The Pursuit of Mastery in the Worlds of Medicine and Wine

Medical school becomes a blur after a few years in practice. You forget about all the hours spent in classrooms and then every night after a quick dinner. You somehow block out the “pimping” [There is a nice explanation on what this word means in medical school here] and public humiliation of being questioned about topics not quite under your belt. The worst feeling? The fear of wondering if you will master medicine enough to do no harm.

Medical training is, quite frankly, a brutal process that can make or break a person. Your every fear can come up during this process. It’s not enough to pass tests or to know the Krebs cycle. It takes physical and mental resilience to get through seven-plus years of intense training and learning. Then, imagine being a partner to someone going through this. The partner will always be secondary to the subject of study. And it almost has to be be that way… for a time. Missed birthdays and weddings…. Late nights studying with fellow students or your assigned cadaver…. Fictional television shows about doctors-in-training often focus on casual sexual relationships or budding romances. But in real life, I’ve seen marriages dissolve and people have nervous breakdowns under the stress, as well.

I had forgotten about all these details, anyway, until I recently watched Somm, a documentary about four men trying to pass the Master Sommelier exam. What is a Master Sommelier (MS)? See below (from website):

I was completely engrossed in the personalities of the candidates for the MS exam. While it may seem to have very little to do with medicine, I couldn’t help but see my medical student self (and former classmates) in these young men. If you’ve ever been a medical student or lived, breathed, and ate a specific topic for a specific goal, all the while foregoing sleep and relationships, you might relate to this movie. (Insert artist, musician, scientist, etc. here).  The marathon-like effort rewards a few, though many try. There are currently only 135 Master Sommeliers in North America and 19 of them are women. There have been 214 worldwide who have been given the title of Master Sommelier since the exam’s creation.

After you watch Somm, you realize drinking wine is clearly only one tiny part of becoming an MS. Many people have some knowledge about wine or medicine. But mastering these fields involves intense study to quickly calculate and retrieve applicable and accurate information. It also takes a certain amount of competitiveness, observed one of the MS candidates in the documentary who was formerly a baseball player, to attempt to pass “a test with one of the lowest pass rates in the world.” Even some of the terms they use to describe aspects of a wine’s taste or smell (“a freshly opened can of tennis balls”), while seemingly completely bizarre, are reminiscent of some of the unusual analogies we use to characterize various things in medicine. “Ground glass” on a CAT scan of the lung, for example, is not ground glass, but it is the best way to describe something and recognize it quickly.

If you’re curious about the world of wine, what it takes to be an MS, or the psychology of the pursuit of mastery of a subject, I would recommend watching Somm. Though the documentary is a little drawn out, it is not particularly long and you look forward to the ending to find out if any of them passed the test. 

Interestingly, at a recent dinner I had the opportunity to speak with an MS who was working at the restaurant. Everyone at our table had just seen the movie the previous night and we queried him about his experience studying for and taking the MS exam. He did corroborate that it was an intense period of study to learn all the minutiae and details about wine. He reflected that it was all about “the hunt” (to pass the exam). However, he said that in the end, after you pass, “fifty percent is about people skills.”

True in wine as it is in medicine.

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(*please note that original version of this post stated there were 135 Master Sommeliers. To clarify, there are 135 in North America and just over 200 worldwide.)

Winners, Losers at the Golden Globes

Beautiful dresses, talented actors.… What’s not to like about last night’s Golden Globes? Well, how about this little detail from the NYTimes that surprised me:

 6:27 P.M. |To Smoke or Not to Smoke at The Globes

Here’s the difference between Hollywood on screen and off: cigarettes. On screen they are taboo. If you see one it’s accompanied by some carefully scripted moralizing about the ills of smoking. And even then the folks at scenesmoking.org are wary. But here, they give the things away. Seriously. Out on the smoking balcony where we saw Sean Penn pacing and puffing a couple of years ago, tables are thoughtfully stocked with little glass holders crammed with dozens and dozens of recessed-filtered Parliaments. As for drinking don’t even ask.

— Michael Cieply

I cast no judgment on individuals who smoke. In fact, I cringe when others refer to smoking as “ugly” or “disgusting,” both very strong and judgmental adjectives. My job as a physician is to teach people about the harms of smoking and to help them try to quit when they are ready.

Though Hollywood often seems to live by different rules than “the rest of us,” I am fairly certain they are no more immune from the dangers of smoking. That is why I found this “thoughtful” provision of carcinogens at the Golden Globes to be a poor choice from a health and health economics perspective. People should be allowed to smoke if they wish, but maybe the Golden Globes should reconsider having cigarettes readily available next year.

No one but Big Tobacco wins when it comes to smoking.

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*As an aside -because I can’t help but comment on the fashion- my three favorite dresses of the Golden Globes were worn by Berenice Bejo (Elie Saab), Rooney Mara (Nina Ricci), and Nicole Kidman (Versace).

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Doctor 007

Let’s imagine an action-packed screenplay full of suspense and intrigue and romance (just a little) and… medicine.  Yes, medicine. And why not? After all, in medicine we have potential for biochemical warfare, technological advances in diagnosing infectious disease in relatively remote areas , glasses that would detect the slightest bit of emotion in an enemy’s expression, issues of governmental influence, conlicts of interest, and public confusion surrounding the intent of our efforts. Take the CIA’s strategy to catch Bin Laden by implementing a vaccination campaign, for example. Legitimate controversy surrounds this approach, but even the most imaginative screenwriter couldn’t have written that storyline.

Well, if one were to write this Bond-esque screenplay, the hero/heroine would likely be unrelenting and bullheaded. At times, he/she might be somewhat simplistic in his/her purist nature. This person would be dealing with frequent bureaucratic issues and reprimands from above while still trying to save the world from injustices. This doctor would have no time for meaningful relationships and would most likely be closer to a “cowboy” than a member of the “pit crew.” Like Bond, this doctor would be simultaneously loved and hated.

And if one were to produce this screenplay, there would be no need for a new theme song, as it has already been written:

Lyrics (though the music –having the classic 007  “feel” to it – is worth listening to):

Monday finds you like a bomb

That’s been left there ticking there too long

You’re bleeding

Some days there’s nothing left to learn

From the point of no return

You’re leaving

Hey hey I saved the world today

Everybody’s happy now

The bad things gone away

And everybody’s happy now

The good thing’s here to stay

Please let it stay

There’s a million mouths to feed

And I’ve got everything i need

I’m breathing

And there’s a hurting thing inside

But I’ve got everything to hide

I’m grieving

Hey hey I saved the world today

Everybody’s happy now

The bad things gone away

And everybody’s happy now

The good thing’s here to stay

Please let it stay

Doo doo doo doo doo the good thing

Hey hey I saved the world today

Everybody’s happy now

The bad things gone away

And everybody’s happy now

The good thing’s here to stay

Please let it stay

Everybody’s happy now

*Thanks to Jan Handerson for inspiring this post by pointing out the appropriateness of this song to the field of medicine (sometimes, anyways).

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A Health-Related Art Exhibit in Philadelphia

If you happen to be in the Philadelphia area between now and the end of July 2011, check out a unique exhibit of historical health advertising from the late 19th-early 20th century at the Philadelphia Museum of Art. Today’s New York Times Science article, “Spoonfuls of Medicine, Marketed for Centuries” has a couple great links. One link provides a slide show of a few of the posters being displayed. The other is a link to a video showing an animation of a piece of German artwork described below:

But the star of the show may be the single image intended neither to cajole nor to terrify but to educate and amuse. The five-volume anatomy and physiology textbook that the German physician Fritz Kahn brought out in the 1920s was illustrated with a poster-size folding color plate depicting “Man as Industrial Palace,” a work that combines the Lilliputian charms of “Where’s Waldo?,” Willy Wonka’s factory, the world’s best dollhouse and a really good pinball game.

– Abigail Zuger

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Film Screening This Weekend!

I am excited to be presenting The Vanishing Oath tonight and on 4/24. There is still time and room to attend. Tickets still available. If you read my blog and are attending, find me and say hello at the event.

Why the Show Must Go On

Last night, I attended a concert put on by Robert Plant and The Band of Joy. It was an excellent performance. Of course, to see a legend perform is always amazing. There is something about witnessing someone in his element that is so inspiring. The energy in the theater, particularly towards the end of the performance, was infectious. The crowd, which appeared to span the age range of adolescence into the 60s, was mesmerized and star struck. (And a few were perhaps a little under the influence of something else that my olfactory sense detected).

I have written before about music and medicine and its value for a physician. It is very personal, as well. Music is inextricable with my life. Having started playing the piano at age 5 or 6, then the clarinet in grade school (and then other endeavors best left to be discussed in person), I have learned much about life through musicianship. Three years ago, I took up the guitar and have been hooked since. I was fortunate to find an excellent teacher who possesses equal patience for a busy physician who tries her best to practice and for 4-year-olds with significantly limited attention spans.

Each year, my teacher arranges a “recital.” This is not your average recital. In fact, it is called “The Jam.” You can play solo or have a band backing you up. You can even sing, if you care to share your voice. During the first year of my lessons, I declined to perform. At that time, I hadn’t performed in a few years and felt uncomfortable now that had become a physician. Why would people want to see a doctor strumming a six-string? Would I be held to a higher standard? When I started taking lessons, I was conflicted enough about what it meant to be a doctor and to continue to pursue music that my teacher didn’t know what I did for a living for at least a year. At times, I questioned why I was even taking the lessons. Somewhat of a Type A perfectionist, I would often get frustrated by slower progress than I was expecting, and I have contemplated cancelling my performance in these recitals at the last minute, including a performance coming up next week (!).

Before a public performance (which I simultaneously look forward to and dread) my heart races a bit and my palms get a little sweaty. I know what I should play because I rehearsed it over and over and I can hear it in my head, but it all comes down to this one very short moment in time. I get a little anxious. I don’t know how I will be received. I might even mess up. The faces of the audience may express boredom or perplexity or excitement. Ideally, at the end, I would feel support from the audience. Otherwise, my fears of dismissal or even disapproval will come true.

Does this sound familiar?

So, last night, as I was watching the performance of legendary artist and growing nervous about mine, I was reminded why this hobby has value for me as a physician. What I described above could just as easily have been a patient experience in an office visit. Sure, it’s not a crowd. It’s definitely not a hobby for a patient. But the pathophysiology and emotions involved in facing a doctor during a relatively brief office is similar.

Most people seem to prefer to “perform” in life within a realm of comfort or mastery. But there is something to be said for trying something with which you are not familiar. When we tread uncharted waters, we remind ourselves of our vulnerability. There is nothing like a bit of nervousness or fear to remind you of your humanness.

This is why, despite my nerves, the show must go on.

Wish me luck.

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Pharma and Doctors as Bedmates: Notes from the Movie “Love and Other Drugs”

Preface and disclaimer:

1. If you haven’t seen the movie and plan to, DO NOT read this blog post.
2.  If you haven’t seen the movie and weren’t sure if you should, let’s just say it’s a 3 out of 5 stars, in my opinion
3. I am not a movie critic.

With that out of the way, “Love and Other Drugs,” starring Jake Gyllenhaal and the always endearing Anne Hathaway, is a love story set in the heydays of the pharmaceutical industry. Jamie (Gyllenhaal) loses his job selling electronics and becomes a hot-shot pharmaceutical representative. He runs into and falls in love with Maggie, an very medically knowledgeable young woman with early onset Parkinson’s and a medication list that suggestive of polypharmacy. Sounds like a perfect couple, except that Jamie specifically represents Zoloft, Azithromycin, and – later in the movie – the king of all prescriptions in terms of demand and no-questions-asked prescribing – Viagra. There are poignant observations and classic stereotypes. A comment made by Jamie’s struck-by-dumb-luck-but-emotionally-immature-internet-entrepreneurial brother suggests that being a doctor is certainly not the road to riches it once was. The main physician character in the movie finds that the solution to dealing with the demands of practicing medicine is to say “Sure. Why not?” and write out needless prescriptions to appease patients and get through a packed schedule. Casual and reckless sexual interactions throughout the film serve as apt metaphors for the role of Big Pharma in the practice of medicine. Reap rewards now, pay for the consequences later.

The film portrays how perfect as bedmates they were in the 1990s. MDs were seduced – figuratively, but also literally in the movie – by former cheerleaders and athletes turned drug reps (“Because it’s the only entry-level position that pays $100000 per year”) who were supplying them with free food, trips, and even pens (!). Of course, all of these items are now considered contraband in most clinics. But it was a great arrangement at the time. Even the third party (patients) were unknowingly complicit. After all, free brand-name samples were better than paying a small copay for generics, right? And why wouldn’t one keep going back to the generous doctor who gave them to you? Unfortunately, as the saying goes, you don’t get something for nothing, and free samples were no exception. Why? If it works well for a patient, it is much easier to continue to prescribe it than to change it to a more affordable, equally effective, generic option when the free samples run out. Patients, who also prefer not to change medications that are working well for them, are then essentially “hooked” on an expensive treatment. To quote yet another age-old adage, if it sounds too good to be true, it is.

This says almost nothing about the love story between Jamie and Maggie. The former is driven to be successful, and the latter has a chronic and incurable illness. The most intriguing aspect of the movie for me was Maggie’s perspective of day-to-day life (not just in the doctor’s office waxing poetically about her delayed diagnosis and multiple treatments). How she felt about herself and what she felt she deserved. Why she was willing to forego the possibility of true love because of a fear that it was not unconditional and that her illness would get in the way. The unpredictability of her symptoms. The cover-ups. The witty, sarcastic words that she thought hid her pain. How she hid her diagnosis and, at other times, hid behind it.

Now that is great subject matter that gets a little lost in the drama and ease of exciting new drugs, like Viagra. But isn’t it also lost in real life, when doctors look at a medication list and presume to know their diagnoses or find themselves using their pens more than their ears? How many of the meds we prescribe are actually treating the results of a patient’s self-perception of their illness? Benzodiazepenes for anxiety, muscle relaxants for the tension that comes from the anxiety, the sleep medication for the insomnia that is caused by ruminations and perseverations, etc.  

How much is our self-worth tied into our health? It is fascinating, integral, but little understood by the very people who prescribe treatment just how a disease and prognosis affects the psyche of a patient suffering from chronic disease. Once that diagnosis is made, reality is altered and with it, the definition of oneself.

Elizabeth Taylor – humanitarian

Elizabeth Taylor died today.

In addition to acting, she was well-known for raising awareness and funds for AIDS, receiving the Jean Hersholt Humanitarian Award in 1993 for her work. I never had an opportunity to meet her, but I remember this lovely and striking work (at the Musée Nationale d’Arte Moderne – Centre Pompidou in Paris), which is the closest I got:

RIP to a legendary woman who tried to make the world a better place with her humanitarian work.

Music in Medicine: Not Just for the Surgeons

Earlier this month, I had a conversation with a family member about her observation that many physicians are musicians. A few days later, I encountered an interesting blog post by Rahul Parikh, MD entitled “The Truth about Music in the Operating Room,” which included interesting facts about the relationship between music and medicine. For example, there are studies that have shown more steady vital signs in doctors performing surgeries to music – even with rock music.

It seems obvious that the manual dexterity and discipline required of musicians would be requirements for surgeons, as well. As a musician, myself, I recall being drawn to procedural specialties during medical school. Once I had the unique opportunity to “open” a case with a gynecologist performing a laparoscopic tubal ligation because all of the residents were at a conference. My attending was closely monitoring me, of course, but the patient was in the good, steady hands of a pianist/clarinetist. Aside from the technical aspects, operations performed to music seemed to be associated with better communication, a calmer environment, and a greater sense of teamwork.  

Surgeons are not the only physicians who can benefit from music during the workday, although it seems they are the only ones afforded the ideal venue, with a “protected” space and time during their procedures. Listening to music while seeing 20+ patients a day is possible and not as distracting as one may think. What’s more, doing so might just keep a physician sane.

At one point, I had a small space in a room with both an ARNP and RN. Phone calls and conversations were very distracting. But I found that listening to music kept me focused on my tasks. (Other publications have referred to studies that corroborate this effect). Of course, I used earphones to keep from bothering my officemates, which probably reduced unnecessary interruptions, as well. Even if there is limited time, as little as two measures of a favorite melody can not only calm you, but reconnect you to your human side, the one most important to relating to your patients. Without that side, after all, it would be easy to function as a robot, seeing patient after patient after patient. It’s not for everyone, however. For example, physicians who do not regularly listen to or feel a particular benefit from music may be more distracted by it.

The true value of music is in the way it takes us outside of ourselves and our narrow minds and repetitive thoughts.  This is important during and outside of our workday. Music encourages creativity, calmness, inspiration, and productivity. What more can you ask for in the work environment? It even inspires me as I write this blog post….

Foodmatters: Deepening the Divide

“Man has been called the reasoning animal but he could with greater truthfulness be called the creature of suggestion. He is reasonable, but he is to a greater extent suggestible”

– from “The Theory and Practice of Advertising” (1903)

Sometimes people recommend movies to me and, if they are of a scientific nature, I try to watch them when my mind is ready to absorb and analyze the information. Some movies, such as An Inconvenient Truth, have inspired me to reevaluate my lifestyle and rekindle an appreciation for the world around us.

Last night, I watched Foodmatters. This movie, quite frankly, caused me to cringe. I neither refute nor support the movie’s claims regarding food as medicine or the use of high-dose vitamins in the treatment of disease. My intention here is not to assess the validity of the movie (which may not be worth the space on the web).

Unfortunately, the inaccurately titled Foodmatters had little to do with matters of food. Rather, it contained a concerning underlying message that the “medical industry” is greedy, maleficent, and a perpetuator of illness. I would argue that much of what was called the “medical industry” actually referred to the pharmaceutical industry. Regardless, an inordinate amount of film was devoted to Andrew W. Saul’s diatribes, whose propagandist approach really made it difficult to be open to any other aspect of the film. I suppose my reaction would have been expected had I known that Dr. Saul (who earned a PhD in Human Ethology) wrote a book entitled Fire Your Doctor!  Yes, with an exclamation point.

When I was a medical student, I shadowed a Family Physician who used alternative medications to treat things like acne. I will freely admit that I was hesitant about accepting it at first. Really, at the end of the day (literally) I only had the time and brain space to memorize hundreds of drugs along with their mechanism of action, indications, adverse effects, and interactions. But, as Complementary and Alternative Medicine (CAM) is becoming more acceptable as a choice that patients might take, physicians are making strides to learn more about these treatments. I am not an expert, so I learn from my peers and from journal publications. There is also a small subset of MD physicians who have been trained in CAM, as well.

As CAM becomes more popular (and lucrative), the providers of this approach gain more trust and credibility from the general public. My hope is that naturopathic students – whom I have heard from insiders can have a deeply negative attitude towards allopathic medicine – are taught to be open-minded towards Western medicine, as well. If patients pick up a sense of disdain or judgment from an alternative medicine spokesperson – Dr. Saul, being a not-so-subtle example – it might deepen what I felt was a closing divide between two potentially integrative fields.