Practicing Sam Freeman

Of all the problems we face in clinical medicine, few are more vexing than patient interactions that don’t go well. Dealing with a “difficult patient,” as they’re commonly referred to, can ruin your day and set off a spiraling cascade of thoughts and emotions. Those patient encounters frustrate us and drain us as clinicians. They can leave us feeling at once helpless and self-righteous, empathetic and disdainful. Often, they make us want to run away. Other times, they suck us in, to an uncomfortable degree. I’d say doctors spend as much – if not more – time talking to each other about difficult patients as they do about difficult diagnoses.  


Hearing Dr. Autumn Fiester lecture on the difficult patient was one of those rare moments when a phenomenon I thought I had a handle on based on my own experience was completely reframed. Her ideas led me to see the problem from an entirely different angle, and to reinterpret my past experiences as a result. 


Autumn Fiester is a philosopher and bioethicist at the University of Pennsylvania, where she is Vice Chair for Education in the Department of Medical Ethics & Health Policy at the Perelman School of Medicine as well as the Faculty Program Director for the Master of Bioethics (MBE) and Master of Science in Medical Ethics (MSME) degrees. She is the Director of the Penn Program in Clinical Conflict Management, which promotes conflict resolution training for clinical providers and clinical ethics consultants. She is the author of over 100 publications in the areas of clinical ethics, clinical conflict management, and more.

I think my conversation with Autumn will really appeal to clinicians who have necessarily had the experience of navigating conflictual or dysfunctional patient relationships. But I also think what Autumn has to say is enlightening for anyone who’s been a patient. As she says, we have all been, or have the potential to be, difficult patients.


An Announcement!
This is the 20th episode of “Practicing,” a milestone I’m not sure I ever thought I’d reach when I started the podcast two years ago. It seems like a good time for me to take a break, regroup and dedicate some time to other projects. Now, this isn’t a farewell, it’s just a “see you later.” I may return with the occasional interview over the coming months, but my hope is to come back with fresh ideas. So stay subscribed! Thanks to all of you for your precious attention, and to those of you who sent feedback, subscribed, shared or rated the show, or helped and supported me in countless other ways. I couldn’t have done it without you. And of course thanks to all my guests – you are what Practicing is all about. 
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Links:
-Autumn's bio

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Recorded July 11th, 2023
Art: Jeff Landman
Music: Mr. Smith
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A little over two years ago, two good friends of mine, whose daughter Fera was born just a few weeks before my daughter, came to me with concerns about their baby. Fera was about 9 months old and at a routine check-up her doctor had found that her weight gain had slowed. 
When her mother, Vanessa, reached out to me about this, I wasn’t too worried – so often in pediatrics health concerns turn out to be nothing, or small hiccups that get better on their own. Not to mention the fact that I hated to imagine that my friends’ baby could be sick. But once I saw Fera’s growth curve and heard all the details of her symptoms, including the fact that she was fussy and always thirsty, constantly soaking her diapers, and preferred water to her mother’s milk, I was alarmed. So I arranged to have Fera seen by a colleague and tested at the clinic where I work.

Within a few weeks, it emerged that something was very wrong with Fera. She was losing everything through her kidneys: water, electrolytes, sugars, proteins. Once that was clear, Fera was hospitalized, and as you’ll hear from her parents, Vanessa Bonneau and Sylvan Lanken, she was diagnosed with cystinosis, a rare genetic disease that causes the amino acid cystine to build up in every cell of a person’s body over time.

Fera’s diagnosis was devastating: cystinosis is degenerative and though it can be managed and treated with a tremendous amount of work, there is no cure.

Over the last three years, I’ve seen Fera and her parents struggle, but I’ve also seen her grow up, stabilize, and play with my daughter like any other child.

I wanted to speak to Vanessa and Sylvan about their experience, about their interactions with the health system and the cataclysm of Fera’s diagnosis. My intuition was that many people – including me – would benefit from hearing their story, and after recording our conversation I’m more convinced of that than ever.

In addition to being Fera’s parents, Vanessa Bonneau is a writer and editor, and Sylvan Lanken is a musician who also works in higher education.
 
The following interview isn’t easy to listen to at times and it deals with very difficult themes. So please be warned. But I do encourage you to listen if you can – Vanessa and Sylvan brought all of their humanity and openness to this interview, and as a result it is a gift.

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Links:
-Cystinosis Research Foundation
-Basic information on cystinosis (NIH)

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Recorded June 29th, 2023
Art: Jeff Landman
Music: Mr. Smith


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The phrase “evidence-based medicine” is uttered so often in the medical world that it can lose its meaning. So what does it mean? We use the phrase to highlight the ways that medical knowledge and practice are based on scientific data, systematic studies that allow us to determine what really works, to distinguish cause and effect from random associations. And modern medicine has been built around that notion of scientific objectivity. 


But I also like to think of the many gaps in that evidence, the known unknowns but also the unknown unknowns. We can only use the evidence we’ve first sought to gather, after all. We can only seek answers to the questions we think – or allow ourselves – to ask.


My next guest, Olivier Drouin, is trying to ask questions that might expand our notion of evidence-based medicine. With his focus on behavioral science, Olivier seeks to better understand the ways we behave and make decisions, the influences that shape and distort our thoughts and actions. As you’ll hear, Olivier sees this as an untapped evidence base, one that scholars in psychology, economics, political science and law are familiar with, but that medicine has tended to ignore. 

Olivier Drouin is a pediatrician and health services researcher in the Division of General Pediatrics at Sainte-Justine university health center, a pediatric research hospital in Montreal. He trained as a Research Fellow at Harvard, where he also obtained a Master’s of Public Health. Before that, he completed his clinical training at Sainte-Justine and at the Montreal Children's Hospital, where we were fellow residents. He conducts fundamental and applied research in the fields of behavioral economics, public health, global health, and health policy. He’s often called upon to comment on topics related to child health in local and national media. 


Olivier and I first met in pediatric training at the Montreal Children’s Hospital, when he was my chief resident and one of my earliest clinical teachers. We’ve been friends, and occasional collaborators on writing projects, ever since. One thing I’ve always appreciated about Olivier is his commitment to research that has concrete, practical applications, and his broad intellectual range, which allows him to make connections across disciplines.


A NOTE:  we use the terms “obesity” and “overweight” in this conversation, because they are typical medical terms. However, I realized after recording that they can be hurtful and stigmatizing. I apologize for that, and I intend to use more inclusive and respectful language from now on, but I did choose to keep the discussion on the tape, as I do believe it’s valuable.

A CORRECTION: I refer to ozempic and related drugs as GLP-1 receptor antagonists. In fact they are GLP-1 receptor agonists.
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Links:
Olivier's website
Daniel Kahneman: "Thinking, Fast and Slow"
Richard H. Thaler and Cass R. Sunstein: "Nudge"
Daniel Kahneman, Olivier Sibony, Cass R. Sunstein: "Noise"

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Recorded May 2nd, 2023
Art: Jeff Landman
Music: Mr. Smith
www.practicingpod.com
Twitter: @practicingpod
Instagram/Threads: practicingpod
LinkedIn: Practicing Podcast

When I first started reading Lisa Rosenbaum’s work in the New England Journal of Medicine a few years ago, I felt I had discovered the voice I’d been searching for since starting my medical career. At once evidence-based and deeply human, Lisa’s reportage on topics such as vaccine hesitancy, the war on science, or the Covid pandemic provided something I craved, which was to see the medical world explained and exposed in a way that questioned and transcended the assumptions and dogma that so often govern it. 


Lisa isn’t just a critic though. She has a deep love of medicine and as you’ll hear she believes in its potential for good. She is, however, lucid about its shortcomings, and her skill as a writer allows her to approach even the most controversial topics with nuance, sensitivity, and intelligence. She is, to my mind, one of the very best physician-writers working today. 


In addition to her regular written contributions, Lisa recently launched a podcast with the Journal called Not Otherwise Specified, in which she interviews leading thinkers in medicine about their work. 


Dr. Lisa Rosenbaum is a national correspondent for the New England Journal of Medicine, assistant professor of medicine at Harvard Medical School and practicing cardiologist at Brigham and Women’s Hospital in Boston.


Lisa completed medical school at the University of California, San Francisco, did an Internal Medicine residency at Massachusetts General Hospital and a Cardiology fellowship at New York Presbyterian Hospital Weill-Cornell. She spent a third year of fellowship at the New England Journal of Medicine and was also a Robert Wood Johnson Foundation Clinical Scholar.



Lisa and I spoke about her dual career as a writer and physician, the longstanding, in some ways inherited importance of writing and storytelling in her life, the state of US healthcare and the future of medical work. 


This was a special conversation for me – an opportunity to speak with one of my role models – and I hope you enjoy it as much as I did. 
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Links:
Not Otherwise Specified Podcast
Lisa's Writing @ NEJM

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Recorded March 29th, 2023
Music: Mr. Smith
Art: Jeff Landman
www.practicingpod.com
Twitter: @practicingpod
Instagram/Threads: practicingpod
LinkedIn: Practicing Podcast

In the clinical work I do in urgent care pediatrics, most of the kids I see come in with an injury or an infection – a fever, cough, runny nose, GI symptoms. That means that – as is the case for many pediatricians – so much of what I do revolves around diagnosing infections and counseling families about them. It’s often routine work, but it has its challenges. The most difficult thing, I think, is seeing parents who are desperate for relief, exhausted from a few sleepless nights with a sick, crying child, and having to tell them that their child isn’t in danger, that nothing more needs to be done, and that this too, shall pass on its own. That disconnect between the distress – which I too have felt as a parent – and the routine nature of these illnesses, is tricky to navigate.
In the last few months, and in particular this past Fall, it seems all of society and much of the news cycle in Canada and the US turned its attention to childhood infections. With an extraordinary wave of RSV and then influenza, pediatric emergency rooms and hospitals were overwhelmed with sick patients. Coming in the midst of the Covid pandemic, this wave of viral infections had health systems reeling. In Canada, shortages of medications like common antibiotics and pediatric formulations of ibuprofen and acetaminophen compounded the sense of chaos and of a breakdown in health services. 


All that has now passed, but I wanted to revisit those events and talk a little about what happened. My next guest is someone I’ve come to trust on this subject for his abilities as a communicator. 


Alasdair Munro is a senior clinical research fellow in pediatric infectious diseases at the UK National Institute for Health and Care Research (NIHR) in Southampton, England and a medical doctor. He’s currently a senior trainee in pediatrics working in pediatric emergency medicine. During the pandemic he led the live evidence review of COVID-19 in children with the Royal College of Paediatrics and Child Health while running a number of different COVID-19 vaccine clinical trials. He also sat on The Lancet commission on COVID-19 (safe work, travel and schools) as well as the NIHR working group for the study of transmission of COVID-19 in schools. 


Alasdair’s gained a large Twitter following, and his substack newsletter, the Munro Report, is widely shared. Whenever I read Alasdair, I feel he captures the way I and most pediatricians I know think about COVID, other infections, and pediatrics more broadly. We cover all of that in our conversation, and I hope you enjoy it as much as I did. 


Although I never provide medical advice on this show, since this episode is about my area of clinical expertise, I wanted to make it extra clear that nothing in the following discussion should be construed as direct medical advice to you or a child you know. For those questions, you should see a health care provider yourself. 


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Links:
Alasdair's newsletter
Alasdair's Twitter: @apsmunro
Don't Forget the Bubbles (pediatric evidence review site)

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Recorded February 9th, 2023
Music: Mr. Smith
Art: Jeff Landman
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“I’m twenty-nine years old, writing in my journal in a sloppy felt-tip pen (no ballpoints are allowed), trying to understand how I went from being a newly minted physician in a psychiatry residency program at Columbia University to a psychiatric patient at Bellevue, the city’s notorious public hospital.”

That’s a quote from the first page of Carl Erik Fisher’s The Urge: Our History of Addiction (Penguin Random House, 2022). As he reckons with what has brought him to that point and enters recovery, Carl revisits his own history of alcohol and drug use and comes to pose broader questions. “Why was there a totally separate system for addiction treatment? Why do we treat addiction differently from any other mental disorder? If everyone seems to know that the system is broken, why isn’t anyone changing it?” he writes. 
“The Urge” explores these and other questions, offering a history of addiction and medicine and society’s response to it through the ages. Drawing on sociology, anthropology, and theology along with psychology, neuroscience, and of course medicine, Carl’s book is part memoir, part work of popular science. But it’s also something more. That’s why I was so eager to explore it with him.
Carl Erik Fisher is an addiction physician, bioethicist, and person in recovery. He is an assistant professor of clinical psychiatry at Columbia University and maintains a private psychiatry practice focused on complementary and integrative approaches to addiction and recovery.  His writing has appeared in The New York Times, The Guardian, Slate, and elsewhere. The Urge was named one of the best books of 2022 by The New Yorker and The Boston Globe. He also is the host of the Flourishing After Addiction podcast, which I highly recommend.
Carl’s work is so compelling to me because it combines his scholarly curiosity with his clinical experience and personal past. It’s one thing to write a history of addiction; it’s quite another to do so while also working with patients who struggle with addiction and who are in recovery while being in recovery yourself. The result is work that I’d describe as integrated, a rich whole that combines the general and the specific, the scientific and the experiential, the analytic and the critical. It’s no exaggeration to say that The Urge helped me see the world around me – both current events and medicine’s particular role in them – as I hadn’t seen it before. 

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Links:
Carl's website
Carl's podcast
The Urge website


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Recorded December 13, 2022
Music: Mr Smith  
Art: Jeff Landman
Photo of Carl: copyright Beowulf Sheehan


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