History of Medicine in Practice: An Interview with Dr. Adam Rodman of Bedside Rounds

By: Ariel Gershon

In my previous posts, I have been trying to share some interesting facts from medical history, and have been trying to describe why studying the history of medicine is meaningful for those of us entering this profession.

For this post, Dr. Adam Rodman, the creator of one of my favourite medical podcasts joins me for an interview.

Dr. Adam Rodman is an internal medicine physician at Hospitalist at Beth Israel Deaconess Medical Center, and an Instructor at Harvard Medical School. He runs the podcast Bedside Rounds, which is chock full of fascinating narratives from the history of medicine.

Could you tell us about yourself? What does a typical work day look 
like for you?

Thank you for having me! I’m a hospitalist now, though initially I was a global health physician through the amazing Beth Israel Deaconess Medical Center Global Health Fellowship program, where I worked at Scottish Livingstone Hospital in Molepolole, Botswana. I was the physician on the medical and tuberculosis wards; physician there means, as it still does in much of the world, an internal medicine-trained doctor. My life is a little less exciting now that I’m permanently in Boston, but I still have a great job. It’s actually not that different than Botswana, though the pathology is different, of course. I care for medically-complex patients in the hospital, with either myself as their sole doctor, or as part of a larger team of residents and students.

In a typical day, I get to the hospital around 8 and start to “bedside discovery round” with my team — that is, we go and see each of our patients together, and along with the patient we review their data and discuss their plan for the day. In the afternoon, I’ll either help my team by seeing patients, teach the students and residents, precept in a student-run clinic,  or even just work on my academic research, including my podcast Bedside Rounds, which I make in partnership with the American College of Physicians.

At what point in your medical career did you become interested in
the history of medicine?

Oh, that’s a great question! I’ve always been interested in history, unsurprisingly — I was a history major in college. But I don’t think my interest in the history of medicine came until well after medical school. As I’m sure you know, medicine is presented very ahistorically — you drink from a firehose of information, with very little context or background for why or how things developed. Like most students, I just accepted this. This is how medicine was:MONABASH* after MI, a fever is 38 centigrade, make sure you pre-round on all your patients or the attending will be mad. When I was a resident, though, I became more and more curious about WHY we do the things that we do. There are lots of ways to address the question “why”. A lot of basic science research seeks to answer these questions, as does the evidence-based medicine project at large. For me, medical history was my outlet for curiosity. So, to answer your question, I’d say the second year of residency was when I really started getting comfortable enough with my own medical practice to start questioning things.

Do you feel that studying the history of medicine changes how you
practice medicine? If so, can you share an example?

Yes, yes, and yes! Studying history has changed my entire approach to practicing medicine. So first, at a concrete level, it helps me question dogma. So, like I was mentioning before, the study of medical history will quickly reveal that so much of what we’re taught in medical school stands on shaky foundations.

One of the classic examples is the definition of a “fever”. We’re all taught that a fever is 100.4 or 38 degrees Celsius. It’s scientific simplicity. You’ll even see some of our colleagues confidently announce, “it’s either a fever or it’s not!” and make fun of patients who say, “I run low, so 99.7 is a fever for me.” But even a cursory examination of history will show that this was based on mid-19th century data from Wunderlich, using an esoteric thermometer, axillary temperatures, unclear data analysis, and a, let’s just say… an imprecise method of measuring data. Moreover, numerous studies have shown that body temperatures are not only lower, but vary throughout the day — and in fact, the most important thing appears to be variation from the patient’s own baseline. It turns out, in this case, that taking an historical approach is, in fact, taking the scientific approach, critically appraising data that has real clinical impact. And while we’re at that, taking an historical approach also shows that our patients’ own experiences are probably accurate — they probably do “run low” because 98.6 F is high! **

And once you start to realize this with one subject, you realize that a whole spate of medical knowledge is equally shaky or contingent. You’ll discover arbitrary drug dosing and durations, very real epistemological concerns about our ability to know what causes disease, and even reason to doubt some randomized controlled trials — I don’t want to turn this interview into a lecture about skepticism, but I’ll add that the more you read about the fragility index, the more you’ll see that the basis of our knowledge is often far shakier than we’d like to admit.

I don’t want to say that a study of history has made me cynical — it hasn’t; if anything, I’m far more aware of how much good we can do now compared to past eras. But it’s made me very humble about the limits of our knowledge. And it’s made me focus on many of the older qualities of being a physician — compassion, good communication skills, and being at the bedside.

In your episode “The Cursed” you describe the outlandish      
autopsy findings of King Charles II of Spain as an example of how a
different system of medical knowledge can produce a difference
medical gaze. Can you talk about how being aware of your own gaze
changes how you approach medicine, if at all?

I was hoping you’d ask this question! So as a brief explanation to your readers, the clinical gaze refers to the postmodern concept first stated by Michel Foucault in the Birth of the Clinic that our scientific and epistemologic structures fundamentally shape how we approach the patient. Listen to the episode if you want more! Or even better, read the Birth of the Clinic!

As medical students, you are all becoming acculturated in a very specific gaze. It’s not necessarily a bad thing, I should add — my clinical gaze allows me to suspect, say, pericardial tamponade within minutes of talking to a sick patient (as happened in the past few weeks). But being aware of my own gaze has made me realize that many of the things I do are for my gaze, rather than for my patient. Examples abound, but generally we want data at the expense of our patient’s experiences; we have elderly patients who are woken up every 4 hours overnight for vitals checks. We draw “daily” labs at 4 AM on patients who have long since showed clinical stability; if a patient is getting better, you do not need to “trend” their leukocytosis resolving; if they are stably anemic you do not need to “continue to monitor” their hemogram. That only satisfies our gaze. We forget that the patient is in front of us, and not in the computer (another postmodern concept — the EHR as simulation).

It’s also made me re-prioritize how I spend my limited time during my day. Often one of the least useful things to a modern clinical gaze is the thing that patients most appreciate — sitting at their bedside and chatting with them about their lives. I think we all know we need to spend more time with our patients — but being aware of my gaze has really made me understand why.

Is there anything else you would like to add or talk about?

Yeah, one final thing — a plug for students. You do not need to be really into medical history to be a good doctor. But the impulse that is behind it — curiosity — is essential, and often squelched in medical education. We have an amazing field that privileges such an important position in our patients’ lives. What differentiates the great doctors from the merely good is a deep, abiding curiosity — about science, about our patients, about why we do the things the way we do. Make sure to cultivate your curiosity and creativity throughout medical school, and not just in medicine. Keep playing your instruments, keep producing art, keep reading for fun. The curious mind makes a wonderful physician!

If you are looking for a podcast to listen to in between your 
studying sessions, I highly recommend Bedside rounds
(http://bedside-rounds.org). Dr. Rodman is starting  a medical
podcasting clinical elective in Boston later this year. Follow him
@adamrodmanMD (https://twitter.com/adamrodmanmd )

* Editor’s note: MONABASH is a mnemonic for remembering the management of acute coronary syndrome. It stands for Morphine, Oxygen, Nitro, Aspirin… (review this here: https://www.timeofcare.com/monabash-management-of-acs/ )

** Editor’s note: There is a discussion of the origin of fever measurements in episode 33, found here: http://bedside-rounds.org/episode-33-alexis-and-william/

About Author: Ariel Gershon

Ariel Gershon (Meds 2019) completed a BSc at the University of Toronto in pathobiology before starting at Schulich. He was a president of Schulich’s Osler Society from 2016-2017, a group of medical students who meet to talk about the history of medicine over lunch. He‘s interested broadly in the medical sciences, medical humanities, and indoor gardening. Tweet at me @GershonMD2019

Photo Credits: American College of Physicians (ACP)

Do I Spend My Last Day Studying the Brachial Plexus?

January 25th

This is one of the many questions racing through my head as I walk through Victoria Hospital, tail between my legs and eyes at the floor. I’m approaching the Obs/Gyn call room after calling my boyfriend in tears for the millionth time this week while he tries to get his daily 6 hours before returning to night float. The bags under his eyes remind me that I’m the worst. I’m selfish, needy and lifeless. I’m not the person he fell in love with, I’m not the friend my classmates have relied on, I’m not the student that got into medical school. That person has been stolen with the body left behind.

I feel like I’m watching my life through a screen while an unidentified figure presses random buttons on the remote. The brightness has been turned down, colour desaturated with random alternations between fast forward and slow motion. The volume has been cranked so much that light vibration of emails, messages and schedule alerts and the inner mumblings of eating disorders past overwhelm my senses. Everything real that occurs around me is muffled and agitating. I’m begging them to press pause but they would rather taunt me with the OFF button, caveat being that there is no button to turn it back on. The OFF button has never looked so temping.

We are now laying in the call room which could also be used as an industrial sized fridge. I don’t cover need to cover up. My skin has numbed itself, so it can no longer feel the sweat of anxiety or the tears of depression. My stomach tied itself in a tight knot. My body is on standby – unwilling to fall asleep but never completely awake.

The exhaustion from this morning weighs me down like a ton of bricks. How many calories did I burn smiling and laughing in all the right places? I’m not cut out for this. One clinical methods session feels like I ran a marathon and I want to be a doctor. Good luck.

How did I get here? Last week I was bouncing around from study spot to the gym to the next exam feeling on top of the world. I may have gotten through an exam week without failing at least one, this was huge. I developed a foolproof plan to rock MSK and was pumped to spend a weekend in Blue Mountain with my class. I was going to clean up the apartment and leave some special treats to give my hardworking clerk the weekend to himself. Now the thought of leaving the apartment ties the knot in my stomach tighter and tighter. The thought of telling people I’m not going doubles it. Disappointing my boyfriend and impinging on his need for rest and solitude sends me into a tail spin. I have nowhere to go. Nobody deserves to put up with me right now.  I don’t want to put up with me right now.

There has already been three episodes like this since September. I’ve been dealing with mental illness since I was a kid. I always got tremendous satisfaction when doctors, counselors, whoever would ask “have you ever thought of hurting yourself” because the answer was always a definite no. Through the panic attacks, critical weights and depressive episodes, suicide was never an option I explored. It was empowering to think that even though my brain hates me, it wasn’t going to kill me. So now that these thoughts have popped up after 15 years, they are hitting me hard. Maybe they were by the 22 pounds I’ve gained since starting medical school. Maybe it’s the fact that I’m walking on eggshells around the UME due to my failed exams and missed mandatory sessions last year. Mental illness has finally gotten the best of me and I wasn’t strong enough to stop it. Imagine fighting a war for 15 years and losing. Imagine doing ground-breaking research for 15 years and having it thrown in the garbage and discredited. Would you want to start over?

What I should be doing is going to class and learning about this dreaded and deadly brachial plexus everyone is raving about. Hypothetically, if I was to take my own life, how pissed would I be if I spend my last days worrying about the brachial plexus?

January 27th

I am someone who wants to dedicate their life to caring for others and alleviating their pain and suffering. I believe that is he goal of most medical students. I feel tremendous guilt when I’m having suicidal thoughts because my mind always goes back to the patients. There are children diagnosed with terminal illnesses. We lose mothers, fathers and loved ones to cancer every day. These people did not deserve their fate and would do almost anything for another day. And here I am telling myself I care for these people while I take my life for granted. I wonder if the other physicians struggling with mental illness feel this way. I wonder if these thoughts contribute to the shame and secrecy that pushes us into a corner.

January 28th

My class should be getting back from Blue right about now. I’m dreading the explanations of why I ghosted everybody. Double dreading the explanations on why I don’t know the brachial plexus yet. As you can tell, I did not spend the last couple days studying the brachial plexus but I’m happy to report that it is not because these are my last days. I can feel the fog lifting and I’m not ready to give up yet. I realized I wasn’t ready when I spent two hours planning my clerkship rotations and talking about all the opportunities I have. My eyes are wider, my feet are faster, and my head is higher. Once I open this textbook to the brachial plexus in a couple minutes we will be 100% certain that I’m not going anywhere fast.

I could go back, cut out all my run-on sentences and edit this into a clean reflective piece but I’m choosing not to for three reasons. First, I think my chaos narrative is best reflected this way. Second, reading my thoughts and feelings from three days ago is petrifying. I barely remember that day, I can only remember the overwhelming sense of guilt and darkness. Third, and let’s be honest probably the most likely, is that I’m lazy and words are hard.

I also don’t know how to end this gracefully, so I’ll end it with some people I’d like to thank. The beauty of having a broken mind is that a somber reflection ends as an award acceptance speech.

To my mother, sisters, best friends and family: I am sorry I’ve been keeping this from 
you and not answering my phone.


To my niece: I could never leave you.


To my class: Even though I haven’t been open and honest with you guys please know 
that you are all the most welcoming and trustworthy people on the planet. I am 
in no way doubting your FIFE capabilities and I’m always here to FIFE you
right back.


To my favourite clerk and on-call superhero: I don’t know what I’d do without 
you these past months. Your confidence in my recovery makes me believe it’s 
possible. You are the love of my life.


To Learner Equity and Wellness and Schulich School of Medicine: You are doing a wonderful job. 
Thank you for caring about us.


And finally, to medical students and future colleagues: Be honest with each other, reach out 
when you need it. We got this.
If you or a friend is experiencing a mental health crisis, please contact 911 or visit your closest Emergency Department.
Visit Learner Equity and Wellness on-site or online for resources and support:
https://www.schulich.uwo.ca/learner-equity-wellness/learner_wellness/index.html

By: Cheyenne LaForme

Cheyenne LaForme is a second year medical student at Western University and the Local Officer of Indigenous Health.  She is using a portfolio-style reflection piece to raise awareness about, and cope with mental illness. She is originally from Hamilton and Mississauga’s of the New Credit First Nation and received a B.Sc. in Life Sciences at McMaster

 

Photo Credits: Creative Commons, Reaching