Healing the Wounds: How Medicine Lost Its Way and What To Do About It

By Jeffrey Kleiman

"To the typical physician, my metastatic cancer is a routine incident in his (her) rounds, while for me it's the crisis of my life. I would feel better if I had a doctor who at least perceived this incongruity." wrote author Antole Broyard.

Medicine in the United States is widely regarded as the best in the world. Hardly a day passes without a major scientific breakthrough. Many formerly fatal diseases are now curable. People are healthier and live longer than ever. Still, patient dissatisfaction with doctors has rarely been more acute. Although physicians are increasingly able to cure disease and prolong life, the American public is suspicious, distrustful of, even antagonistic to the profession. Doctors universally acknowledge a crisis in healthcare. With the focus on colossal medical expenditures, amounting to trillions annually, most of the numerous solutions involve containing runaway costs. This book, Healing the Wounds, reaches a different conclusion about what is ailing our healthcare system.

Medicine's profound crisis is only partially related to ballooning costs, for the problem is far deeper than economics. The basic reason is that medicine has lost its way, if not its soul. An unwritten covenant between doctor and patient made over several millennia is being broken.

At midcentury a doctor's image outshone nearly every other profession. Yet it appears that with each new medical miracle, the image of physicians shrinks and grows more tarnished.

No significant transformation results from a single or simple cause. Reflecting on forty-one years of medical practice, I see that something vital appears to be vanishing. A three thousand year tradition, which bonded doctor and patient in a special affinity of trust, is being traded for a new type of relationship. Healing is replaced with treating, caring is supplanted by managing, the art of listening is taken over by technologic procedures. Doctors no longer minister to a distinctive person but concern themselves with fragmented malfunctioning biological parts. The distressed human being is frequently absent from the transaction.

The introduction of increasingly sophisticated technology is certainly one reason. Compared with the sharp images provided by CAT scans, MRIs, endoscopy, and angiography, a patient's history is flabby, confused, subjective, and seemingly irrelevant. Furthermore, it takes a good deal of time to elicit a full history. According to some doctors, technology has become a sufficient substitute for talking with patients.

And, what about the lost art of the physical exam? The old-fashioned touching, looking and listening — the once prized, almost magical skills of the doctor who missed nothing and could swiftly diagnose a peculiar walk, sluggish thyroid or leaky heart valve using just keen eyes, practiced hands and a stethoscope and reflex hammer.

Society places a much higher premium on technology than on examining, listening or counseling. Time spent in the operating room or performing an invasive procedure is rewarded tenfold more than conversing with patients or family. In addition to obviating discourse, current medical practice focuses on the acute and emergent and is largely indifferent to preventing disease and promoting health. The rot will continue until doctors reconnect with their tradition as healers.

"Healing the Wounds" attacks the issues from multiple perspectives. Patient experience and stories are the core starting points. The book explores physician burnout and frustration. It compares different world wide healthcare systems. Finally it suggests solutions for a better future for all.

• Language: English
• Publisher: BookBaby
• Release date: Jun 1, 2024
• ISBN: 9798350947328

Jeffrey Kleiman

Dr. Jeffrey Kleiman is a board certified Family Practitioner of 41 years. He was born and raised in Baltimore, Maryland. Dr. Kleiman ran a medical ethics group for ten years and was head of his hospital's Medical Ethics Committee for five years. His hobbies include songwriting, martial arts, playwriting, taking broad based courses and continuous reading. He always felt honored to be a physician, thinking it the best profession in the world. He does extensive volunteer hospice work. He lives in Cape Elizabeth Maine along with his wife, children and grandchildren.

Book preview

Prologue

Bob does not look well. His left hand is clutching his chest, he’s in obvious pain, sweating and anxious,, his wife Florence, says into the phone. It started almost two hours ago., He is gritting his teeth. We called that darn ambulance forty minutes ago. What the heck is going on?... Bob says it feels like another heart attack.

It’s one o’clock in the morning and the answering service calls me at home. I am on call for my group. I’m still trying to wake up as I question Mrs. Curtis, who is obviously in a panic mode. I know that heightened anxiety only makes things worse. I am limited in my response. I will wake up earlier to make medical rounds on Bob in the hospital who will admit him. I will obtain his version of the events,and then visit other patients in the hospital before beginning a full day of patients starting at 8 a.m.. Earlier, I’d looked at my schedule and learned that the first patient was Eritte R., who has uncontrolled diabetes, hypertension, and problems with her husband and 15 year old son. The 11:30 patient, George, always complains if I am late coming into his room after the set appointment time. Probably no lunch once again tomorrow. I feel pressure and it is not even 2 o’clock.

Like many doctors, I went into medicine because I wanted to help people. And, like many medical students, I quickly discovered that medical education is more about chemical structures, biology, organs and diseases than about humanity and healing.

I have a curiosity in many other disciplines as well, including history, psychology, philosophy, literature, politics, and music. I remember pitying my fellow pre-med classmates who only concerned themselves with grades. I got my ‘A",’ Rich Schneider would proclaim after another biochemistry test in college. (Rich went on to become a dentist. ) What about focusing on the complexity and ambiguity of human lives, without reducing them to disembodied cells, parts, and processes?

Yes, I needed the principles of cell biology to understand why, say, a platelet transfusion lasts only two weeks in most patients (platelets live in the body for only about two weeks). Anatomy helped me know why a man had woken up from a surgical procedure with his entire lower body paralyzed (a clot had blocked his anterior spinal artery, an artery that supplies the lower spinal cord had become blocked by a clot, resulting in a stroke of the lower spinal cord). An equation from pharmacology reminded me why one dosing of a particular antibiotic was four times a day, while its close molecular cousin was given only once a day (the two chemicals decay at differing rates in the body).

But all this information could not tell me why a typical patient would probably not take their medicine four times a day. Nor would it teach me what separated simple grieving from serious depression? I had plenty of facts drilled into me, but what good did that do if the patient did not take their medicine? And could I remember all that I learned anyway?

In our third year, our class entered the hospital, presenting a myriad of challenges and humiliations. It sometimes seemed like the constant change in approach and people, the frequent changes in course and place was designed specifically to keep us anxious, insecure, and off balance. We learned to work without sleeping, eating, or urinating, without fresh air or clean clothes. We often felt horror and disgust without the privilege of tears or time off. It was brutal, and yet much better from the previous two years. At last, my days now included learning about actual people with stories, frequently so wild denigrating those television dramas of imagined reality. My hospital work gave me some deep human insight into real situations with actual people. I returned home each night feeling that not only had my time been well spent, but that my life mattered in a larger way, even though my contribution was very small. It was a wonderful feeling. And yet, I understood how little I knew.

Thus began the little blue notebook. Beginning in our clinical years of training the school provided our class with a pocket sized notebook with charts, formulas, and diagrams. It bulged in the white coat jacket pockets along with our stethoscope, reflex hammer, flashlights, and 3 x 5" file cards. We looked like penguins waddling in groups with the attending physician on rounds. We kept note of each patient on the file cards. These were the days before cell phones and laptops where one could quickly look up any medical mystery with the push of several buttons.

I loved knowing a little about a lot, reassured that later, I could always do a deep dive with some research into those thick textbooks like Harrison’s Principles of Medicine. I understood the foundations of medicine, anatomy, physiology, pharmacology, organic chemistry, and medical language. There was the medical library which housed textbooks and journals if one had time. I loved those books as much as my vinyl record collection. Today, when we search the internet, we get a lot of information quickly. Those thick heavy books, however, gave the backstory. They were as much my pals as my Crosby Stills and Nash albums are to listen to again. I would record any nuggets in the little blue notebook. I remember one incident when starting my clinical rotation, I asked the medical library where the magazines were? Education was continuous as the librarian informed me that they had no magazines. Did I mean the journals? My face turned beet red as I said that I did. Science was about being precise.

However, Medical education seemed to routinely undermine its mission by minimizing the sorts of knowledge that made the biggest difference in people’s lives. My medical knowledge taught me plenty of facts, but little about the spaces that live between facts. I had no way of knowing years later that after spending so much time arranging a consultation with one of the world’s experts on pancreatitis at a major medical center, that my patient would never show up because of a lack of transportation. Although science provides invaluable information, and technology can be transformative, neither is well suited to addressing critical aspects of human life, from individuality, to suffering to wellness. Science and technology helps, but does not fulfill my mission of promoting lives of flourishing individuals, a concept that the Greeks called eudaimonia.

My mission resonated in all age groups, from pediatrics to geriatrics. I cringed when a parent belittled their child in front of me. How could I intervene? Would the parent be receptive to this young doctor who couldn’t possibly understand the complexity of child rearing? Only with years would I internalize that people’s lives are complicated. Rarely would they allow for simple answers to their struggles. What could one do for someone over 60 experiencing cognitive decline? My patients taught me what really matters as we age. That included how people can live happier, more meaningful lives. It surprised me to see that older people often prioritized living over safety. No knowledge of this could I write in the little blue book.

Despite the tidiness of facts, medicine seemed to be lawless, unruly, and uncertain. In Harry Potter, a teacher of wizardry asks Hermione Granger, a young witch-in-training, whether she wishes to learn the Magical Laws to pursue a career in magic. No, says Granger. She wishes to learn the laws so that she can do some good in the world.. I too wished to learn the facts and magic in order to do some good.

Like a contractor building a house, this book is constructed from the ground up. First comes the big slabs of foundation, then the necessary load bearing walls, the elegant but impermeable roof, and the lovely interior decorations.

Each chapter expands on the previous one. We will take a trip down memory lane to understand the history of medicine, where we’ve been from ancient to modern times. We will uncover how discoveries about health and illness changed across the ages, and yet, how the field of medicine remained much the same over time. Together, we will unearth how important lessons from the past can inform us today. How stereotypes slowed us down. How hidden motives and agendas play an integral role in diagnosing and healing. The reader will discover how to best approach his / her own issues in dealing with the healing professions and gain understanding to the complexity of the entire system.

Finally, we will end with some proposed policy changes to make the American medical world work better. Articulating problems is not useful without proposing solutions. As Mark Twain said: I could not really complain, because he had only given me his word of honor as security; I ought to have required of him something substantial. Substantiality is promised in the book.

Throughout, there will be real life case studies to dissect with an eye to explaining what works and what doesn’t. The little blue book of charts and formulas added to with thoughtful exploration.

I love the practice of medicine and feel lucky to have been entrusted by many over my forty year career. I wish to impart that love and beauty to the reader. My hope is that any new student of medicine will be excited to work through these challenges, and be enriched by pursuing such a rewarding career. We will also look into the big picture of policy and improvements in the journey.

People are So Very Interesting

Twenty years ago, I was leaving my office when I saw Ernest in the large waiting area. He was 95 years old at that time. He was waiting for Teodolinda, his wife, to finish her dialysis. Both Ernest and Theodolinda were quiet people. I never knew how long they were married, for as Seventh Day Adventists, they never celebrated any occasions such as birthdays or anniversaries. Throughout his 102 years, Ernest always arrived at my office in the same gray striped suit, white shirt, and tie. He explained that he was an elder in his church. I did not know what that meant and had to look it up. He and Teodolinda had no children and lived simply. They were happy and content. When Ernest died, his health care proxy was his nephew Donald, 80 years old himself, who felt the need to tell me all his own health problems. At the time Ernest and Teodolinda started seeing me they were the oldest patients that I ever treated. I certainly knew no Seventh day Adventists. They taught me about loyalty and caring, about knowing the limits of the material world, about dignity and presence., about the understanding that there were things more important that we, in the Western World strove for. Teodolinda died at age 92 of renal failure. Ernest died at age 102 of heart failure. My teachers were no longer people in white coats with diagrams and formulas but patients. My task now became listening and watching closely.

Errors in the thinking

and the History of Healing

I once read a story about a medical professor who worked with a group of first-year medical students. He asked them to write down the first words that came to mind when he described a person as old. He asked his first year medical students to put down the initial words that came into their minds when he used the term old in reference to a person. Don’t filter, he said. Just write. The students began scribbling on scratch paper the teacher provided. He was not surprised when the most common associations with the word old included wrinkled, bent over, slow moving, bald, and white hair. Some of the older students in their forties to sixties used words like, wisdom, but more chose sad, stubborn, and lonely.

A dietician performed a similar experiment with the word obese.. Yet here words like lazy, sedentary, undisciplined, and depressed emerged. These students had at least seven to ten years more of training in their future. Would their stereotypes change? Training generally takes place in an insulated, high-pressure enclosed atmosphere. There was no time to really get to understand people. Patients were reduced to the labels stubborn, stupid,, or non- compliant.

When I think back over the years, I remember the stupid, stubborn, silly, and hurtful things that I said. My wish was to be the perfect doctor: smart, up on the literature, kind and wise. However, there were so many pressures and little time to be reflective. Should I order one more test, or would I be wasting resources and money? Would the discharge nurse be calling to urge an early discharge if the patient was over the standard length of stay? If I order a certain imaging technology, would I need to go through the arduous, and time consuming prior approval process on the phone with the patient’s insurance company? (In order to obtain an expensive test, doctors needed to creatively lie, and tweak information.) There were so many questions I did not know how to answer. I had succumbed to imposter syndrome. (Impostor syndrome is the internal psychological experience of feeling like a phony in some area of your life, despite any success that you have achieved in that area.)

Like many doctors, I’d sometimes find myself feeling furious, frustrated and futile. It felt like there were forces working to undermine patients, doctors, and health in general. In the late twentieth and early twenty-first centuries, society seemed more interested in cosmetics, and breakthrough technologies, rather than in the slow hare like ‘’ business of promoting and preserving human health and well being. The United States typically showcases the newest machines, genetic advances, heart operations, and cancer treatments. Flashy and cool things. Yet cares little about mental health, poverty, food insecurity, frailty, or suffering. It prioritizes treatment over prevention, parts over the wholes, fixing over caring, averages over individual results, and the new" over the proven. We fast tracked