an internist's perspective
Dr. DANIEL PANISKO
Dr. Daniel Panisko is director of the undergraduate Medical Education Program, University of Toronto; a professor of Medicine at the University of Toronto; a member of the Clinical Studies Resource Centre at the Toronto Western Research Institute and director of the Master Teacher Program, for faculty and senior trainees.
Dr. Daniel Panisko grew up in North Winnipeg, the son of a mechanical engineer (father) and a bookkeeper. Fascinated by sciences and stories of medical discovery, medicine was a natural attraction. By 23, he was a graduate doctor from the University of Manitoba. "Was that too young?" he asks. "It wasn't for me. I was pretty sure what I wanted career-wise. But it might be for some people. Some people might need and want more time and exposure to a broader range of experience."
He completed his core residency in Toronto and specialized in tropical medicine. Near the end of his course work, on a flight to a conference in Washington, D.C., he bumped into his old University of Toronto teacher, Dr. Herbert Ho Ping Kong.
"He asked me what I was doing the next year and I said I did not know," Panisko recalls. "It turned out Herbert had an opening for a clinical associate in internal medicine."
Panisko seized the opportunity and for the next three years immersed himself in patient care. He spent another year earning a master's of Public Health at Johns Hopkins. "I knew I wasn't going to be a researcher. Part of my attraction to medicine has always been the desire to work with people. I didn't want to spend 80 percent of my time in the lab or doing stats."
If art is an expression of man's humanity, Panisko says, then the art of medicine is what is human about medicine. "It takes several forms. There's the compassion part — the face-to-face contact and empathy. There's the creativity part—problem-solving in medicine, and in the health care system, because finding solutions for patients often does not follow a prescribed pattern. And there is the thinking outside the box part, being ready for differences, individualities, nuances. The science of medicine is protocolized. 'Here is the route and this is what you will follow.' Too many people are being railroaded into that box. The art lies in dealing with the patient who may not fit into that box. How do you decide if he does or doesn't? How do you accommodate them and not get frustrated, but learn to enjoy those differences and diversity?"
Although some observers believe the great pendular shift to the science side of the equation has begun to tilt back, Panisko isn't persuaded. The economics of modern medicine, he says, create severe time pressures — pressures for efficiencies. The system is built on a foundation of "volume-funded care and pushing patients through too fast, without time for personal reflection, without time for the patient."
Doctors are responding to the growing waiting lists and the shortage of family physicians. But they are also motivated, he says, by the desire to earn triple-digit salaries. "You hear about clinics that will only schedule one doctor on overnight call. They don't want to bring in additional staff because it will split the revenue stream. It would be saner and healthier and more humanistic for patients, but it isn't happening."
The medical community, he says, is also wrestling with the question of whether the new generation of doctors is — or may become — too reliant on technology, at the expense of humanism. "It's a huge debate, particularly in medical education. Are we all going to become cyborgs, perpetually attached to devices of some kind? Or do we take advantage of technology to accelerate and magnify what we can do — so it becomes power? Technology, we know, is fallible."
Still, Panisko thinks younger doctors are at once more conversant with and more dependent on technology. It's a trend he expects to increase, because it "does yield efficiencies and it does help doctors deal with the vast amounts of new information. But this does not diminish the importance of the art of medicine."
Medical educators are also pondering how much students actually need to learn, given the exponential, growth of information. "There are more diseases, more drugs, and therefore more side effects," Panisko says. "And we understand mechanisms more. But what proportion do we need to know? Arguably, training would be better aimed at teaching problem-solving techniques, including how to search and find relevant information at point of care. It's constantly evolving."
Other aspects of medical education are also evolving, including how to combat the erosion of ethics and empathy that has historically marked the passage of students through med school. New studies, Panisko says, suggest that a direct apprenticeship system and a "longitudinal relationship" with a single physician/ role model, confers a better understanding of what proper treatment should be.
"Imagine," he says, "that you are an overworked medical student on a late-night round in the emergency department. Your default-setting attitude is slightly negative or frustrated. A patient is admitted with an overdose of some kind. Your reflex tendency will be to blame the patient for his or her social behaviour. That is roughly how the current system works — encounters with patients are episodic. In the longitudinal model, originated at the University of Minnesota in the 1970s and now in place, in whole or in part, at 11 of 17 Canadian medical schools, students work with a single doctor for three or six months and get to know patients in a more complete way. So when a patient arrives in emergency at 3 a.m. in. crisis, you know his or her background and the whole person."
Research at Harvard University suggests that this approach— more contact with the patient, more contact with the supervisor/teacher — reduces the degree of ethical erosion in new doctors. "The other system," says Panisko, "in which you bounce from one preceptor to another, and one rotation to the next, always encountering new challenges and affronts to the ego because of what you do not know, induces a certain hardening. In the longitudinal relationship, there's more mentorship. The student is less likely to get lost in the shuffle. You can see if the student is feeling down or needs help." The University of Toronto is hoping to pilot its version of this curriculum approach in 2014 or 2015.
Panisko sees a generational shift in the doctors coming up through the system — more interest in quality-of-life issues (hours of work per week), the extent to which medical training will impinge on personal lives and remuneration. "That's new," he says. "Those questions never came up when I trained. Now they are top of mind."
The other reality is that the market for some high-priced medical specialties is now saturated. "In Toronto," he says, "it is now difficult for cardiologists and specialists in dialysis to find jobs."
As medical education moves increasingly toward broader, evidence-based modalities — the science of randomized studies, what's better overall for a group of test subjects — Panisko insists there is still a genuine need for the Herbert Ho Ping Kong art-of-healing approach. "He's dealing with the individual, focussing on the human journey of the patient to highlight memory and teaching points. Tying the emotionality of the anecdote to treatment points improves retention. It can be just as effective."
Dr. MANSOOR HUSAIN
Dr. Mansoor Husain is the director of the Toronto General Research Institute, director of the Heart and Stroke Richard Lewar Centre for Excellence, a senior scientist at the Toronto General Research Institute and professor of the Department of Medicine, University of Toronto.
The son of a petroleum geologist, Dr. Mansoor Husain is both a cardiologist and a scientist. He grew up in Libya, Malta and Calgary and, precociously, entered the University of Alberta at the age of 16. After two years of science studies, he was admitted to medical school and graduated as the gold medallist in 1986. "I did well in medical school and that became a self-reinforcing, iterative loop," he says. "I continued to do well in part because I had already done well. I aspired to more and did well, and aspired to more and did well."
Encouraged to broaden his horizons by leaving Alberta, Husain won an internship at Stanford University, but turned it down to do a rotating internship at Toronto's St. Michael's Hospital. He became chief resident at age 26, then studied cardiology, and did further post-graduate work in basic science, studying molecular genetics at Massachusetts Institute of Technology in Boston.
Husain was ultimately drawn to internal medicine for the same reason many practitioners are — the deep, intellectual challenge it poses. At St. Michael's, he worked under the legendary internist Dr. Ignatius Tong, a charismatic specialist in infectious diseases. He says Drs. Ho Ping Kong and Fong, also a Chinese-Jamaican, represented the British/Canadian tradition of medical practice, strong on bedside manner. "That was really attractive in a charming, elegant way. It slowed things down, giving you time to process the information. But even then, I think, I recognized its limitations."
With the growth of medical imaging, Husain saw, certain kinds of training were no longer as critical. Great clinicians of the past were often able to determine the severity of mitral valve heart disease, for example, by the use of a stethoscope alone. They had a lot of practice, because they would confront, in a career, perhaps 1,000 cases of mitral stenosis. Now, trainees are lucky if they see 50 cases, because there has been a gradual decline of rheumatic heart disease worldwide.
Moreover, medical imaging technology has "completely changed the game of diagnosing the condition." The same technology has changed other specialties as well. "Why would you blindly palpate the abdomen when you can do a CT scan?" Husain asks. His own brother-in-law, a general surgeon, used to appear in the emergency room and automatically lay hands on patients. "Now, he tells me, he just says, 'Have you done the CT yet?' Because there's no way his hand is better than the CT."'
Husain insists that the laying on of hands — the traditional approach of a doctor to patients — continues to have inherent therapeutic and bonding value. But as a diagnostic tool, it lacks the sensitivity or specificity of scanning technology.
It takes time, typically an hour, to take a new patient history. With older patients, dealing with more complicated conditions, "trainees today may not have the time that is needed," Husain says. "A skilled doctor knows how to take shortcuts and elicit that information, but not the trainee. Indeed, the argument is that there is so much to learn in any one subspecialty than you can't afford the time to spend in general medicine. Therein lies the dilemma. What becomes of the renaissance physician and what will the legacy be? I don't know the answer."
Husain also identifies other troubling consequences of technological change. It's virtually impossible for the mind to absorb the reams of new scientific and medical information that pour forth from scholarly journals and research institutions. Instead, there is Wikipedia. Increasingly, he says, "nobody actually knows anything. They just Google it. That's what's happening and it's happening on the rounds."
Before, doctors needing to confer with a colleague had to physically find them. There were no cell phones. If they needed additional information about a disease or drugs, they had to visit the library and know how to look it up.
"Now," Husain notes, "everything is at your fingertips, like never before. Every piece of information you might need is accessible on your tablet or phone. There's no longer any excuse for not knowing something. But we are short of the time and space needed to bring it all together, to synthesize. You don't need to retain it — why bother? But having access to all the information also means we are expected to deliver instant answers."
The larger question, Husain suggests, is how does one retain the knowledge bank of what is required to be a good physician, without all the memorization of which previous generations had to be capable. "Memory was the reason I did so well in medical school," he concedes. "You can't teach memory, but it is possible that technology has replaced that burden or borne some of it."
Even harder to teach is synthesis — using logic to put ideas together and solve problems. "I don't think technology has yet, and I emphasize yet, replaced the human mind in terms of logic and synthesis," he says. "But that's where these software programs are headed. But relying on algorithms to make medical deductions means that there will be no laying on of hands, no actual talking to the patient and getting a sense of how much of his or her complaint is being embellished or whether there is excessive stoicism — not enough disclosure of symptoms."
With the great clinicians Husain has known and worked alongside, including Dr. Ignatius Fong and Dr. Herbert Ho Ping Kong, the tendency is to be overwhelmed by their prodigious feats of memory. But in fact, their greater skill, he insists, is the ability to communicate and connect. "There aren't many idiot savants in medicine, because it's inherently a human skill."
When leading medical students on rounds, Husain makes a practice of role modelling the bedside approach, asking patients about their work and their families. And he takes time after the interview with patients to point out to interns and residents that, even when he has not come up with an extraordinary diagnostic insight, a human connection has been made and that learning has occurred — from doctor to patient and from patient to doctor. "I will leave the room and say, 'You realize why that was important . . . because this patient's job prevents him from doing A, B and C, and if we don't help him address that side of it, it won't matter what prescriptions we write.' That's not in any textbook. That can be taught only through the apprenticeship system of medicine."
But Husain is well aware that he remains, professorially, an anomaly. For most students, he concedes, the patient is simply a symptom or a lab result.
In one of his books, writer and surgeon Atul Gawande — he practises at Brigham and Women's Hospital in Boston and teaches at Harvard — recommends that doctors, no matter how busy or how exhausted they might be, try to connect with every patient on a non-medical level and learn something new about them to prevent fatigue and the effects of the grind.
"That's very insightful," says Husain. "It's really much more for the physician than the patient, but it does help in bonding and establishing trust. The patient sees that 'This man cares for me as a human being.'"
Sometimes, the questions posed may yield medically relevant information — does the patient's lifestyle assist or inhibit his or her ability to follow a diet, rehab or pharmaceutical regimen? But Gawande's point is that even the non-utilitarian question has value, if not for the patient, then for the doctor. "It is refreshing," says Husain. "You get re-energized in your desire to help that individual, just by learning a little more about them."
Ironically, just as the human factor seems to be receding in medical care, patients need it more. They are, after all, confronted by a system that is increasingly dependent on technology, often subject to long, dehumanizing wait times and attended by physicians who are too pressed for time to provide much succour. Moreover, patients — especially the elderly — are battling diseases that are increasingly complex, often requiring them to take a confusing smorgasbord of drugs.
Husain says he makes a practice of telling patients, after his first meeting, what he thinks may be wrong, even before he has sent them for tests, and even if it might be bad news. It is, he suggests, a way to reduce their anxiety, rather than dispatch them to a possible limbo of serial appointments and tests with various specialists. "I think it's important to take them through the possibilities, the differential diagnosis. Here's what I think we may find... if it's A, we'll do this. If it's B, we'll do this. Et cetera...That's therapeutic, practically. That's important. It shows them that you have connected, that it's not all technology."
When Husain was an intern, telling the patient what you thought was called medical paternalism. In some ways, he now believes, "We have probably swung too far away from that. I'm not sure whether it's driven by fear of legal-medical retribution — being sued — or by the anxiety of just being wrong and recognizing limitations."
But for himself, Husain says he's prepared to say to patients, "I think I'm 80 percent right or whatever the percentage it is. It's not based on the latest studies, but simply on a desire to communicate certainty versus uncertainty. That's what makes patients anxious — uncertainty. To quantify it is important. Some people will fret about it and you have to gauge that, with each patient. There's no cookie-cutter approach."
Husain thinks the model of excellence in clinicians will inevitably change. "Maybe the next generational version of Herbert Ho Ping Kong will be someone with all the greatest apps on his iPhone and a great personality, someone who can integrate all the technological advances and knows the advantages and limitations of imaging. A hybrid form, in other words."
Resisting the suggestion that the modern world has made diseases more complex, Husain offers another view: that because our knowledge of biology has expanded, we better comprehend the multi-faceted nature of many diseases. The reality, he says, is that biology lies at the core of many diseases.
"With time, biological systems degenerate," he notes. "We are machines. We wear out. Arthritis, heart failure, dementia — all are degenerative diseases. If you understand the biological principles of degeneration, you will understand all of those diseases. Genetic and environmental influences explain why some people degenerate faster than others. The current excitement about stem cells and regenerative medicine is really an attempt to thwart degeneration. Because if as a child, you break your leg, it will regenerate and you'll never even know it was broken. If you are 90 and you break a leg, you are in big trouble."
Another one of what Husain calls his big concepts focusses on immunology. In medical schools, the subject is seldom taught for more than a month. Most doctors have only an elementary grasp of its principles. Yet, he maintains, it is one of the foundational mechanisms of disease. Autoimmune disorders such as lupus, osteoarthritis, rheumatic fever and polymyalgia rheumatica are essentially immune system diseases.
The body's most important organ, vis-a-vis immunity, is neither the skin nor the lungs — it's the stomach. "It's the first line of defence, because we put things in our mouths," Husain says. Gastroenterology, he predicts, will eventually become immunology because it is microbes, a complex function of what we eat, and our immune system, that determine many of the diseases that affect us. "Vulnerability to coronary heart disease and high blood pressure are dependent on the bugs in you. So it's not just your DNA that matters, but the DNA of every bug in your body, and how it interacts with your DNA."
This, Husain believes, is the medical horizon, and it troubles him. "How do you keep teaching the bedside manner and the human touch when you have to continuously integrate all this new information? People who are conceptually at the leading edge of understanding this nexus of biology and medicine typically don't learn this material until you finish your fellowship — the final polishing-off phase."
Although he studied sciences almost exclusively in school, Husain endorses the notion that a background in the humanities makes for a more well-rounded physician. "I don't feel I missed out big-time, by not reading literature and history. Most stories are derivative, either of the Bible or of the Greek and Roman fables and myths. If you understand those stories, you are connected as a human being. If you are a logical thinker who understands human beings and their vices, then the rest, the science, is pretty easy. It's where some doctors fall down. They have the science, but are lacking the human understanding."