 On behalf of the McLean Center, the Center for Health and the Social Sciences, and the Bucksbaum Institute, I'm delighted to welcome you to this third lecture in our 2019-2020 series on the present and future of the doctor-patient relationship. Can you hear me up there? Yes, good. It's now a pleasure to introduce our speaker today, Dr. Roman DeSantis. Dr. DeSantis, as you can see behind me, is the Evelyn and James Jenks and Paul Dudley-White distinguished professor of medicine emeritus at the Massachusetts General Hospital. After completing his fellowship in cardiology at the Mass General, Dr. DeSantis stayed on there for a while. He had an illustrious career as a distinguished cardiologist from 1955 to 2014, a total of 59 years. During that extraordinary career, Dr. DeSantis assumed many leadership positions, including organizing the Massachusetts General's first coronary care unit, serving as the director of that for 10 years, and later, from 1981 to 1998, Dr. DeSantis served as director of clinical cardiology and later as the chief of the cardiac unit. He's continued to play a vital role even since 2014 in the teaching and training of a huge number of academic cardiologists. In 2007, Dr. DeSantis became the first recipient of the Massachusetts General Physicians Organization Trustees Medal. This award recognizes individuals who have made monumental and lasting impacts on the Mass General Hospital and on its physician community. This award in 2007 seems to me to be a particularly big deal in the sense that the Mass General was founded in 1811, so the award came 196 years after the founding of the hospital. To this day, Dr. DeSantis continues to support the Mass General Hospital and its physicians with the aim of helping to train the next generation of cardiologists. In light of such outstanding accomplishments and acolytes, Dr. DeSantis regards his greatest success to be the relationship he has developed over the 60-plus years of practice with his patients. In this area, his great work closely mirrors the central goals of the Bucksbaum Institute. The Bucksbaum goals are to support research on the doctor-patient relationship, on doctor-patient communication, and on decision-making between doctors and patients, also to strengthen medical education about the doctor-patient relationship and to improve approaches to personal humane medical care both within the University of Chicago and nationally. In a paper that Dr. DeSantis wrote in 2015, he captures all the goals that the Bucksbaum Institute has come to support, and actually quite a few more. When you leave the lecture today, you'll find a copy of this paper on the back table. It's called Reflections on 59 Years of Doctoring, and I've read it and re-read it many times, and it's very moving paper. Today's lecture by Dr. DeSantis is entitled Reflections on 60 Years of Doctoring. We're so honored that Dr. DeSantis has come to speak to our lecture series today. Please join me in giving a warm welcome, Dr. Roman DeSantis. Thank you, Mark, for that wonderful introduction. It is great to be back at the University of Chicago with many of my old friends. I was not at the MGH in 1811 when it was founded, but I came shortly thereafter, and it has been my entire professional life, basically, has been there. And I would like to share with you today, by the way, if you read that paper, you can leave. There's no need particularly to listen to this lecture. I'd like to share some of the principal practices and values that have guided me on my long medical odyssey. I should note that much of this paper was put together for a lecture that I was invited to present to Harvard Medical School graduates in 2014, which was when I retired, and it's since been published as a small booklet. There are five guiding principles which form the bedrock of my philosophy with respect to caring for patients. These are as follows. One, the patient always comes first. Two, in any given circumstance and at any given moment, weigh all the information in hand and always try to do that, which is best for the patient. Three, the golden rule of medicine enunciated so beautifully by Dr. Robert F. Lerb, a legendary longtime chief of medicine at Columbia Presbyterian Hospital. He stated, the patient should be managed the way the doctor or a member of his family would wish to be treated if they were that patient and that bed at that time. Four, to attempt to be not only a caregiver to your patients, but also a friend. And finally, five, the immortal words of Dr. Francis Weld Peabody, shown here. The senate of a Boston-Brahman family, there was actually a suburb of Boston called Peabody. Dr. Peabody graduated from Harvard Medical School in 1901 and eventually became head of the Thorndyke Laboratory at the Boston City Hospital. He gave a lecture to Harvard Medical students on October 21st, 1926, and that lecture was published in the Journal of the American Medical Association in 1927, the same year that Dr. Peabody died quite prematurely. It is a classic and is allegedly the most cited paper in the entire medical literature. He concluded his lecture with these transcendent words that should be emblazoned in every caregiver's mind. One of the central qualities for clinicians is an interest in humanity, for the secret of the care of the patient is in caring for the patient. The secret of the care of the patient is in caring for the patient. But Dr. Peabody said so much more in that talk. For example, medicine is not a trade to be learned, but a profession to be entered. The practice of medicine in its broadest sense includes the whole relationship of a physician with his patients. It is an art base to an increasing extent on the medical sciences, but comprising much that still remains outside the realm of science, true in 1926 and even more true 93 years later. The significance of the intimate personal relationship between physician and patient cannot be too strongly emphasized. This will be a recurrent theme in my talk. I don't think I've ever seen so much wisdom come in such a small package of Dr. Peabody's lecture. I think it's a must read for anybody in the medical profession. So how do we go about truly caring for our patients? It starts with the noble virtues of compassion, kindness, sensitivity, and understanding. Passion and respect for patients is crucial. We should treat patients gently. We must try to listen carefully and sympathetically to what our patients are telling us. A study published a few years ago reviewing videos of Dr. Patient Encounters found that doctors interrupt patients roughly every 15 to 30 seconds. Remember that when you talk, you're not learning a thing. You only talk, you only learn when you listen. Today the history may be taken by a nurse practitioner or a physician's assistant. I've always preferred to work alone in the outpatient setting, which was allowed to do until I retired, I guess I call it grandfathering. But if the history is taken by someone else, make sure that you at least review the high points of the history. When the diagnosis is obscure, the physician should take additional history with particular attention to details. Sometimes the answer is in the small stuff. Another way that I tried to respect my patients was to respect their time by trying to keep my appointments running on schedule. I sometimes think we call patients because they often wait so patiently for such a long time to see their doctors. I know of one physician at the Mass General who scheduled entertained patients all at the same time, and I guess there was some sort of a Darwinian system by which the patients were processed. Our time is precious, but so is that of our patients. Remember any time that anyone weighs can never be lived again. This may sound ridiculous to you, but I encourage you to examine your patients. These days, many physicians rely on their non-MD assistants to examine the patient and perform no examination or at best a very cursory one themselves. Nothing connects us physically more closely to the patient than a physical examination. We actually touch the patient, which I think is very important during an examination. In a different, even though my interest is in the cardiovascular system, I can't tell you how many important incidental findings I've detected over the years on physical examination, skin cancers, pathological lymph nodes, and large organs and masses, breast cancers, aortic aneurysms, and many more. Also, I encourage you to regard the findings of diagnostic tests, which we are basically addicted to at this point, especially imaging studies, with a healthy degree of skepticism. For example, echocardiography notoriously overestimates the degree of valvular regurgitation, lesions of severity of which can often be better assessed at the bedside with a careful history and a physical examination. There are many other occasions when findings on a physical examination are more informative than those on an image study. As I've said, I try to cultivate friendships with my patients. I gave them a warm greeting and a warm farewell. I'm a pretty informal guy. I was on a first name basis with many of my patients, although many patients have trouble calling a doctor by their first name. With patients who I've come to know very well, you'd be amazed how much a gentle hug, which comes naturally to me, can convey to patients your affection for them and how much you care. I guess we have to be a little bit careful about hugs in the current atmosphere, but I think it's a very affectionate and caring thing to do to a person. One of the treasures of my life is that so many of the friendships I made with patients when I was in practice have endured after my retirement. I tried to know as much as I could about my patients, their jobs, their families, their interests, their concerns. I tried to make a point of discussing some important aspect of their lives other than their medical problems at each encounter. Let's face it, the world is about people, and as far as we know, that is what disagree says from any other place in the universe. To me, there's not a person on earth who doesn't have an interesting life story to tell, and that includes every one of you people. I consider a sense of humor to be one of life's most important and valuable assets. When appropriate, I try to keep the patient visit light. Many of my patients know I enjoy a good joke, and several made a point of having a couple zinger for me when they came in for their visits. The ultimate in this regard was a delightful lady whom I followed for several years. She invariably came in every six months with a couple of off-color jokes until she died at the age of 92. The one thing I knew for certain when she came to the office is that I was going to have a good laugh. At a communication with patients is of paramount importance. It's almost impossible to communicate with patients too much. In today's world, communication is of course facilitated through the use of IT. Systems like Patient Gateway give patients access to all of their records. This is great, but I can assure you that patients always appreciate hearing from their doctor. I never allowed a patient to get the results of various studies only from the information systems. I almost always sent them a note discussing the pertinent aspects of the test result. You'll probably do it by email, and obviously that's fine. If there was a potentially serious finding, I urgently called the patient myself and discussed the finding and how we should proceed. Educating patients about their illnesses and their medications is not only a necessity, but certainly may help facilitate their care. This is an area where the computer and peer materials are very helpful, and again, much of this is done today by medical assistants. The more informed patients are about their condition, the more intelligently they can care for themselves. Meticulous informed consent by the physician, particularly if it involves a high-risk procedure, is crucial. I tried to address all questions and concerns a patient may have. Remember that even the risk of, if the risk of death from a given procedure is only 2%, for any vaginal undergoing that procedure, it is either 0% or 100%. Therapeutic decisions often include options, sometimes as many as three or four. In such circumstances, I outlined the various possibilities to the patient, detailing the risks and benefits, but I never asked them, what do you want us to do? I decided what option I thought was best and so advised the patient. Sometimes a patient will choose a different option on the basis of the information that they've been presented by me, and that's fine, I think that's prerogative. I need to hardly say that it's important to be scrupulously honest and dependable with your patients. If you tell them you are going to do something like, I'll give you a call in the next two days, make sure you do it. If a terrible mistake in management has occurred, we should tell the patient the truth, although you may want to consult with the risk management team first. Even our presidents, particularly the present occupant of the White House, have never learned that an attempt at a cover-up is always worse than the truth, no matter how bad the truth may be. Also, you'll be amazed at the power of a simple unexpected phone call from a doctor to a patient. After my patients were discharged from the hospital, I tried very hard to call them at home within two to three days to see how they were doing and if they had any questions. This is often now done mostly by medical assistants, if it has done it all, but it only took me a moment. It's surprising how many patients have important questions about their discharge instructions and medications and I can assure you that patients never ever forget those calls. Many years ago I was running late at night in a four-bedroom in the old Baker building at CMGH. I finished visiting with my patient and as I was leaving the room I heard this far-law and boys say, she's Doc, I wish you were my doctor. When I asked him why, he said he hadn't seen his doctor for two days. I couldn't believe it. I cannot emphasize to you strongly enough that the most important part of a hospitalized patient's day is when the patient's doctor comes by, not the nurse practitioner, the physician's assistant, the resident or the fellow. They want to see their doctor. An offshoot of this is that in the increasingly popular team system of care, which is the system at the MGH, especially in academic hospitals, patients often have no idea who is the responsible physician in charge of their care. If you are part of a medical team, a single physician should be designated as the patient's primary doctor and the identity of that person should be clearly conveyed to the patient. While I'm talking about the hospital I want to say a word about our esteemed partners in the care of patients are incredible nurses. The satisfaction of patients with their experience, with their hospital experience, is far more dictated by the quality of their nursing care than it is by that of their physicians. I cannot adequately express the intensity of my gratitude toward nurses in all settings for the magnificent and dedicated care that they deliver to our patients. One of my highest priorities has been the maintenance of close relationships and the recording of great respect to the indispensable and underappreciated angels of mercy. We're in a hurry all the time and doctors often make hospital rounds with one foot pointed at the patient and the other toward the door. I find that a very simple way of indicating to the patient a high level of interest in caring is to quietly sit on the bed while I deliver the discuss today's medical issues with them. When you get to know your patients you can get some sense of what on my term they're disease tolerance. We care for patients who are alarmist, we care for patients who are stoics. As some anxious patients in whom when they're called I divided their symptoms by five and others more stoical symptoms I multiply by five. Some patients never call unless there's a real problem and those patients get my immediate attention. This relates to denial which is a two-edged sword. It enables patients often to coexist with serious and debilitating illnesses but one extreme it can also be very destructive. I have a tragic example of destructive denial shortly before I retired. The patient a widower and personal friend of mine was the 85-year-old gentleman with critical aortic stenosis who might have followed for years. At every six-month visit he denied any symptoms and I exhorted him to call me if there were any changes in his symptoms that might indicate a need for intervention on his aortic valve. Because I knew he was a denier I even sent him a letter detailing the symptom that he should look out for. He called my secretary the day before I scheduled six-month appointment and canceled the appointment because he wasn't feeling well. I called him immediately home to find out what was going on and he told me it was short of breath and had swollen ankles. When I asked him how long this had been going on he said for two months and I didn't say what he's thinking which is damn it why didn't you call me. I admitted him to the hospital immediately and he was advanced right and left heart failure and patients with critical aortic stenosis longevity in this situation is generally measured in days and weeks. He was slowly improving but after five days in the hospital he developed a refractory rhythm it went into cardiogenic shock and died before we could intervene on his aortic valve. This was a case of malignancy now in an incredibly historical man but was also a failure on my part not to have followed him more closely knowing that he was a stoic and a world-class denier. I would like to spend some time discovering several somewhat uncomfortable situations that arise in the course of doctoring. One predicament that's frustrating to both the doctor and the patient is when we're unable to arrive at a definitive diagnosis despite an exhaustive workup. One of the reasons I went into medicine was because I thought it was a pretty exact science. On the contrary it seems that we don't know what is going on with patients about as often as we do know what to have. One approach that I found to be helpful in this unsettling situation is to emphasize to the patient that even though it is important to know what disease that patient does have it is equally as important to know what diseases that patient does not have. I was delighted when I could tell patients that they did not have cancer or some other serious disease on the basis of the information that had been gathered. I explained to them that if their symptoms are continued of course we would do whatever additional tests are indicated. Much of the time either whatever the patient has results without a diagnosis or a definitive diagnosis eventually becomes clear. The management of these patients reminds me of the definition of medicine by Gilles Ménage who lived in France in the 18th century. He said medicine may be defined as the art of the science of keeping a patient quiet with frivolous reasons for his illness and amusing him with remedies good or bad until nature either cures him or kills him. Equally frustrating are those patients in whom the diagnosis is known but the patient fails to respond to treatment. This dilemma demands patience on both the part of the doctor and the patient sometimes a measure of panic arises on the part of the physician a well-known English psychiatrist by the name of T.F. Mayne posted this warning the patient who frustrates the keen therapist that is a doctor by failing to improve is always in danger of meeting primitive human behavior designed disguised as treatment. In particular patients is crucial if an invasive or surgical option is under consideration we must not be pressured into doing something that can make an already difficult situation even worse. I did not send the patient for an invasive procedure until I believed it was necessary and unless I was convinced that it would benefit the patient. Timing is critical in this setting. Dr. Benjamin Rush the most renowned American physician of the 18th century and incidentally the only physician who signed the Declaration of Independence put it as follows. Solomon places all wisdom in the management of human affairs and finding out the proper time for performing certain actions. Skill in medicine consists in an eminent degree in timing remedies or as that great philosopher Kenny Rogers said you've got to know when to hold and know when to fold. What about the difficult sometimes characterized as the hateful patient? Well they come in many different forms you'll be treating patients with bona fide psychiatric illness if you're a psychiatrist that's all you treat. The most common of which are anxiety obsessive propulsive disorder and depression which is very frequent. In particular I urge you to learn to recognize depression which is actually pretty easy to spot and diminishes the quality of so many lives somewhere between 10 and 20 percent of our population and is a treatable as well as a potential lethal disease. Compulsive patients compose a challenge. I followed a lady this is my most compulsive patient with an obsessive compulsive disorder for years and always scheduled her appointment for the end of the day because I couldn't come close to getting her out of the office in half an hour. She always came with a list of complaints questions and articles from the media as long as your arm which I tried patiently to address. This is just part of what doctoring is all about. It turned out this this lady had a constant morbid fear that she was going to die. Remember that there are always two components to a patient's illness the illness itself and the reaction to the illness. Sometimes the reaction is more debilitating than the disease itself. The physician must recognize and treat both of those components. This is a point which Peabody really emphasizes in his paper. Some patients are just plain angry nasty unpleasant and hard to like. In most such patients I tried to listen not so much to what they were saying but I tried to determine why they were saying what they were saying. Sometimes you find that their anger is related to a bad situation at home or somewhere else in their lives but they can be difficult and some patients are just plain angry the the road rage folks. Other patients are somewhat paranoid. I followed a patient who wandered from one doctor another for years. She blamed everything adverse that had ever happened to her in her life. On some accident a doctor had taken particularly and she also included me in that particular category. She was very unpleasant. After I'd followed her for a few years during which time she continued to criticize just about everything I did. I recommended to her that I followed her for several years. I did not feel I had helped her. She was critical of my care. Maybe it was time for her to find a new doctor to whom she could relate better than I and I would be glad to help her find such a doctor. She looks squarely at me and angrily said Dr. DeSantis there's no way that you're ever going to get out of being my doctor. I guess that's what they call tough love. So I followed her until my retirement mercifully did us part. She's one of two patients in my entire career that I suggested perhaps another doctor could do better than I. In patients with chronic complaints and little therapeutic success we should try to determine early on whether or not there's an element of secondary gain to the patient's illness. There is no more legitimate shelter from the daunting storms of life than sickness and some people enter those shelters with no intention whatsoever of ever leaving them. Don't knock yourself out trying to get a patient better who has no intention or desire to get better. As a Roman philosopher Seneca said it is part of the cure to want to be cured. I usually made minor adjustments in their program carried them along from visit to visit at let somebody else such as a psychiatrist or psychologist deal with what is in fact the basis of their problem. When you alter a patient's therapy only one of three things can happen they're going to get better they're going to get worse or they're going to feel the same. If the patient feels better that's great if worse I want to hear from them and if the same I went along until the next visit. I caution you to be careful of changing the medical program of a patient who feels well. If indeed the patient feels well you can only make that person feel worse with a change in therapy. Some diseases may be unaccompanied by symptoms but warrant treatment such as hypertension in such cases medications whose side reactions bother the the patient may be necessary in order to get the blood pressure under control but always try to use medications which have the greatest therapeutic effect with the fewest side reactions. Side reactions are the most frequent reason the patients discontinue their medications. Caring for dying patients demands the full measure of all of the noble virtues I've mentioned in dealing with patients in their families. It demands the ultimate of compassion, concern, sensitivity, and understanding. Cardiologists especially in which there are a fair number of deaths over time but I've never been comfortable having patients die under my care especially if death was sudden and unexpected or if death represented a failure on my part such as death occurring from open heart surgery that I'd recommended. When a patient dies there is small measure of consolation if you can honestly say to the family that everything was done that could possibly have been done to save that patient's life. I found it agonized into it to deal with families in these circumstances yet it's our responsibility to bring them a measure of solace and comfort. When every one of my patients died I am failing to either call the family or send a note of condolences to the family and I tried to attend as many wakes and funerals as I could. I'd like to speak a moment about failures. Regrettably failures are inevitable and you will find as I have that you remember your failures much more vividly than your successes. I recall with Anglies three women aged 21 35 and 42 who had mitral valve prolapse and ventricular irritability. All were completely asymptomatic and fully active all died suddenly unexpectedly and tragically before we had implantable effibrillators and it saddens me to say there are many other examples of unfortunate therapeutic failures in patients for whom I have cared. I refer you to an interesting editorial in the March for 2014 issue of circulation by Dr. Joseph Lascazzo chief of medicine at the Brigham and Women's Hospital entitled A Celebration of Failure. We are a society the place is the highest premium on success. However he points out that failures are inevitable they are an important part of our life and proceed practically every great advance. He concludes that we cannot avoid failure and if we view it through the constructive lens of self-improvement the only mistake we can make is one the failure from which we learn nothing. Paul Tudor Jones said failure is the fire that forges this deal. Another question you get asked is doc how long do I have to live? The most obvious answer that I've been tempted to give but never have is until you die. Seriously this is a question that I answer very carefully and even ambiguously. I try not to give the patient a definitive time frame for example six months because you can be sure that patient is going to start looking with dread at the calendar and we're often so wrong. I usually speak in generalizations such as people with your condition can live for months or years or the average length of life for people who have what you have is 10 to 12 months but many patients go on much longer. I try to convey a touch of optimism and there are so many advances that can offer hope to seriously ill patients. People with in-stage heart failure who would have previously died may now get heart transplant or ventricular assist devices. Many patients who were dying most recently of non-small cell cancer and other malignancies have lived long enough to see the development of genetic typing of their tumors leading to the use of new chemotherapeutic and immunotherapy and now are much improved. In fact you probably saw President Carter was improved enough to have his second fall and break his pelvis. He's being treated as you know for melanoma. Some who were close to death are now even free of cancer and there are many examples of patients with incurable diseases who've lived long enough for a life-giving treatment or a cure to come along to what aids in hepatitis C. I would like to address some human qualities which I believe have no place in our interactions with patients. These include anger, arrogance, insensitivity, sarcasm, in fact anything that demeans patients or makes them feel any more vulnerable or uncomfortable than they already feel simply from the visit itself or the problems they face. Have I ever been angry with a patient? Of course, although I have a very high threshold for anger and I try very hard not to convey feelings of anger to the patient. One thing that really raises a doctor's ire is the failure of the patient to follow our instructions. There are many reasons for this from denial to forgetfulness to the fact that many patients hate taking pills and the fact that patients don't even care about their health that much. Most of the time patients try as best they can to follow our recommendations but I've had numerous instances in which a patient failed to follow my advice. This is of course frustrating but remember that we as doctors are advisors. We are not enforcers and patients are free to do whatever they choose with our advice. One thing I think is very important is that a patient should never be afraid of their doctor. One of my colleagues at the MJ used to tell me, used to tell his patients if you don't lose 20 pounds in the next six months that won't be your doctor anymore. Not only is that wrong but it doesn't work. And patients are often apprehensive enough just going to the doctor's office and the reason for their apprehension should never be because they're afraid of their doctor. Another event that can annoy many doctors when patients ask for or seek on their own consultation with another doctor. This may bruise one's ego but I've never had any problem with it. In fact on many occasions I've suggested and even initiated further consultation or to be unable to diagnose or to help the patient myself. After all our overriding mandate is to get the patient better however we do it. Arrogance is for me one of the most unpleasant obnoxious and unacceptable of all negative human traits. For whatever reason there's a rather high prevalence of arrogance among doctors. A prevalence it seems to increase the further doctors jitters themselves from the idealism of medical school. Beware of arrogance that demeans people most of all the person who is being arrogant. It has been said that humility is the highest form of conceit. I don't agree. I've never forgotten where I came from. In fact the most important event that ever happened to me happened before I was born and that was the decision when I learned father to emigrate to the United States from a small impoverished town in central Italy in the early 1920s. Everything else in my life has followed and they're not come to this country. I'm what might well have spent my life tending sheep on the side of a mountain in Italy. There were a few days in the past 60 years when that might not have been such a bad idea. The media now barrages the public with all sorts of medical information as well as a great deal of misinformation. Patients in turn beseech us with what they see in here. Much of the advertising on television these days is for prescription medications which invariably advise the public to ask your doctor about taking the medication after they recite all the terrible things that can happen to you if you take the medications. Some patients come in armed with all sorts of medically related articles. Sometimes it's annoying. Sometimes I actually learn something. Always I try to be patient. It's just part of the information driven society of today. Well know what you're thinking now. This old guy is one of the last dinosaurs from the Jurassic age of medicine and you're probably right. The way I practice medicine has been labor intensive and time consuming. A doctor is in a sense a bigamist. We're married to our spouses and we're married to our profession and the profession can be a demanding taskmaster as it was for me. Fortunately my late wife and my four daughters were great. They rarely complain about my being an absentee husband and father even though my wife raised our four daughters almost as a single mom. Actually many stories that circulated around the harvard count harvard atmosphere about me and the way I practice but we just have our birthday birthday cakes at 5 30 or 6 in the morning and perhaps the story made it into that awful book the house of god but my I have four daughters my second daughter got up one day and said to my wife mommy daddy was home last night in my way said how do you know she said because the toilet seat is up the advent of IT and financial pressures have revolutionized the way in which medicine has practiced today and not necessarily for the better computers iphones ipaths have been a annoying burden to me that places a bigger and bigger humanistic wedge between me and my patients but they're part of your DNA and also part of the DNA of many of your patients especially those who are your cohorts or younger and this revolution will continue you will have fully unlocked electronic records robots which make rounds on your patients and communicate with you at home patients monitored in the amateur setting with physiologic apps to hold and to help anticipate changes in their condition and guide therapy and who knows what else any information that you have or might need is at your fingertips and the expectations of patients may also be different in this brave new and less personal world than they have been for mine but technology is not warm and fuzzy it cannot comfort a wife whose husband has just passed away it must be blended with a large measure of humanism there are many who feel that artificial intelligence will greatly reduce the need for physicians in the future that is possible but what is true is that artificial intelligence will further edge humanism out of medicine you will live in the world of medical assistants nerve practitioners physician assistants and others yet to come economic pressures will allow you 30 minutes with the new patient and 15 with the returning patient in the clinic no matter how you cut it you will have less time with the patients than I did at least in the clinic but my best perhaps the most important sentence in my whole talk but my message to you is loud and clear make whatever time you spend with the patients count and as humanistic as possible take your gaze off your computer and make eye contact with the patient at least once one moment during the visit and don't forget eye contact is a very very important thing when you're relating to people the five pillars upon which are based by practice which I outlined at the beginning the fourth one making friend with patients is the only one that is really jeopardized by the new look of medicine and perhaps you will make friends with your patients in other ways such as through social media and networking so widely used today by everyone except me I suspect I've dealt primarily with humanism in medicine but I'd like to say a brief word about science although humanism is a sine qua non in caring for patients it is equally important for physicians to remain abreast of the science of medicine especially as it pertains to their areas of interest this is no easy task because new discoveries in virtually every field are coming so fast and so furiously Dr. Herman Blumgard who was the physician chief cardiologist at the Beth Israel hospital in Boston for many years said it very well without scientific knowledge a compassionate wish to serve mankind's health is meaningless and it should be possible to acknowledge the triumphs of medicine without denigrating the art of medicine in the six decades of decades that I've been a doctor there's been an explosion in the treatment of virtual diseases in my own field of cardiology a new miraculous treatment has come along every five to ten years to extend both the quality and the length of life of patients with heart disease the same has been true of all other fields of medicine where entering a time in medicine when breathtaking advances will come that are almost inconceivable at this time I predict that in the not too distant future virtually all forms of cancer will be curable serious neurological diseases such as Alzheimer's disease ALS Parkinson's disease immobile sclerosis will be both treatable and preventable it is very likely that animal organs will be transplanted into humans or organs may be grown from cell cells there will be vaccine for age malaria and many other diseases and the list goes on and on advances in the prevention and treatment of disease means people will be living better and longer lives which in and of itself poses challenges for society we cannot be complacent some horrific new monster is always lurking around the corner in the late 1970s and early 1980s who would have dreamed that disease called AIDS would come along resulting in the deaths of some 55 million people worldwide will there again be something new and catastrophic like AIDS I suspect probably so I would like to briefly discuss teaching and mentoring it is likely that all of us will teach in one form or another I always felt that we had an obligation to teach in fact you may know that the word doctor is derived from the Latin word or teacher teaching has been a large part of my life and indeed it was the reason I chose to stay in academic medicine at the MGH teaching and mentoring are labors of love I've often said that there are only two rewards for teaching one getting a name on a plaque on a wall and two the gratitude of those who may teach when I joined the staff of the MGH in 1962 teaching was expected of you being appointed an attending physician on a medical service was an honor there was no financial remuneration all of that is changing now many academic hospitals have some full-time teachers in the clinical sciences who are paid a salary for their teaching responsibilities and attending physicians on medical services and in the various sub-specialties are accorded some remuneration for the supervision of patients being managed by residents and fellows in training you can build a career as a clinical teacher hand-in-hand with teaching goes mentoring this is a picture of dr. A. Clifford Barger dr. Barger was a professor of physiology and the most popular professor in our first two years of basic sciences when I was in medical school is also the reason I'm standing before you today I never knew how in the world someone from the University of Arizona should get into Harvard Medical School until 1996 when a book called Harvard Med written by John Langone was published in that book Langone devotes a chapter to HMS admissions in that chapter dr. Barger was critical of the HMS admission process and he singles me out as a specific example of how we advocated for my admission over the objection of everybody else on the admissions committee and somehow prevailed indeed I never met dr. Barger before I came to medical school and he was later become my patient and esteemed friend he was remarkable for his ability to do something about everyone in our class in his long tenure in HMS he mentored hundreds of students and influenced the direction of their careers including mine each year hms Harvard Medical School gives several mentoring awards to faculty members in dr. Barger's memory dr. Barger passed away in 1996 to get back to teaching and mentoring it is remarkable how you can influence students at all levels medical students nurses house offices fellows sometimes without even knowing it I've amazed and deeply touched on upon announcing my retirement I got letters and emails for many people from all over thanking them for having influenced them and the choice of a career or in some other way some of that could not honestly remember because the teaching encounter was so casual and brief yet that encounter had made an impart on the person a few closing remarks I ask that you never forget how privileged we are to be in our chosen profession of medicine we go to work every day with no other purpose than to relieve pain and suffering and to heal the sick I cannot think of a higher calling medicine is a universal language that unites people of any extreme political cultural ethnic and religious differences religious differences though dehumanizing external forces currently impacting on medicine make it increasingly difficult to enjoy this noble calling we should also never forget that the beauty and the essence of medicine still lies in the highly personal and precious interactions between ourselves and the patients we serve and as Dr Peabody urges us let us truly care for our patients remember that there are thousands of doctors out there and your patients will have chosen you as a curator and custodium of the most precious assets their health well-being and even their lives this is a great honor but it's also a huge responsibility and never ever underestimate the importance of you the doctor to your patients so follow your dreams may they all come true and I hope that well in 60 years for now maybe for a few people whatever that is you can look up back on your life in medicine with the same sense of satisfaction and fulfillment that I feel at this time practicing and teaching medicine have been sure joy for me and I hope they will be and will continue to be for all of you as well thank you very much well I'm you have one of the masters of doctor patient election share I'd like to hear your comments well I thought your talk was extraordinary and deeply moving your first five principles are those that I might not have been able to write them the way you did but can completely move free as something that I would like to accomplish in my care of patients I loved your quote from Dr. Lerab at Columbia and later you said you know that if your patient is doing okay don't change it and I what came to mind if you probably know this well Lerab's fall laws Lerab's fall laws were if what you were doing is working keep doing it if what you are doing is not working stop doing it if you don't know what to do do nothing the fourth law was never call a surgeon actually I'm fortunate enough to know Dr. Lerab actually trained at the mass general before I went to Columbia and I interviewed for an internship there at Columbia and I spoke to him and then I by the time he came back he retired he came back I did rounds at the mass general again and it would have been I guess about five or six years since I'd seen him and he looked at me says I don't remember your name but I know you're from Arizona it was pretty amazing he's an incredible guy please question questions and comments and comments for Dr. Desantis thank you sir for such a wonderful lecture just open our minds and let us appreciate all these teachers that taught us growing up I have a question in in in your time you saw your patients you called them and you did all that and they love you for it and this is still in the present with people in my generation is happening and patients our patients love us and they don't want to see another doctor however we are dealing with a new life in new responsibility the doctors don't have that much time to talk to the patients and call them and stuff like that we are more busy with the epic and typing and stuff like that is there an advice that we give the new generation how do we how can we do both how can we be imitating your generation and then also trying to deal with all these nonsense of computers and stuff like that do you want let me ask you what are your thoughts on that well it it's I presume you're in the trenches right with patients it actually taken more time it we need more time in the day to do both to see 20 patients and write their notes and call the other patients at home then you're really neglecting your family totally so there must be a happy medium between both I do all be gyny maybe that's why it's easier maybe if you are in intensive medicine or other subjects but well I I sort of react against I sort of react against information the whole information thing as a matter of fact I retired just as epic was coming in and there's not a physician at the mass general anywhere else on earth and I know of the likes epic and one thing I think we've got to do is that it's basically it's a system for billing and liability as much as anything else and it just weighs so much time for Christ's sake I in fact I told the president of the hospital do this a while back get a committee and figure out how to make practicing medicine fun again for the doctors because it just isn't that much fun and only that but it takes away so much from the time that you could be spending interacting with patients but I one thing I think it just be cognizant all the time of the presence and your interactions with patients patients are always given off signals too I mean it's not just what they say but it's how they look and you can tell whether patients apprehensive or whether they're down or depressed or anything like that and and I think just try to be as sensitive as you can as far as the patient is concerned and I think trying to even if there's not much time in the visit trying to talk about something else that indicates just you're really interested in them and their families and their life and what they do is of some importance as well just something that that humanizes the visit as much as you can how about you well I think this exchange is very important we've been thinking of doing a major research project on the question of whether that is not a short term but a longer term project on on whether the doctor-patient relationship will be able to survive the technology that that is available already and that will become available in the 21st century that is whether there will be opportunities for people to spend time and engagement the way you've described it with patients there's a modest literature on that but not very much and thinking about perhaps organizing it through the Bucksbaum Institute and the McLean Center both on a local basis but but even possibly reaching out nationally to find people to consider that and think about it I'm hoping that this lecture series the one that that that Dr. DeSantis is speaking in may be the beginning of such an effort but there'll be a lot more to be done I should tell you that Oxford University Press has approached us about the lecture series and I'm hoping we'll get your copy of your of your paper for it too but uh but but it's going to be an ongoing question and problem Barbara and then Dan yeah yeah I kind of worry about young doctors and and students because the way they things are acting now I mean I was accused my chairman came in they wanted to know why I was spending too much time and walked out saying you teach too much and I said this is why people come to the University of Chicago they come with their questions they've read on the internet and they want to know about their diseases and this is this was wrong and I mean I think most people know what they want to do but they don't have time to teach their the students are actually um servants to a schedule and that's the overriding issue about what they're learning about the practice of medicine and it's what none of us ever went into medicine nor do we think it's the right way to have a patient physician interaction and I think they shouldn't be thought that that's the correct way to do it so is a criticism Barbara of your effort based on time limitation or yes time of the patient it turned out it was a mother with metastatic cancer divorced from her husband whose child was facing surgery of a procedure that they didn't understand or know why it was being done and the child was going to have to go through that and I gave whatever time I thought was necessary for everybody to come to this conclusion that they were having trouble coming to and uh I was one of the reasons I actually decided to retire and leave medicine because I thought I'm no no longer a part of that practice of medicine it's wrong as far as I'm concerned one thing is uh there's a doctor's secret thought there's a long time question is actually can compassion and caring be taught you know I think every student who gets into medical school when you read what they submit for entrance into the medical school they also a great deal of compassion and concern because that's what you have to show to get into medical school but do they all necessarily have that compassion and concern um I think uh there's just no way no no way of doing that I mean I get up here and talk about all the things you should do but if a person doesn't have the basic sort of instincts of being compassionate and sensitive and things like that it's not going to do much yeah thank you for your thoughtful talk I was curious um since you have been around for a while about your impressions of sort of the evolution of the specialty um specifically cardiology I my understanding is that initially in the 50s and 60s that it was more of a primary care that you were the primary care physician for patients with heart disease and that with the evolution of specialty to what we see now doctors became very um they became much more focused on their own area of expertise could you comment on that evolution and how you um well I think I think it's just sort of the progression of knowledge you talk about going for sort of what would be general practice primary care to cardiology now within cardiology you have heart failure you have a rhythm in as you have cardiac catheterization you have a whole bunch of things so that that the parts of cardiology room practice I knew very little about and send my patients to other cardiologists I think it is as knowledge advances the question arises whether you need a body of people around that body of knowledge um and I think it may be carried a little bit to an extreme every time anybody branches off anywhere they want to make a society of such and such or suspects of such and such but but I think you're absolutely right I mean when I started in cardiology we had digitalists we had mercury hydrant uh we had warfarin and we had quinidine and pronestal and that was about it you know there was no pacemaker there's no cardiac surgery no echocardiography and as an area advances it becomes so suspect such specialized and important within the specialty that attracts a group of people who basically make that their life's work I don't know if you've read it we have two economists across the street Kevin Murphy and Bob Topel who have written about 10 papers on the extraordinary advances in cardiology and their achievements over the last 30 or 40 years I think the mortality from cardiac disease unlike many other diseases has declined by something like 40 to 45 percent um prompting Murphy and Topel to write these articles on the limited research investment that has resulted in an extraordinary societal benefit I mean you go from an investment of something like a billion dollars to a return of 10 trillion dollars in terms of lives saved and people functioning so that that is an that's an ongoing issue and of course other areas of medicine as you said in in your talk will likely over the next 20 or 30 or 40 years reach those goals I think that's entirely true yeah but cardiology has really been a very fascinating specialty to be in because as I mentioned it about every five to 10 years you know whether we there were pacemakers and there was well open heart surgery pacemakers interventional catheterization uh a rhythmic treatment and it is um it's just something that's very positive but for you as a cardiologist and for your patients to see advances that are so helpful Tracy hi I am a pediatric ICU doctor by training um and I have now become a patient who collects doctors and diagnoses um and I really appreciated everything you said during your lecture um my one thing that I've noted as a patient um as I think when you started you probably cared for most of the issues with your patient and I literally now have a doctor for everybody part practically and I quickly realized that everybody was telling me different things to do and had different opinions about everybody so I picked the person not my internist but the person that had followed my cancer the longest that I really felt very comfortable with and I said she's in charge I know I have other cancers now and she's not she doesn't do those cancers but she's in charge and that's been helpful that she's been willing to be that person um and that I've had someone to go to and since I'm on your spectrum of I'm just gonna be hearty and just keep moving forward I get calls from her nurse practitioner saying you will be seen in clinic tomorrow and it's like being called into the principal's office you're doing too much and you have to take time off so I really do think that that's another piece as we move forward that we have to ask our patients who is who do you consider your doctor I have to say that um the sort of the messages that I delivered um can we really be summarized maybe in four words like be nice to people I mean it's relevant not only for medicine but in any aspect of life we should be caring considered listen to people treat them with respect it's I think a reflection of our society which is sort of tuning out all of the great virtues and values that we've been held for so long I mean now it's good to be be great people the insult people the then a great people uh to be made nasty and it's we just need some sort of a current in the opposite direction but medicine in particular we're saying last I think there's there's something a little spiritual about being a doctor I think it's about as close to a person as you can get in a profession and I think it demands something a little different than a lot of other other professions I wonder if you see any essential changes in doctor-patient relationship between the time that you were resident and now that you observing others having relationship with their patient well I think the thing that we had which they don't have now it's time and when you have time you can do a lot of things and particularly in terms of interacting with patients and get them know the get getting know them better I think that's why and it's something that put a premium on but I really have some wonderful friendship for the patients that I formally treated now consider to be my friends but it's there's no question you know with an abbreviated period of time to see a page only so much you can do and I think we have to try to figure out and I think Dr. Ziggler and people will in this current milieu we'll be giving constant thought as how we can continue to retain as best possible the personal interactions between doctors and patients but there's no question I mean we didn't have much to do when when Peabody was a doctor there was almost nothing they could do except hold hands and talk to patients and support them and you know I remember when I first started out there were no time constraints for one thing there was no problem there was no blue cross or blue shield or anything that telling you have to see patients uncertain in a certain amount of time I think if you look at the major things that have kind of resulted in a change as much as economic considerations and anything else it's sort of insist that you have to turn these patients over as quickly as you can so that the bottom line is maintained and it's a it's antithetical to humanism needless to say you have any comments on it building on that could you comment on the business of medicine comments on what comment on the business of medicine well you probably I'm really not an expert on that that particular thing but there's just no question that if anything has emerged along with advances in treatment the whole economics of medicine is just so completely different when I first started the mass channel there were there was a baker building that I mentioned and that was sort of like middle-income type building and they actually had a set of fees one two three four forward for the more affluent patients one for the less affluent patients and they only charged that sort of thing but otherwise doctor charged sort of whatever they wanted and now this sort of overwhelming reach of business of insurance companies of you know monitoring and permission and all the authorization on this stuff it's just killing it's absolutely killing and you know I again I think one of the one of the problems that I see in all of this is that doctors for the most part don't protest very much I mean we watch at the mass channel we watch as epic running over everybody I know there I know there are other systems besides epic that are a lot easier to use and a lot friendlier but for god's sakes you know we ought to rise up ourselves and we just sort of sit passably behind the steamroller goes over us and people get burned out and leave so do we about epic I mean I think the business of medicine is very tied in to the patient physician interaction the major complaint I hear from friends in Hyde Park is the lack of attention that they get and and people listening physicians interacting with their patients it's a huge concern here and if you want patients and a good business thing I always thought I was in competition with Mayo Clinic actually and that I had to give at least as much as everybody else to bring people here and I think that you have to care enough about the patients that that comes first and then they come but money doesn't bring the patients here you mentioned I fully agree about when a patient passes about sending a note or making a call to the family and you said you frequently go to funerals or wakes or something has that ever has that ever have you ever wished you hadn't in some of those situations is that too too much on the patient's turf if you will to be there I'm sure most of the time it's greatly appreciated that you're there but have there been times when maybe that was a not the best decision well that's that's a good question I honestly don't remember having made that sort of an action and regretted it and I think for the most part I think obviously this is what sort of relationship you had with the patient and I say I didn't have sort of this godly relation with all of my patients but for the most part I think they appreciate everything that you did for their loved one in the period of time that they were alive and and I have nothing but but for the most part appreciation from the family for making the effort to try to get there and I I can't remember a single time that I regretted going to anything like that and I when you said that I wanted to come to throw that same question they helped me because that is unusual and I wanted to ask dr. Hoffman if he took in oncology these days is that done number one number two what have you told when you were a trainee in oncology has there been any change because it is unusual like I can currently uh well I am an oncologist I actually have not done it very much I've done it occasionally with a patient that I've cared for over many years or felt particularly close to I've had some hesitancy because I sort of feel like this is a an area of privacy that perhaps I shouldn't be intruding on I've never had a bad experience so I certainly you know never felt burned by having done so but I don't necessarily represent the best time of that patient and you know they may want to be reflecting on the other times than when I was involved with them I think it's a I think most of the time it's a good thing to do if you have the opportunity well I'll just say one thing I was in med school 40 years ago at Stanford and they were getting the lymphoma program going with uh uh Rosenberg was it? Rosenberg and then the the leading lymphoma specialist with radiation treatment on Henry Kaplan exactly a lot of the oncologists then sit when they had a good response and the patient lymphoma patient invited them to the wedding they were very ambivalent about going you know and then to to weddings and birthday parties for that you know and I think you know why? Well I can see and I'm sure they're in my own experience uh situations in which the way the patients illness evolved in any relation to whether it may be just as well not to go but um for the most part if you have a nice relationship with the patient the the families generally greatly appreciate you're making the effort to um to agree with them I'd say so thank you very much for your talk um I guess you mentioned on a couple of occasions uh besides EPIC and IT sort of and the issues there but you also mentioned sort of all of these other practitioners that are taking care of patients these days and although I think everybody is in agreement that we need various practitioners and in our to help us care for patients I wonder what your take is on the relationship as it has evolved over the years with all of these other sort of helpers or middlemen or whatever you would call them in how that has impacted the relationship? Well it's been my practice to show appreciation and gratitude to the employees of the hospital at all levels you know when I walked down the hall of see the janitor and I know he knows who I am but I know who he is and but it's not isn't you're right it's not just the nurses it's the therapists it's the dietitians it's the social workers all it's a team it's a huge team and I actually in a subsequent revision of my little book I include thanks all the other people who help take care of patients as well and sometimes in a hospital in terms of your place in the hospital getting to know the people at the lower levels is as important as getting to know the people at the higher levels and that's always been kind of a priority of mine yeah thank you really we're just we're just talking about being nice to people as I say I guess I was also leading to the other part of care in that sometimes you know we all our doctors were also all patients here but sometimes you call to get an appointment with a doctor and you may not be getting an appointment with a doctor at all yeah and I wonder what your take is on that I just want to say a quick word about that you mentioned the increase in team medicine not only at the mass general but around the country and I think that's unquestionable that that in hospitals there there is particularly in intensive care units and and other high-risk areas there are teams taking care of patients rather than individuals does anybody in the room know how many inpatient admissions there are yearly in the United States give me a number 35 million so 35 million inpatient admissions in the US with with an increase in team medicine now an outpatient medicine an outpatient medicine the majority of interactions remain not by teams but by individual encounters between the doctor and the patient anybody want to guess how many outpatient encounters there are annually in the US I thought you were going to tell me 1.2 billion so you have 35 million inpatient missions with an increase in team medicine you've got 1.2 billion in encounters as outpatients the majority of which I'm not saying a hundred percent are still on an individual doctor to patient encounter so I'm I'm thinking that as we go forward the inpatient system is has changed and will continue to change and we'll see what happens to the outpatient system and actually have a better chance of developing nice interpersonal relationships for the inpatients than you have for the outpatients more time I just want I just want to remind you to take take a copy of this paper that's waiting out back and I want to thank Dr. DeSantis for this extraordinary talk and for joining us today thank you thank you for your attention