internist's perspective


Dr. Stephen Hwang earned a master's degree in Public Health (epidemiology) from Harvard School of Public Health, an M.D. from Johns Hopkins University and a B.A. (biochemistry) from, Harvard University. His current titles include scientist, Centre for Research on Inner City Health in the Keenan Research Centre of the Li Ka Shing Knowledge Institute at St. Michael's Hospital; director, Division of General Internal Medicine, University of Toronto; associate professor, Department of Medicine, University of Toronto; associate professor, Dalla Land School of Public Health, University of Toronto; associate professor, Institute of Health Policy, Management and Evaluation, University of Toronto and staff physician, Division of General Internal Medicine, St. Michael's Hospital.

Raised in southern California and educated in the American Northeast, Stephen Hwang came to Canada in the mid-1980s to be closer to his wife's family in Toronto. He had recently graduated from Johns Hopkins with a degree in medicine. His first year in residency was not a happy one. "I realized I wasn't getting the education I had hoped for," he says.

Learning from fellow residents that the city's choice place for training was Toronto Western Hospital (TWH), he made an appointment to see Dr. Herbert Ho Ping Kong, who then directed its residency program.

"I was required to do two years at the same hospital, sol still had one year to go," he recalls. "But I essentially pleaded with him to let me into TWH. He took my pleadings to heart and let me in. I don't know whether he had to pull any strings to do that."

Hwang ended up spending two more years at Western, and then became chief resident at both Toronto Western and Toronto General. "What I discovered is that Western, led by Ho Ping Kong, had developed an incredible culture of general internists who were expert clinicians and diagnosticians and who took delight in teaching. They showed by example how general internal medicine could be practised and taught. That was a formative experience. At clinics, HPK, as we called him, would grab me and say, 'Look at this patient. Listen to the heart.' Or he'd start grilling me on the sounds made by mitral stenosis, a valve disorder, which is rare now and was uncommon then. I was preparing for my Royal College exams and after I successfully identified mitral stenosis, he said, 'Now I'm confident you'll be okay."'

For his college exam, Hwang found himself in Montreal's Royal Victoria hospital. At the time, the oral portion of the exam was not standardized. It required physicians to see a real patient, take a full medical history and conduct a full physical examination, and then be grilled by a panel about the findings. "It was a source of dread," Hwang recalls, "because you could encounter a condition you had never seen before, in which case you were probably doomed. Moreover, the patients often seemed to think their role was to withhold information about their condition. So you'd ask, Are you short of breath?' And they'd say, 'I'm not sure I'm allowed to tell you.'"

Purely by chance, the patient Hwang encountered for his exam had been attended by Dr. Ho Ping Kong during his years in Montreal. Although she was a lupus sufferer, he had successfully nursed her through pregnancy with the disease. In fact, she was convinced that Ho Ping Kong's treatment had saved both her life and the life of her child.

"So it's not just about skill. HPK is able to form a connection with his patients. They see and feel that his caring is genuine," Hwang says.

Although the number shrinks every year, there are still some conditions, Hwang maintains, that can only be diagnosed by careful physical examination and talking to the patient. "Moreover, as human beings, we require doctors with whom we can form a real connection, not just technicians. You can learn from a teacher that provides the information and facts, but the best teacher is the one who makes a connection with students and inspires them and lights a fire for more learning."

Hwang says he has thought deeply about this issue. "I don't think you can have a fully therapeutic, healing relationship or process if it's purely technical. There are computerized programs that do diagnoses. They were primitive when I was in medical school and they are better now, and I'm sure we will have, perhaps in 10 or 15 years, machines that can do as good a job as the best clinician in making a preliminary diagnosis and ordering the right tests. But I think fundamentally, we would find that unsatisfying and sterile. Very few people would be happy with such a system, even if the right diagnosis was made and the treatment was successful. It's who we are as social beings and why medicine is both a science and art and requires ability to connect with people."

From his own research on public health — he works principally with the disadvantaged and the homeless — Hwang says it's clear that the limiting factors with respect to positive outcomes pertain not to diagnosis and/or treatment but to society's ability to affect the environment of patients and their behaviours.

A case in point is lung cancer. Over the past few decades, medicine has made significant advances in the field, both with respect to surgery and drug therapies. But the fundamental problem remains: how to get people to stop smoking. "We know the answer is not better surgery or chemotherapy," he says. "The answer is to quit smoking. But that's really hard. So it's not a technological problem. It's a human problem."

Many problems in medicine, he insists, are like that. "We could reduce the burden of disease if we spent more time addressing the human contributing factors and less time focussing on better scans or genetic tests. I'm not against technology, but if you look at the untapped potential to reduce disease, the greatest possibilities are in the human area."

Why is it so important to maintain the art of medicine? Without it, Hwang suggests, we will suffer a "loss of common sense. As you become more enmeshed in the technology, you stop listening and seeing what is plainly in front of your face."

Consider, he says, the true story of the British driver so enamoured of his gps device that he followed its directions blindly — into a river. Unfortunately, in charting the most direct path to the destination, the machine failed to take account of the fact that it followed a road that often washes out in the rainy season.

"In medicine, too," says Hwang, "we sometimes follow the gps and don't see the river we are about to drive into. With increasing reliance on technology — on the E-patient and lab work — we are losing the skill of looking at the patient and making smart deductions."

The great impediment, he notes, is time. If the art of medicine relies, in the first instance, on getting to know patients and their history, and spending unhurried time in examining them, the reality is that many physicians find their workload an obstacle in the way of that objective.

"We have to be careful," Hwang says, "to create that time for thoughtful contemplation and observation of the patient, including talking to them — despite the constraints and the pressure to move on to the next patient. It requires effort and mindfulness."

One of the "arts," then, is knowing when to invest that time — and when not to. "You can't do every patient, head to toe. You can't take a two-hour history with every patient. Some will require it, but many will not, and you have to be able to identify where and when it will be beneficial and when it will be a waste of time, because the condition or illness does not justify it."

More critically perhaps, with the rise in human longevity, the nature of disease itself is becoming more complex. Increasingly, doctors find themselves treating patients — particularly the elderly — with multiple, chronic illnesses. It's not atypical for a group of internists and specialists to treat a single patient simultaneously for heart failure, diabetes, liver problems, skin cancer and other ailments.

Thus, while modern science has learned how to combat many serious diseases and extended human life, the advance is not without consequences.

Twenty-five years ago, it was unusual to find an elderly patient taking more than five medications a day. Today, says Hwang, "We have medical reconciliation sheets, with space for 12 drugs, and it's not at all uncommon for a single patient to have three sheets." In some ways, he says, "We are victims of our own success."

Our ancestors rarely got cancer because they typically died of infection or trauma before the age of 50. "I don't think we want to go back to the 'good old days,'" Hwang notes, "but the reality is we now have multiple illnesses to treat and we have to decide which ones get priority and setup drug regimens that take account of the complex chemical interactions. It's far more complex than it used to be. We live longer and are healthier — and this is a side effect. It's a reality we have to address."

It's that very element of complexity, he says, that underscores the need for the discipline of general internal medicine. "The specialist knows everything about a narrow area, but a general internist understands the complexity and the big picture. We treat forests, not trees. That role is increasingly needed." The recognition of that may have been lost during the era of subspecialization, but Hwang believes it is coming back.