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
Photo Credits: American College of Physicians (ACP)