Humility
2018; Lippincott Williams & Wilkins; Volume: 65; Issue: CN_suppl_1 Linguagem: Inglês
10.1093/neuros/nyy290
ISSN1524-4040
Autores Tópico(s)Ethics in medical practice
ResumoCNS: Congress of Neurological Surgeons HER: electronic health record HIPAA: Health Insurance Portability and Accountability Act MRI: magnetic resonance imaging I am very fortunate to be working at Johns Hopkins, the cradle of neurosurgery, whose doors opened in 1889 (Figure 1). This is where the “special field”, as it was called, was founded by Harvey Cushing, with reluctant consent from his mentor, William Steward Halsted, who had major concerns about the dire outcomes in the limited number of operative cases that had been done in prior years. Today Hopkins is one of the finest medical centers in the world, with new towers donated by Sheikh Zayed of the United Arab Emirates and Charlotte Bloomberg, mother of Michael Bloomberg—an Arab and a Jew forging new ground in Baltimore (Figure 2).FIGURE 1: Johns Hopkins Hospital. CC BY-3.0, Lizardraley99.FIGURE 2: Johns Hopkins Hospital – New Towers. Photo courtesy of Johns Hopkins Medicine.Being here today is the greatest honor of my career, and I want to express my heartfelt gratitude to the Congress of Neurological Surgeons (CNS) and to CNS President Alan Scarrow. Alan was a former student of mine, and I take great pride watching his sky-rocketing ascent in our field. It is another example, all too familiar to me, of the mentee surpassing the mentor. The topic of my talk today is humility, and how much this can contribute to the art of healing in our rapidly evolving and highly technical specialty. First, a few words about my background. I came from simple beginnings. My mom was a writer, intensely dedicated to her family, and my dad was a very humble man who grew up in poverty in the Lower East Side of New York City. He went on to become a great physician, graduating first in his class in medical school, something he never told my mom—she learned this years later from a friend. Unfortunately, the humility gene did not seem to get passed on to me. I was educated in public schools, but somehow, miraculously, was accepted to college at Harvard, a fact that most of the people in my hometown of Poughkeepsie, New York learned from my proud mother within days of my acceptance (Figure 3). But Harvard was a huge culture shock for me. My classmates had names like the Viscount Slane from Slane Castle in Ireland, and Walter Isaacson, who went on to become a Rhodes Scholar, CEO of CNN, Managing Editor of Time, President of the Aspen Institute, and a world famous author. I was clearly way out of my element and frequently felt hopelessly overwhelmed.FIGURE 3: Harvard.Things appeared to turn around for me in the second semester of my freshman year, when I was notified by Harvard that I was awarded the Edward Whitaker Scholarship (Figure 4). Of course my mom was thrilled and shared the news with pretty much everyone in my home town. However, I was shattered, to say the least, when I received the official notification letter, which listed the value of my scholarship as $13.50 (Figure 5). Apparently, Harvard's value of my scholarship and my own were not very much aligned. I eventually pulled myself together and moved on, but this taught me a valuable lesson about humility, the central theme of my presentation.FIGURE 4: Edwards Whitaker Scholarship.FIGURE 5: A, Scholarship check. B, Scholarship check, close-up view.Humility is an under-recognized but extremely powerful component of the art of healing. Harvey Cushing and Walter Dandy, the early neurosurgical giants, both from Hopkins, were focused mainly on the technical matters necessary to get their patients safely through surgery and out of the hospital alive (Figure 6). The past century has brought tremendous technical advances in our field and we can do things today that Cushing and Dandy would never have dreamed possible.FIGURE 6: A, Harvey Cushing. Reprinted by permission from Springer: Springer Nature, Springer eBook, Udelsman R, Harvey Cushing, Jan 1 2015, Copyright 2015. B, Walter Dandy. Reprinted by permission of the Congress of Neurological Surgeons.But what has happened to us over the years? What has come of our specialty? Here's a 32-yr-old man whose complaint was only nonradicular back pain. His exam and imaging were normal. Look at his treatment (Figure 7). How does something like this happen? We commonly think of malpractice as doing what is necessary poorly. Here's an example of doing what is unnecessary well, what Norton Hadler has called type 2 malpractice in his book, The Citizen Patient.FIGURE 7: A, Preoperative sagittal T2-weighted MRI. B, Postoperative lateral lumbrosacral spine film.Our field has become rife with conflicts of interest and some neurosurgeons have developed a tendency to over-diagnose and over-treat our patients. Recently, the chief of neurosurgery and hospital president at a major medical center were ousted because of billing concerns. This represents the dark side of doctoring and we read about it all too frequently in the newspapers. Medicare fraud landed a neurosurgeon in prison for 20 yr for maiming patients and cheating insurers. Manslaughter earned another neurosurgeon a life sentence in prison for a drug and alcohol-fueled string of botched surgeries that left his patients paralyzed or dead. Yet another neurosurgeon is in jail for the first degree murder of his wife, a physician and the mother of his 3 children, who was found strangled and stuffed in a bag under a bridge. And this is all in the past few years. We need to reclaim our specialty. To do this, it is important to first figure out how we got here. Some individuals, in our field and others, are simply sociopaths with character flaws and mental health issues. Neurosurgery is certainly a high-stress field, and stress can lead to anxiety, depression, and burnout. There is also greed, the corrupting power of money. There are inherent conflicts of interest in the practice of neurosurgery, and for some in our field, greed trumps ethics. We need to restructure our specialty, and some of these issues can be addressed by changing the selection process for residency and the certification process for practitioners. In training, we spend an inordinate amount of time developing and polishing our technical skills. I don’t wish by any means to diminish the importance of technology in neurosurgery. I recently did a book, “Pediatric Neurosurgery: Tricks of the Trade”, about nuances of neurosurgical technique, focusing on tips for operating smoothly and staying out of trouble. Technology has enabled us to make great strides in neurosurgery, but technology comes with a price tag that is not purely monetary. Today we are lucky to have magnetic resonance imaging (MRI) and even intraoperative MRI that takes some of the guess work out of neurosurgery. We can even see papilledema on imaging, such that some say with the advent of MRI it does not matter whether you do the Babinski with the shoe on or the shoe off. We have diffusion tensor imaging to give us beautiful representation of fiber tracts. One interest of mine is minimally invasive neurosurgery, and here is an example of the endoscopic resection of a third ventricular colloid cyst (Figure 8). But while technology has revolutionized neurosurgery, it has also, in some ways, driven a wedge between the doctor and patient.FIGURE 8: Endoscopic view of colloid cyst.As technology has advanced, less attention has been paid to the importance of bedside diagnosis and bedside manner. Remember the words of William Osler: “Listen to the patient, he is telling you the diagnosis.” There is a lot to learn at the bedside if one is able to take the time to carefully listen to and examine the patient. The importance of developing a rapport with the patient and family is under-emphasized in medical training. When I worked at Rainbow Babies and Children's Hospital years ago, I had 8 bulletin boards on the walls of my office, filled with countless of pictures of my patients, sent to me for display by them or their grateful parents. The kids and their families inevitably enjoyed finding their photos on the wall when they would return for follow-up visits. But these bulletin boards were actually a violation of the Health Insurance Portability and Accountability Act (HIPAA), because I did not have written consent to display the photos that had been sent me for display. HIPAA was passed by Congress and signed by President Clinton in August 1996, years before Google and Facebook were even founded. In my opinion, this is absurd, and the pendulum has swung too far in the wrong direction. So-called “meaningful use”, employing the Electronic Health Record (EHR) to facilitate patient care, has in many ways become meaningless. The coding revolution is driving many practicing physicians crazy. Some of you may remember advertisements for Dos Equis Beer featuring Jonathan Goldsmith, the most interesting man in the world, and his catchphrase- “stay thirsty my friend.” There is a parody of these ads in which he says, “I don’t always get sucked into a jet engine, but when I do I use ICD-10 Code V97:33XD.” Funny for sure. But the problem here is that V97:33XD is a real code- sucked into a jet engine, subsequent encounter! Another absurdity. If we spent a fraction of the time we devote to coding on patient care we’d be in a much better place. The mighty HER, which most will agree has improved our ability to transmit and store huge amounts of data, is significantly flawed. The use of rigid templates that are auto-populated has led to a degradation of documentation. With its cut-and-paste formatting, the EHR has lost much of its value, and doctors have less trust in one another's notes anymore. The EHR has become emblematic of “garbage in, garbage out.” It has found its place as an effective automated generator for coding and billing, though it has become the source of considerable burnout by its users. As a mechanized piece of technology, which is sometimes managed with scribes and other intermediary personnel, it has done much to interrupt the sanctity of the doctor/patient relationship. As we spend so much time focused on technology, there is a tendency to forget about the patient as a person. Doctors have become health care providers and patients have become clients. For those of you seeking medical care yourselves, you may feel like an afterthought, peering at the back of your provider's head as he or she logs your personal story into the computer. We would be wise to take our hands off the computer keyboard from time to time and place them on the patient. We have forgotten the importance of connecting with the patient and the power of the laying on of the hands. Some of the simplest things we do are often the ones that are remembered most by our patients and their families. And these unique rewards of our chosen field are so much greater than anything money can buy (Figure 9; the patient consented to the publication of these images).FIGURE 9: A, Laying on of the hands. B, Laying on of the hands. C, Rewards of the job. The patient consented to publication of her these images.Humility is an essential part of the art of healing, but it's not a word in the lexicon of many neurosurgeons. As the legendary Yogi Berra said, “It ain’t the heat, it's the humility.” But humility comes from the Latin, humilis, the act of being humble, having a modest view of one's own importance. What we do in neurosurgery requires a certain amount of confidence and brazenness, but that doesn’t undercut the importance of humility. Moses Maimonedes, the great medieval physician, philosopher, rabbi, and teacher said, “May I never forget that the patient is another fellow creature in pain. May I never consider him merely a vessel of disease.” Humility is the antithesis of narcissism, the excessive interest in oneself and one's physical appearance. All too often we are victims of our crushing clinical responsibilities, rushing to the ER to see 2 new “bleeds” without time to remember that each “bleed” is a patient and each patient is a person. Humility is composure, or equanimity. Equanimity is mental calmness amid storm, evenness of temper, clearness of judgment in moments of grave peril. Aequanimitas was regarded by Osler as the principal quality of the good physician. Aequanimitas was the valedictory address delivered by Osler when he left the University of Pennsylvania in 1889 to become Physician-in-Chief at the newly opened Johns Hopkins Hospital. In Osler's words, “The good physician treats the disease, the great physician treats the patient who has the disease.” Osler is recognized for a number of firsts: he created the first residency program in the world and he was the first to bring medical students out of the classroom to the bedside for their training (Figure 10). He is considered the father of modern medicine and his words still resonate: “He who studies medicine without books sails an uncharted sea, but he who studies medicine without patients does not go to sea at all.”FIGURE 10: Sir William Osler. Public Domain.Humility is essential to the art of doctoring, and there is an important distinction between treating and healing. Compassion without technology does not cure, but technology without compassion does not heal. The physician at the bedside often must choose the best mixture of honesty and hope. That mixture will be different from 1 patient to the next. When it comes to the art of healing, “Simplicity is the ultimate sophistication,” to borrow the words of the great Leonardo da Vinci. The 3 most important factors to remember: Listen, Empathize, and Offer Hope, hence the mnemonic, LEO. When interacting with patients, listening is most often the thing we doctors do least well. Listening is an active process, and to be a good listener you must use all your senses. One tries to listen beyond the chief complaint and beyond the patient's words. Make eye contact. Watch for body language. Look for nuances—is the patient anxious, depressed, angry? How much does the patient want to know about the diagnosis? Listening is a potent way to strengthen the connection between doctor and patient and its importance cannot be overemphasized. Empathy is the next important concept in the art of healing. Though it may be difficult to define, most of us know what it means. Remember the words of US Supreme Court Justice Potter Stewart describing pornography: “I know it when I see it.” In the case of empathy, the patient knows it, when it's not there. Lastly, the skilled physician will search for ways to offer hope, even when the outlook is bleak. Hope is not sugar-coating the situation or offering false promises. Realistic hope is something that can be shared by the doctor, patient, and family. Rudyard Kipling, addressing the Royal College of Surgeons in London in 1923 said, “Words are, of course, the most powerful drug used by mankind.” Saying something simple that's positive can occasionally have a remarkably therapeutic effect. Neurosurgery is a serious business but it's important to not take yourself too seriously. This is particularly true for those of us who work with children, as we do in my field, pediatric neurosurgery (Figure 11). The Old Testament notes, “A merry heart doeth good like a medicine.” There is a healing power of humor. Humor is vitamin H. Do not be afraid to let your guard down. Make yourself vulnerable. Vulnerability is not weakness, it makes you more human. And being more human enables you to cement the all-important bond between doctor and patient.FIGURE 11: The healing power of humor.The healing power of humor is not doing stand-up comedy at the bedside of a terminally ill patient in the ICU. But humor can sometimes help you connect with your patients. As Voltaire noted, “The art of medicine consists in amusing the patient while nature cures the disease.” Humor can help to reduce stress, reduce pain, and aid in overcoming fear. So these are my thoughts about humility and the important role it plays in our daily interactions with patients and colleagues. Do not over-value your own importance. Consider the words of Steve Jobs addressing the graduating class at Stanford in 2005, 6 yr before his untimely death from pancreatic cancer in 2011: “Your time is limited. Don’t waste it trying to lead someone else's life.” Make sure you continue to enjoy doing what you do. The practice of neurosurgery is one of the most remarkable and rewarding endeavors in all of medicine. The ability to alleviate suffering and restore health to an ailing, sometimes gravely stricken patient, is an extra-ordinary gift granted to those of us lucky enough to be in the medical profession. It is a great privilege to be a pediatric neurosurgeon and share the lives and dreams of my courageous, young, resilient patients, who have taught me more about the art of neurosurgery than I could ever have learned in books. The work is hard but the rewards are rich. As the philosopher Johann Wolfgang von Goethe said, “Treat people as if they were what they ought to be and you will help them become what they are capable of being.” Work hard, be humble, and treat people kindly. And do not forget to enjoy the ride. Disclosure The author has no personal, financial, or institutional interest in any of the drugs, materials, or devices described in this article.
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