On Becoming a Healer Saul J. Weiner and Stefan Kertesz

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.

In his book, The Present Illness, American Health Care and Its Afflictions, physician and historian Martin Shapiro, MD, PhD, MPH presents a scathing critique of a profession suffused with status, money, and power. At the same time, he also describes many deeply caring and rewarding patient care experiences, his own and those of colleagues.  But these relationships are only possible when the clinician has a clear understanding of the pernicious corrupting forces in medicine and consciously rejects them.  This is a moral act that must be renewed continuously. They also require a capacity to confront one's own insecurities -- Dr. Shapiro describes years of psychotherapy that were essential to his own growth as a physician who can be fully present in the face of suffering.  
Martin indicts the profession for producing far too many doctors who want to get rich and who are unprepared, through a faulty process of selection and training, to be truly caring towards those they serve.  Martin reminds us that the motives of the profession have long been suspect, quoting Plato's Republic in which Socrates asks, "Is the physician a healer or a maker of money?" Never before, however, and nowhere on the scale found in the United States has health care become such a massive industry, one that keeps growing. Martin argues that the profession can only heal itself if it confronts its demons honestly and openly, beginning at the earliest stages of medical training. 

A recent NEJM article and accompanying podcast episode (“Tough Love”) authored and hosted by the Journal’s national correspondent sound the alarm that a culture of grievance among medical students and trainees about the discomforts of medical training is threatening to undermine both their medical education and patient care. She also describes widespread anxiety among medical educators who feel fearful of speaking because of concerns of retaliation on social media.  Absent from the discussion, however, are the voices of students and trainees who, in the podcast, are referred to as “our children.” Medical Students and trainees we spoke with did not feel that their concerns are experiences were accurately characterized. We propose that medical educators are ill prepared for the shifting power dynamics, both in terms of knowing how to listen and how to lead.

“Sonny’s Blues” is a 1956 story by the author, James Baldwin, about a “sensible” and pragmatic algebra teacher and his younger musically gifted younger brother (“Sonny”), who struggles with heroin addiction. Both of them, raised in Harlem, are deeply affected by anti-Black racism.  Although the older brother, who narrates the story, feels responsible for Sonny, he struggles to relate to him. With the help of an English professor, Laura Greene at Augustana College, we reflect on some of the lessons of this story for the physician-patient relationship, especially when caring for individuals with substance use disorder. We explore the cost both to patients and to ourselves, as healthcare professionals, of holding patients at arm’s length because we fear engaging, especially in the face of suffering.
A PDF of “Sonny’s Blues,” can be accessed from the story’s Wiki page (scroll down to external links).

In a 2021 episode that we reran last month, “About me being racist: a conversation that follows an apology,” Saul talked with a former Black colleague after apologizing to her for something racist he had done twenty years earlier that hurt her for a long time.  
Since then, Saul has been thinking about how he got exposed to racist ideas and notions of power as a white male growing up in the United States (in his case in a liberal, highly educated community) and suggested that he and Stefan talk about it, taking to heart Toni Morrison’s admonition that, “White people have a very serious problem, and they should start thinking about what they can do about it – and leave me out of it!”
Also, next month we’ll de discussing a short story by author James Baldwin with a special guest, and would like to encourage listeners to read “Sonny’s Blues,” which can be accessed from the story’s Wiki page (scroll down to external links).

We are re-running this episode from 2021 because we’re releasing a sequel next month in which Saul reflects on his journey confronting racist ideas he’d absorbed and that became impossible to ignore after he’d acknowledged his role in the incident described here.  We are also re-running the episode because it exemplifies our commitment to facing things -- about ourselves and our profession – to enhance our wellbeing, and our relationships with colleagues and patients.  Rather than disheartening, we find such conversations and the changes they bring rewarding and healing.