it has a constant message that I was dimly conscious of in writing: being with the patient. In the words of the hero of the novel, the Fat Man, "I make them feel that they're still part of life, part of some grand nutty scheme, instead of alone with their diseases. With me, they still feel part of the human race." And as the narrator Roy Basch realized, "What these patients wanted was what anyone wanted: the hand in their hand, the sense that their doctor could care."
And so in 1974 I came away from The House of God aware of at least one thing: The essence of medical care, and life, is connection.
***
Fast forward 30 years.
I have published two more novels -- Fine and Mount Misery. Also, with my wife, co-wrote the play Bill W and Dr. Bob about the founding of Alcoholics Anonymous, and a nonfiction book We Have to Talk: Healing Dialogues Between Women and Men.
Love and death. How lucky we are.
During this time, as they say, life happened. There were many life struggles, and walks through the suffering. Luckily, at the right times, I was accompanied by others.
From Mount Misery, and also from conducting gender dialogues all over the world while writing We Have to Talk, I learned the importance of shifting focus from a center on "I" or "You", to "We." As in, for physicians, "We've got all the information; let's talk about what we can." The patient will say, "I think maybe we should .. " Suddenly there is a concreteness in your approach to treatment, that you are in this together.
From Bill W. and Dr. Bob, I learned that, in Bill's words: "The only thing that can keep a drunk sober is telling his story to another drunk." Alone, an alcoholic cannot resist alcohol. The self alone -- self-will or self-discipline -- will not work. What works is asking for help from a non-self-centered perspective. AA is an astonishing mutual-help organization, because alcohol and drugs are diseases of isolation.
***
My latest novel, The Spirit of the Place, took me in a new direction. I had always wanted to go back to my small town on the Hudson River and join my old mentor, a family doctor, in practice. Life had taken me elsewhere, but the beauty of fiction is that you can do in a novel what you haven't in the world.
At a point toward the end of the novel, the fraught protagonist has to make a choice. He struggles with it until he hears a kind of voice in his head:
"Don't spread more suffering around. Whatever you do, don't spread more suffering around." ...
--Samuel Shem, MD, PhD, is a doctor, novelist, and playwright. He is the author of books including The House of God and The Spirit of the Place.
Showing posts with label training doctors. Show all posts
Showing posts with label training doctors. Show all posts
Friday, November 30, 2012
Monday, February 27, 2012
Many "mistakes" found in newbie-doctors' resumes
Many "mistakes" found in newbie-doctors' resumes
By Kerry Grens
Feb 21, 2012
(Reuters Health)
Honesty and attention to detail are qualities expected of physicians, yet two studies looking at applications to training programs in obstetrics show that up to 30 out of every 100 applicants took credit for research publications that could not be found.
"Our hope is that these are honest mistakes and not willful attempts to mislead," said Dr. Michael Frumovitz, a professor at the University of Texas MD Anderson Cancer Center in Houston, and lead author of one of the studies.
In a field where precision is important, "even if it's an honest mistake it's very troubling," he said.
Earlier studies have found that other specialties within medicine suffer from the same problem.
Anywhere from one to 30 percent of applications to training programs in radiology, emergency medicine, orthopedics and others include references to published research that can't be located by reviewers.
Frumovitz and his colleagues and a separate group at the University of Washington, who published their reports in Obstetrics & Gynecology, wanted to find out if the same was true in their fields.
The team led by Frumovitz collected all 258 applications to a fellowship program at MD Anderson in gynecologic oncology from 2004 to 2008.
The applicants were doctors who had completed their medical school and residency training.
Of the 148 doctors who listed that they had published research findings, 44 included a reference to a publication that Frumovitz's group could not track down.
"We all believe that applicants have the best intention and are representing themselves truthfully. But (this result) falls right in line with others who have done similar work," said Frumovitz.
The University of Washington team, led by Dr. Anne-Marie Amies Oelschlager, looked through two years' worth of applications to a residency program in obstetrics and gynecology.
Residents are doctors who have finished medical school, and are continuing their required clinical training in a particular field.
Among the 937 applicants, 357 put down that they had at least one research study that was published or about to be published in a peer-reviewed outlet.
When Amies Oelschlager's group went to find those publications, 156 of the 1,000 publications listed turned up missing.
They looked online, in publication databases and even contacted the journal for verification.
Of the other publications that were confirmed, the researchers found inaccuracies there as well.
The biggest error was that 62 applicants had listed a publication as "peer-reviewed" when it wasn't.
Peer review involves submitting a study for scrutiny by other researchers before it gets published, and therefore implies a high degree of rigor.
Amies Oelschlager said her study could not tell whether these were honest mistakes or intentional misrepresentations.
"The best you can assume is that these applicants didn't look up what peer review meant or they don't understand it," she told Reuters Health. "None of that is flattering and you worry whether they really understand the tenets of authorship, research, what is peer review and what is not."
Residencies and fellowships are competitive, and research experience is looked upon favorably when applicants are being reviewed.
"Applicants might be deliberately padding their resumes to try and get a spot, and it's concerning. The whole thing about being a physician is that you are expected to be honest," Amies Oelschlager said.
Dr. Lee Learman, a professor of obstetrics and gynecology at Indiana University School of Medicine, said that it's not clear whether errors on applications relate to errors in medical practice, but it is of concern.
He said that medical students and residents should be aware that misrepresenting their work could have negative consequences on their careers.
"Even though we don't know how this predicts future infractions, most directors of residencies and fellowships don't want to take the risk," Learman told Reuters Health. "They might say, this person might misrepresent data about a patient or misrepresent a step they took during surgery."
Learman encouraged directors of residency and fellowship programs to check the accuracy of applications, and if they can't find the publications listed, to ask the person to produce a copy.
Frumovitz said one way to make sure publication lists are accurate is to require that applicants include a copy of the paper or an identification number that will make it easier to look up.
Amies Oelschlager and her colleagues suggested that medical schools should include training in authorship and peer review.
By Kerry Grens
Feb 21, 2012
(Reuters Health)
Honesty and attention to detail are qualities expected of physicians, yet two studies looking at applications to training programs in obstetrics show that up to 30 out of every 100 applicants took credit for research publications that could not be found.
"Our hope is that these are honest mistakes and not willful attempts to mislead," said Dr. Michael Frumovitz, a professor at the University of Texas MD Anderson Cancer Center in Houston, and lead author of one of the studies.
In a field where precision is important, "even if it's an honest mistake it's very troubling," he said.
Earlier studies have found that other specialties within medicine suffer from the same problem.
Anywhere from one to 30 percent of applications to training programs in radiology, emergency medicine, orthopedics and others include references to published research that can't be located by reviewers.
Frumovitz and his colleagues and a separate group at the University of Washington, who published their reports in Obstetrics & Gynecology, wanted to find out if the same was true in their fields.
The team led by Frumovitz collected all 258 applications to a fellowship program at MD Anderson in gynecologic oncology from 2004 to 2008.
The applicants were doctors who had completed their medical school and residency training.
Of the 148 doctors who listed that they had published research findings, 44 included a reference to a publication that Frumovitz's group could not track down.
"We all believe that applicants have the best intention and are representing themselves truthfully. But (this result) falls right in line with others who have done similar work," said Frumovitz.
The University of Washington team, led by Dr. Anne-Marie Amies Oelschlager, looked through two years' worth of applications to a residency program in obstetrics and gynecology.
Residents are doctors who have finished medical school, and are continuing their required clinical training in a particular field.
Among the 937 applicants, 357 put down that they had at least one research study that was published or about to be published in a peer-reviewed outlet.
When Amies Oelschlager's group went to find those publications, 156 of the 1,000 publications listed turned up missing.
They looked online, in publication databases and even contacted the journal for verification.
Of the other publications that were confirmed, the researchers found inaccuracies there as well.
The biggest error was that 62 applicants had listed a publication as "peer-reviewed" when it wasn't.
Peer review involves submitting a study for scrutiny by other researchers before it gets published, and therefore implies a high degree of rigor.
Amies Oelschlager said her study could not tell whether these were honest mistakes or intentional misrepresentations.
"The best you can assume is that these applicants didn't look up what peer review meant or they don't understand it," she told Reuters Health. "None of that is flattering and you worry whether they really understand the tenets of authorship, research, what is peer review and what is not."
Residencies and fellowships are competitive, and research experience is looked upon favorably when applicants are being reviewed.
"Applicants might be deliberately padding their resumes to try and get a spot, and it's concerning. The whole thing about being a physician is that you are expected to be honest," Amies Oelschlager said.
Dr. Lee Learman, a professor of obstetrics and gynecology at Indiana University School of Medicine, said that it's not clear whether errors on applications relate to errors in medical practice, but it is of concern.
He said that medical students and residents should be aware that misrepresenting their work could have negative consequences on their careers.
"Even though we don't know how this predicts future infractions, most directors of residencies and fellowships don't want to take the risk," Learman told Reuters Health. "They might say, this person might misrepresent data about a patient or misrepresent a step they took during surgery."
Learman encouraged directors of residency and fellowship programs to check the accuracy of applications, and if they can't find the publications listed, to ask the person to produce a copy.
Frumovitz said one way to make sure publication lists are accurate is to require that applicants include a copy of the paper or an identification number that will make it easier to look up.
Amies Oelschlager and her colleagues suggested that medical schools should include training in authorship and peer review.
Saturday, June 25, 2011
Physicians in training work "dangerously long hours"
Residents doctors' shifts too long, report finds
CBC News
Jun 24, 2011
Physicians in training work "dangerously long hours" that should be reduced, a U.S. report says.http://www.blogger.com/img/blank.gif
New rules for residency training set to take effect in the U.S. on July 1 fall "considerably short" of what is needed to ensure patient safety, say the authors of a report in Friday's issue of the journal Nature & Science of Sleep. Residents' shifts should to be limited to a maximum of 16 hours to ensure patient safety, the authors of a report say.Residents' shifts should to be limited to a maximum of 16 hours to ensure patient safety, the authors of a report say.
"Few people enter a hospital expecting that their care and safety are in the hands of someone who has been working a double-shift or more with no sleep," said Dr. Lucian Leape, a professor of health policy at the Harvard School of Public Health and a co-author of the report.
"If they knew, and had a choice, the overwhelming majority would demand another doctor or leave," he added in a statement.
The report looked at residents' work hours, supervision, and safety. It is the product of a conference held last June at Harvard Medical School.
Under the new rules, first-year residents will work shifts no longer than 16 straight hours. But more experienced residents could clock up to 28 hours at a stretch.
The report's authors calls for all residents' shifts to be limited to a maximum of 16 hours.
Some of the other recommendations:
Require attending physicians to supervise all hospital admissions.
Identify in real time when a resident physician's workload is excessive and add more staff.
Assign other hospital personnel to fill out paperwork, start intravenous lines and draw blood to allow residents to instead maximize their time on tasks of more educational value.
Provide transportation to all residents who report feeling too tired to drive home safely.
Make fatigue management a national patient safety goal that applies not only to residents but also to nurses, attending physicians and other health care workers...
CBC News
Jun 24, 2011
Physicians in training work "dangerously long hours" that should be reduced, a U.S. report says.http://www.blogger.com/img/blank.gif
New rules for residency training set to take effect in the U.S. on July 1 fall "considerably short" of what is needed to ensure patient safety, say the authors of a report in Friday's issue of the journal Nature & Science of Sleep. Residents' shifts should to be limited to a maximum of 16 hours to ensure patient safety, the authors of a report say.Residents' shifts should to be limited to a maximum of 16 hours to ensure patient safety, the authors of a report say.
"Few people enter a hospital expecting that their care and safety are in the hands of someone who has been working a double-shift or more with no sleep," said Dr. Lucian Leape, a professor of health policy at the Harvard School of Public Health and a co-author of the report.
"If they knew, and had a choice, the overwhelming majority would demand another doctor or leave," he added in a statement.
The report looked at residents' work hours, supervision, and safety. It is the product of a conference held last June at Harvard Medical School.
Under the new rules, first-year residents will work shifts no longer than 16 straight hours. But more experienced residents could clock up to 28 hours at a stretch.
The report's authors calls for all residents' shifts to be limited to a maximum of 16 hours.
Some of the other recommendations:
Require attending physicians to supervise all hospital admissions.
Identify in real time when a resident physician's workload is excessive and add more staff.
Assign other hospital personnel to fill out paperwork, start intravenous lines and draw blood to allow residents to instead maximize their time on tasks of more educational value.
Provide transportation to all residents who report feeling too tired to drive home safely.
Make fatigue management a national patient safety goal that applies not only to residents but also to nurses, attending physicians and other health care workers...
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