Conversations on Healing

Dr. Suzanne Koven

Breaking Barriers in Medicine: Insights from a Physician

Dr. Suzanne Koven
Writer-in-Residence at Massachusetts General Hospital in Boston

Dr. Suzanne Koven received her M.D. from Johns Hopkins and B.A. in English literature from Yale. She went through residency at Johns Hopkins Hospital where she was chief resident and later joined the faculty of Harvard Medical School. Dr. Koven has over 30 years of experience in primary care internal medicine at Massachusetts General Hospital. Additionally, she is an associate professor of medicine at Harvard Medical School and holds the Valerie Winchester Family Endowed Chair in Primary Care Medicine position at Mass General. Her essays, articles, blogs, and reviews have appeared in numerous news columns and magazines. She also wrote a book that is discussed in the episode, Letter to a Young Female Physician, where she examines the role of women in medicine.

In today’s episode, host Shay Beider welcomes Dr. Suzanne Koven to discuss the evolving world of healthcare and the challenges that women face in the medical profession. She shares several studies comparing the impact of gender in medicine and how this can affect patient outcomes. Dr. Koven talks about the increasing digitization and corporatization of medicine that has changed hospital culture, as well as how providers interact with their patients. She provides first hand experience and shared some of the lessons she has learned from slowing down and taking more time with her patients. Finally, Dr. Koven discusses medical literature and the poetry group she began for providers in the hospital during COVID. She draws inspiration from these moments and offers wisdom that reminds us of our humanity.

Show Notes:

  • Check out Suzanne’s website
  • Read Letter to a Young Female Physician here
  • Find out more about Rachel Naomi Remen here

Welcome to the Conversations on Healing podcast, where host Shay Beider speaks with renowned healthcare leaders, practitioners, and thought leaders to explore the world of wellness, the incredible powers of self-care, and what it truly means to heal today. Join us on this journey to become more whole healed and connected.

SHAY BEIDER: Thanks for joining us on the Conversations on Healing podcast. I’m host Shay Beider and today I’m speaking with Dr. Suzanne Coven to learn more about medicine and particularly the role that women play in healthcare. Dr. Coven received her BA in English literature from Yale and her MD from Johns Hopkins. She practiced primary care internal medicine at Massachusetts General Hospital for over 30 years. Dr. Coven is an associate professor of medicine at Harvard Medical School and holds the Valerie Winchester Family Endowed Chair in primary care medicine at Mass General. Additionally, she speaks to a wide variety of audiences on literature and medicine, and particularly the role that women play. In today’s conversation. We cover a broad array of topics including the discrepancies men and women face, and the current movement in medicine towards digitization and corporatization. Dr. Coven shares research that reveals interesting findings regarding patient outcomes that differ by the sex of the provider and the importance of understanding the current medical culture. We also look at her book, Letter to a Young Female Physician, which offers her personal experiences in medicine and how these differ from those of many of her male counterparts. She opens up about some of the things that she has learned from slowing down and increasing the amount of time she spent with her patients. This conversation on healing helps us all to understand a little more deeply some of the dynamics that directly affect us as patients in our western medical systems today. So let’s get the conversation started.

Well, welcome Suzanne. We’re so delighted to have you on the Conversations on Healing podcast. Thanks for joining me today.

DR. SUZANNE KOVEN: Well, thank you so much for having me, Shay.

So I know one of the many topics we’re going to be covering today is women in medicine, and it’s such a different world today than it was even 20 or 40 years ago. There are currently more women enrolled in medical school than men at this time. I’d love for you to speak to why it’s so important, this shift towards more women in medicine, how it affects all of us and the healthcare that we’re receiving.

Yeah, I mean, certainly this is true in American medical schools that as of 2019 there are more women enrolled than men. And if you look at American female doctors under 35, there are more women than men, and I think there are a lot of reasons for this. Going back to Title IX in 1972, which was supposed to promise equality in education and you saw an influx of women coming into American medicine then, and when I went to medical school in the eighties, I was certainly riding that wave, but nothing like it is today. I think what’s really important and interesting and is a great passion of mine is thinking about why it is, and this has a broader resonance I think, across other professions, other industries is why it is that even though there are more of us women in this profession, we have made really so little progress toward equality. And I can tell you what I mean by that, and it’s really tangible things like pay equity. There’s still about a $15-20,000 pay gap between men and women in American medicine all the way to sort of less tangible things, kind of cultural factors. The culture of medicine both for patients and for physicians remains very male dominated.

And I’m also curious, we see trends too just in education in the United States that for higher education in colleges across the country, we are seeing more women enrolled at the university level than ever before. And I’m also interested in some of the peer reviewed studies that actually compare from a patient perspective the different outcomes when you have a female physician or a male physician because there’s some data that we can draw on here too.

Yeah, it’s so interesting and it’s also a little tricky to talk about. So here’s an example. Just a few years ago, a big study came out that showed that if you are enrolled in Medicare, which most Americans over 65 are your chance of not needing to be readmitted to the hospital within 30 days after a hospitalization, and your chance of being alive within 30 days after a hospitalization are greater if your primary care doctor is a woman. Well, of course there were headlines everywhere. Are women better doctors than men? And should you choose a woman doctor from a patient’s perspective, is it a smarter thing to do to have a woman who’s a doctor? An additional study, which interested me very much a couple of years ago showed that women physicians in primary care spend 2.4 minutes, I think it was, extra per patient per visit as compared to our male colleagues. Now, you could look at this and think, well, I mean, come on, 2.4 minutes. That’s nothing. Well, it isn’t nothing if you’re being paid by productivity, meaning how many patients you see in a day, if you kind of average that over a year, it’s about 15% of your income.

And when I sort of put those two together, I find myself asking questions like, so a plus an additional study more recently, by the way, just to get all the data on board that female physicians spend more time answering electronic messages as compared with our male colleagues. So I look at all that and I think are women more responsive to patients than men as physicians? Are we more empathic? Are we nicer? And just to put this in some historical context, this is a conversation that the first female physicians in the US and the UK were having 150 years ago, and the debate went like this is Elizabeth Blackwell and her contemporaries in mid 19th century America.

Should we claim that as women, we are bringing something special to the table that men aren’t bringing? Is that a good thing for us to be claiming? Or do we really want to say that there’s nothing different between, there’s no difference between male and female physicians? Would that be better in terms of advancing equality? And it’s fascinating that 150 years later we’re sort of having the same conversation. So what do I think it’s all about? I have a theory. Here’s my theory. I actually don’t think women are more empathic than men in general or as physicians. I know many very empathic men, as I’m sure your listeners do, and I have known and been a patient of many wonderful empathic male physicians. But what I think is that in the current structure, we have in a very corporatized, very digitized medical profession. There is a lot of pressure to see patients really quickly, which is kind of antithetical to good care. One study showed that doctors interrupt patients an average of about 11 seconds after the patient starts talking.

What I think is, and this is the example I always give and I gave it in my book, is, and this is something that every clinician I know will recognize this scenario. If you walk into an exam room and the patient has been waiting for you and they’re sitting reading a book and you see the cover of that book and you’ve read that book, you have opinions about that book, and now you’re at a crossroads, if you say, oh, what’d you think of that book, I read that book? Then you will probably have an interaction that will increase your bond with that patient, which we know has a demonstrable positive effects on that patient’s health. We know that physician rapport is really helpful to patient health in ways that you can measure, but of course you’ll fall behind and you’ll lose income if you do that.

Or do you want to pretend that you didn’t see the cover and move the visit along? I feel that the difference between men and women, and there are obviously many exceptions to this, is that as women, we are more socialized in this culture to take the time to ask about the book or to ask to see the prom pictures or to ask, how did your daughter’s wedding go? Even if it costs us time, even if it means we’re going to be staying later in the office, even if it costs us money, whereas men are more socialized not to make that trade off. And I think the key here is that both men and women suffer. So it’s really a systemic issue. It’s not a male versus female issue.

And obviously this is so much further complicated in that today more and more people are not even identifying as either male or female, that we’re getting all sorts of new pronouns and ways that people are identifying and feeling like they would determine their identity. So I can only imagine what this will look in another 10, 15, 20 years. I think it’s going to be even further complicated by the changes in how we’re even looking at gender.

I think the fact that our understanding of gender and the fluidity of gender is so much more advanced now than it was even 10, 15, 20 years ago, means that this sort of dichotomy, women empathic men, not empathic, it probably never was incredibly valid. I mean I think even 150 years ago we knew that that was a really sort of unreliable construct. And I think that’s even more the case now.

And to your other point about the bond kind of that doctor patient bond and the importance of that, there’s two pieces of research that I’d read that I thought were really interesting on this topic. One was looking at, you mentioned how often the physician will interrupt within about first 11 seconds. I don’t know if that was an average, but in that particular study, but I had actually heard a wonderful presentation by a physician and she cited a study that if you just wait about 90 seconds, that’s when most patients will stop talking. So they did a study where they let doctors just allow the patient to go until they stopped. And most patients only took about 90 seconds before they themselves stopped and felt like they had been heard. So based on that, she was recommending for physicians to just allow that 90 seconds to happen because it’s really not that much time.

If you’ve got as an example, like a 15 minute visit and then the patient feels like they were so much more seen. And in addition, that bond we know impacts so many things in terms of outcomes. I don’t know if you ever read the book Compassionomics, but it looks at a lot of the data around compassionate practice and how it affects the economics and outcomes. There’s a number of interesting research points in that book, but one point that I’ve also read about that I think is quite interesting is that you are much, because you’re talking to some degree about the economics of it, if a woman will then basically lose money because she’s willing to spend more time so she sees fewer patients, then she generates less revenue as a result of seeing fewer patients. But there’s also an economic side where we know you’re more likely to sue your physician for malpractice if you don’t have as good of a bond. And even studies where if the physician touches the person on the arm or the hand appropriately and says, I’m sorry when they’ve made a mistake that the patient is less likely to sue. So there’s just these very interesting and examples that also have significant financial impact. If you’re not sued, that’s financially beneficial.

So here’s kind of an expansion on what you were just saying. I a few years ago, inadvertently did a little experiment in my practice. It wasn’t an experiment I intended to do, but this is what happened. So I had fallen and severely fractured my shoulder. I’m right hand dominant and I had surgery and I was out for weeks and weeks, so long that the hospital had a rule that when I came back I had to first go to occupational health and see if I needed an accommodation. Well, of course I didn’t think I needed an accommodation stubborn doctor that I am, but the nurse practitioner in occupational health decided that I did, and I don’t even remember who she was, but she was brilliant. This is what she said. She said, well, it’s your right hand and I think what you need to do for the first three weeks that you’re back is do everything you normally do in twice as much time.

So that meant that the 15 minute visits became a half an hour, a half hour visits became an hour, and it utterly changed my practice. And here’s how it changed. One aspect which has to do with the economics of the situation, though not related to getting sued, was that I ordered fewer tests and fewer consultations. Why? Because I realized that very often, and I’m certainly not the only one, I’m sure that very often I was ordering tests, writing prescriptions, ordering consultations simply to end the visit, to make a disposition, to make a decision because there wasn’t time to sort of let the conversation develop. So I was costing the system less money. But there was something else that happened on an interpersonal level, which is that I realized that there is a cycle that occurs in doctor, doctor-patient interactions. And we’ve been talking about doctors and patients. I’m a doctor, it’s more familiar to me. It’s not that this doesn’t happen with nurses and therapists and other health professionals, but I think it’s more likely to happen with doctors. And this is the way that cycle goes.

The doctor is rushed, the patient’s senses that the doctor is rushed, the patient gets a little anxious appropriately feeling as you’ve just said, that they’re not going to be heard. And when we’re anxious, we act in whatever ways that we act as individuals to convey our anxiety. The doctor picks up on this, the doctor gets a little anxious. Things don’t seem to be going well. The doctor also may get a little defensive, I’m here to help this person. What are they so anxious for? Why do they seem angry at me? Why are they arguing with me? And what shouldn’t be an adversarial encounter becomes an adversarial encounter. Okay, so what happened during those magical three weeks, which by the way were among the happiest three weeks of my entire medical career, what I noticed there was something that happened in minute 17 or 18 of what had previously been a 15 minute visit, but was now a 30 minute visit, which is that the temperature in the room seemed to go down, the patient’s anxiety went down, my anxiety went down, and we started talking about sources of stress and sources of worry and all the things that affect health that aren’t covered by the tests that aren’t covered by the prescription, which isn’t to say that tests and prescriptions are never needed and that everything is psychological, but the conversation in a 15 minute visit doesn’t have much time to unspool.

You can imagine in the rest of your life if you had a clock and you had 15 minutes to have a really important conversation with your partner or with your child or with your parent, it’d be bad. I mean, it would feel frustrating and adequate and you wouldn’t be at your best. And they wouldn’t be at their best. And I think, again, I hate to keep talking about the system as if it’s something that’s so abstract. There are actually lots of things that we could do to change it in concrete ways, but this is a systemic issue. This isn’t about mean doctors and demanding patients. This is about a system that’s conspiring to pit us against one another all too often.

This goes to the prior points that you raised around corporatization and digitization. And again, these are systemic issues. I think the fact that you mentioned that when you got past that 15 minute threshold and suddenly had the luxury of an additional 15 minutes that you got into more of stress and lifestyle, these are all the preventative topics. We know that when you get into those topics, you’re actually starting to think preventatively. Also, what I thought was fascinating and what you said was that you ordered less tests because you had more time to sort out, do I really need that test or not? And what we know is that in the economic model we’ve designed currently in our Western medical system, you actually generate more revenue for the hospital when you’re ordering more tests. So we’ve actually created economic incentives that are sometimes in conflict with what may be in the best interest of that patient.

And so I feel like the systemic issues are so real because they are imposing a whole series of things on that patient-physician interaction as we’re discussing in this particular example. So for example, were we to reconsider the economic incentives in the design of the system so that the payment was based upon essentially supporting the maintenance of wellness and preventative care. So if the providers in the system were rewarded economically for keeping their patients healthier longer, that would shift the entire economic model. So there are certain ways that we’ve embedded some of this in the design. So, I think it is very reasonable to have design level conversations because a lot of this, like you said in your own direct experience, having that extra time with the patients felt so good. I mean, you said it was like some of the best three weeks in your practice of medicine.

It was a win-win. I mean, I think I interact with a lot of medical students. I’m sitting at medical school right now. Medical students tend to come in pretty idealistic. I think they’re more sophisticated about financial and other sort of extra medical matters than physicians in my generation were. But they’re pretty idealistic. They want to help people. The average medical student goes into almost a quarter million dollars of debt. There are easier ways to make a living, so they want to help people. And then what happens very often is they come out of training and enter practice and sort of hit this buzz saw of demands that really have nothing to do with good patient care. And that’s why getting back to the issue of women in medicine, an astonishing study a couple of years ago showed that about 40% of women have either left medicine or are working part-time within six years of finishing their training.

And we need them now. Why are they leaving? I think one, it’s that buzz saw and Covid absolutely did not help. Covid was really, really hard on healthcare workers in general, on doctors specifically, and on young doctors even more specifically. But the other thing they get hit with is that even now in 2023, combining family with being a physician, if you are a woman or if you are a parent, but particularly if you are a woman who is a parent, is incredibly challenging. And a lot of women decide rather quickly that it’s not possible. It’s not sustainable. And of course we all suffer for that as anyone knows, who’s tried to find a primary care physician recently.

And I’m also aware there’s a number of ways that women face challenges in the healthcare system, including pregnancy. And I know one of the topics that you and I have touched on is that originally when medical school training was designed and residency was developed, it was only men. And so pregnancy was not on the table at all because it was men and they were expected to live there and be there in the hospital.

That’s why they were called residents.

That’s why they were called residents because they were staying there overnight on a regular basis and living in. And so now suddenly here we have women that are, and you talk about this so beautifully in your book letter to a young female physician about your own experience. And also as a woman wanting to appear tough and understandably, you don’t want to feel like, oh, I’m the weak one. And now they’ll say, oh, she’s a woman. She’s weak. And yet here you were pregnant and really doing, as you indicated in your book, probably more than your body was able to handle, and so much so that you needed to go on bedrest for a period of time because your body probably just said enough.

We put women in this position. And so I’m curious about these level of accommodations that we just simply haven’t properly instilled in the design of the system because women weren’t originally included in the design of the system. And we haven’t made enough adaptations even today.

Well, even today is sort of the key element of this part of the conversation, which is, I mean, gee-wiz, that baby I had as a resident is 35. We’ve had time to figure this one out and we haven’t figured it out. So a really interesting thing happened when I was on my book tour was during the pandemic. So I zoomed all over the country and beyond, and I spoke to a lot of medical students, women’s residency groups and so forth. And I thought that one thing that might happen when I spoke to young physicians and physicians in training is that they would read about what happened to me in the eighties when I got pregnant as an intern and didn’t ask for any accommodation and ended up with a life-threatening pregnancy complication.

I thought they would. Well, oh gosh, things were awful back then. And thank goodness we’ve come so far, but isn’t what they said. What they said is it isn’t that much better. Now. There have been improvements made in terms of maternity leave. There are actually state laws and sort of medical organization recommendations regarding pregnancy and parenthood, so adoption and so forth. But the culture in which someone who is pregnant still feels that they’re asking for a favor to be accommodated still exists very much. And also we know that in male female couples in medicine, women are much more likely to stay home when the child is sick, which is why Covid greatly exacerbated the pay inequity between men and women in medicine because all the kids were home. And we know that women are more likely to arrange the childcare, more likely to be doing the pickups, and more likely to be sort of the glue of the house. That isn’t always the case, but it’s still is the rule, not the exception in male-female couples.

And I’ve seen recently we worked with a resident who was going into neurosurgery and she was pregnant, and I saw what she suffered. I mean, it was just tremendous. She was working 80 plus hours a week and again, had that fear of, if I don’t, I’ll be seen as less than, and then I’m a less competitive candidate, and so then I won’t be selected in this highly-selective field and my reputation will suffer. And so you see the dynamic because we haven’t systemically addressed it properly, that it puts this incredible pressure on women that we internalize to overperform. I saw it so clearly in that case.

Those are realistic fears. I mean, that’s not in her imagination. And it’s not only in matters of health, it’s also pressures to behave a certain way to, for example, accept certain kinds of harassment. The vulgar joke, the vulgar comment is that medicine really values, almost above anything else, is being a team player. The worst thing you can be called in medicine is a weak link or a slacker. That ethos still is very much exists. So, if you need extra time off or an altered schedule because of pregnancy or if you report harassment or don’t laugh at the joke, you’re not quite in the team. You’re not tough enough. And the truth is it really is a very tough field. And so I think often we internalize that ethos. I know I certainly did. I told myself, you can’t complain. You can’t ask for anything because if you show any weakness at all, you’ll somehow be in out of the inner circle. And one of the stories I tell in the book is about having a conversation just in the last couple of years with one of my fellow residents who was black. So this was from way back in the day, and we were talking about his experience as a black man in a predominantly white program, and my experience as a woman in a predominantly male program.

And I was saying to him, I feel a little ashamed and puzzled when I think back to how much I revered a system that had very little regard for me in many ways. And he said, no, I think you’ve got that wrong. I think they actually loved you and they loved me, but here’s what the problem was. We always knew we were just one misstep away from being rejected. And that’s why we were constantly trying to be perfect. And that sort of segues into the whole imposter syndrome question, which is in many ways I think is coming to be understood as a internalization of bias because the people who are mostly likely to have it are women, people of color, members of the LGBTQ community, people who have been told either you’re not okay, or you’re just a little step away from being not okay. And so you sort of get this idea that, well, I’m either going to be perfect or I’m going to fail. There is no inbetween.

Yeah, and I really hear what you’re saying too in terms of how people get put in such a difficult position. I remember bestselling author Rachel Naomi Rein, who many of our listeners might’ve read. She’s had some wonderful books that are very moving, and she’s a physician who started her career at a time when there were not very many women in medicine, and she was surrounded by men in her training. And she tells a story that goes something like this where they were with the cadavers and they thought it would be funny. They cut off a penis and they put it in the pocket of her coat and she didn’t know it was in there, and she put her hand in and discovered it. And somehow, honestly, this is so above and beyond, I don’t even know how she had the fortitude to do this, but she figured out what had happened and she gathered herself and she said something along the lines of, is one of you missing this? Or she turned to the men? But you think about that, you think about, wait, hold on one moment there. Think of everything she just had to process, deal with, and then find a creative strategy and solution to use humor to navigate around it in a way that would still keep her as part of the group that would not humiliate her. She had to use so many forms of intelligence. It’s

A really narrow bridge, isn’t it?

Yeah, it’s a really narrow bridge.

Yeah. I mean, one of my younger colleagues told me about an experience not like that for your listeners. I don’t think that kind of thing happens anymore, that was, I think back in the sixties or seventies. But a younger colleague of mine told me about being a medical student in an operating room where all the surgeons were men and of them making some very obscene reference and then asking her if she knew what they were talking about. And she did the exact same calculation that sort trying to walk on that narrow bridge that you’re referring to with Rachel Naomi Ramen. She was like, well, let’s see. If I say I don’t get the joke, then I’ll look like a dummy or a prude.

And if I say, I do get the joke, I’m not really being true to myself because I don’t really think they should be telling this joke in this setting or anywhere for that matter. But then there’s another layer. So she decides she’s or doesn’t even decide. She reflexively, remember there’s also a big power differential here. There medicine is very hierarchical, and she was really low on the chain in addition to being the only woman. She says, oh, I know what it means. I get it. And there’s a lot of winking and high. Well, there wasn’t high fiving. It was an operating room essentially that. So here’s the more complicated part. What she told me is that she felt kind of proud and pleased with herself.

And I wonder if Rachel Naomi Remen felt a little bit of that too, but that pride was also tinged with a little bit of shame because it wasn’t really her thing to be laughing at a joke like that. And I think not just in medicine, but in all walks of life, I think that that is a narrow bridge that women and other people who are marginalized or in lower positions of lesser power negotiate all the time. This desire on the one hand to be one of the guys a good sport, tough, but also knowing that whatever that is doesn’t reflect your values. It’s hard. There really is no right answer when you’re in that position.

And then we’re now hearing from a lot of people of color that this goes on and on and on and on continuously in this way that feels like a series of microaggressions are constantly happening on a daily basis that then accumulate over years and years and years and take tremendous toll and create a whole other layer of stress on top of the stress of being in a highly stressful medical system that has, it’s very demanding.

Yeah, this is called weathering, and it’s real. I mean, we know that the effects of racism on health are real and that what used to be thought of and was in medical textbooks and articles as racial differences in health are likely to be not racial differences, but consequences of racism. We’re reading a lot now about increased pregnancy complication among black women and lower birth weight infants that a black woman who has college or advanced degree is more likely to have a pregnancy complication or a low birth weight infant than a white woman who is a high school graduate or has lower education. So this idea that, well, it’s some kind of physiological difference between black people and white people, or maybe it’s health is just a marker for poverty that’s really gotten blown out of the water by research.

Yeah, absolutely. I also want to discuss with you, and you dedicate a good portion of your time to medical writing. I know part of the why is that it’s illuminating and can help to in a way, bridge the art and science of medicine to bring that together. And I know you also have worked with a number of physicians kind of using not only literature, but also poetry. And so I want to talk a little bit about what role you see literature and different forms of storytelling poems, like how you see this being beneficial in training and also just patient care.

Yeah. Well, thank you for bringing up my most favorite topic other than my grandchildren. So this is not a new thing. Generations ago, physicians who were, of course, all men back then were educated men. They knew Greek and Latin and Shakespeare and the humanities. Somewhere along the line in the early to mid 20th century, medical and scientific knowledge really exploded. You had the advent of antibiotics and safer surgery and chemotherapy and scientific discoveries that helped us understand how disease worked, which just simply hadn’t been known. And so there was just kind of too much to learn to spend a whole lot of time on Greek, Latin and Shakespeare. And so the medical profession became sort of much more science oriented in its training. Although the reality is, I deeply believe, I know this for a fact, that it never stopped being an art poetry, never stopped being relevant to what was going on in the exam room and at the hospital bedside. Because as has been said since the time of Hippocrates medicine is both an art and a science. An update on that, which I absolutely love from the Scottish physician writer, Gavin Francis, is medicine is an alliance of science and kindness. We’re doing a great job training physicians, especially in the science.

How do we train people in kindness? Is that even possible? If you didn’t learn to share in kindergarten, can you be a nice physician when you’re 40? I think we can. And it’s not just kindness, it’s the understanding that there is a lot of ambiguity in illness, that there is a lot of ambiguity in the relationship between the mind and the body. The way I was trained, and I think this still persists to a large degree, is that, well, there’s the brain stuff and then there’s the body stuff. And the way this is spoken of still in medicine is, well, is this a real symptom or is this in their head? Well, of course it’s both because it’s, as I often have told my patients, the brain bone is attached to the body bone. And so the term psychosomatic illness always seemed kind of ridiculous to me as if you could separate them.

So where does literature come in? I think what literature does, in my experience of this, and I’ve been running reading and writing groups for healthcare workers and coaching healthcare who want to write and doing some writing with patients too for many years now, is that it opens up our understanding of how complicated the experiences of illness and healing are, how much uncertainty there is at times, how much beauty there is. And also breaks down the barriers between sick and well, doctor and patient. Doctors especially, and I talk about this a lot in the book, one of the sort of self-protective things that we do is we convince ourselves and we’re encouraged to do so, I think early on in medical school to think that we’re not quite the same species as our patients are. In fact, a lot of people go into medicine with the idea that, well, if I’m on that side of the desk, on that side of the hospital bed, if I’m operating and not being operated on, then I’ll live forever and I’ll be invulnerable. Well, of course we know that doesn’t work. The doctor is every bit as human and vulnerable as the patient. And what I find when I, for example, read poetry with a group of healthcare workers is the poem provides a safe space to acknowledge our own humanity. And in acknowledging our own humanity, we’re more open to embracing the patient’s humanity.

Yeah, it makes so much sense. And you even give a specific example in your book Letter to a Young Female Physician where you got feedback from a doctor and she shared what she had read and gone over with. You ended up changing her patient interaction after that, and that she thinks it totally reshaped how she interacted with that patient based on that. And so I think this has very, or can have very concrete effects in terms of that level of empathy, that level of kindness, like you’re saying, can we train for kindness? Well, in some cases it is through the humanities that we develop some of that emotional intelligence and some of that comes through, shines through in some of the words.

Well, here’s sort of, I think a simple but effective way of thinking about this. We know in our own lives that the more we know about somebody’s story, the harder it is to dehumanize them, to demonize them, to label them. Here’s an example I often use. If you’re driving down the highway and there’s some old geezer in front of you who’s driving too slow and they’ve got their blinker on and they’re not turning and you’re rolling your eyes and you’re aggravated and you’re thinking, oh, typical old person driving shouldn’t be on the road. And then you pass them and you realize you know that person that that’s your neighbor who just lost his wife, who mows your lawn when you’re not home, when you’re away on vacation, I mean all of a sudden all of these things, you think about them on a superficial level change and you’re not angry at them anymore. You can’t be angry at them because you know them. The cliche is familiarity breeds contempt. I don’t think familiarity breeds contempt. I think familiarity breeds compassion. So what happened in the case that you’re referring to, it was actually a nurse practitioner and we were reading a novel in which a central theme was shame.

And we just got into a deep conversation about shame and how ubiquitous it is and how often patients feel ashamed and family members feel ashamed because after all, to have a part of your body that’s disabled or disfigured or not working, there is a visceral sense of shame that’s associated with that. If you are a parent, and I have been in this position, if you are a parent whose child is ill or injured, even though it’s in no way your fault, there is some sort of primitive feeling of shame about that. You had a job, your job was to protect this person you love and you failed. Or as an individual, you had a job which is to survive. And here you are and your survival is threatened. It’s not your fault, but there’s this feeling of shame about it. I can’t tell you the number of patients over the years who came to see me and apologized, apologized for being ill, apologized for being injured, apologized for wasting my time. And what I would always reply is, well, what do you think I’m for? But I understand that shame. So anyway, we had been talking about shame, and she wrote me the next day and she said, I realized that there was, I had seen a patient who had a kind of embarrassing symptom and she was making a big fuss over it, and I didn’t really think the fuss was warranted. And then I thought, oh, wait a minute, shame. She’s ashamed. That’s what the story is. That’s that sort of moment of passing the car and saying, oh, wait a minute, I know that person. I know that person. I see that person. And that is a very powerful moment. And here’s the secret is that it’s not only good for the patient it, it’s good for the practitioner as well. That moment of seeing and being seen is deeply satisfying, I think for both parties. It’s not just, well, I made I’m happy, but it costs me a lot of time. No, it’s deeply satisfying.

And I think you also see, because having worked with so many patients in the hospital over the last 20 years, a lot of times it is like the arts, the humanities, literature, poetry that gets the patient themselves through tough experiences. Because when you’re faced with an existential crisis, what do you turn to? And I also found very interesting, just to kind of illustrate that point, I have a friend whose family member is a Navy Seal, and he made it all the way through, which is incredibly challenging and difficult to accomplish. And this came up, he said, interestingly in his cohort that people who were the sort of, he was an English major, and he said it was the people that were in the humanities that made it through, and those in the sciences and engineering didn’t. And he could totally see that there was a distinction based on that, and it was very clear. And so immediately of course, I started to ponder and question, well, why is that? Why would that be?

And one of the things that I think he recognized was that when you get into those gut-wrenching soul level moments, what do you turn to you in a way? You turn to the arts, you turn to wait, what is this all even about? And so there is in literature and writing that’s humanizing, that is illuminating, that helps us to cope with some of the hardest things that we face that you kind of can’t understand just through numbers, math, science, not that we don’t love all those tools. I do love all those tools, but we sometimes need something else to get through it.

Yeah, I mean, one of the first times I thought about that was right after nine 11 where here in Boston, and one of the things that happened was that the museums opened their doors and allowed people in for free, that that was one of the responses. And similarly, artists, musicians were sort of reaching out and wanting to offer their art. Personally. I had that experience in March of 2020 when the Covid Pandemic started. What happened for me was that I was practicing primary care and I was also doing the other work I have at the hospital in humanities reading and writing groups and so forth. And I thought, well, I think we’re going to probably end up putting the humanities stuff on hold because after all, we’re kind of in the middle of a crisis here. And I don’t think anybody’s very interested in poetry right now or writing essays.

And I could not have been more wrong within a week of a lockdown. I had more manuscripts sent to me than I had ever had in a single week. We had groups going on Zoom throughout the first phase of the pandemic. I ran a poetry workshop on Saturday afternoons on Zoom for residents, many of whom were signing in from the hospital in full protective gear to read poems and write reflections about poems. So I should have known better, I should have known that would be the reaction, but so why is that happening? I think one of the reasons is that is that the arts and particularly reading and writing involving language are just incredibly effective ways for us to connect with each other. And I think one of the reasons why there’s medical humanities and not so much legal humanities or engineering humanities is that I think a lot of people in medicine, and I include patients in that have the sense that something is missing, something is being left out of those 15 minute interactions and those two minute bedside hospital visits that the prescriptions and the test results and all of that stuff, that’s all important, but that something is being left out and it’s gotten crowded out for all the reasons that we’ve been talking about.

Some of them, not bad reasons. I mean, the advancements of science is not a bad thing, and the electronic medical record isn’t an entirely bad thing. And digitization and even corporatization isn’t necessarily an entirely bad thing. But what’s gotten crowded out is the leisure to let the story unfold. And unfortunately, or it’s just the reality is that letting the story unfold is one of the most powerful therapeutic tools we have. And a story I tell in the book, which it’s worth repeating here, is that a colleague of mine for many years has run an orientation program for incoming medical students. And one of the exercises that she does is she sends them over to the hospital in they’re brand new white coats, and she assigns them a patient who’s agreed to speak with them, and they’re allowed to ask the patient anything they want, but there’s one question they have to ask.

And the question is, what advice would you give me as I embark on my career? And she’s been doing this for decades now, my colleague and she told me that virtually a hundred percent of the time the patient says some version of, I want you to listen to me. And what’s so funny about that is that the medical student, the brand new medical student, they’re probably thinking, oh, listening. I mean, that’s nothing. Everybody knows how to do that. What I’m worried about is I won’t be able to memorize all the facts, and I won’t know how to tie a nod in the operating room, and I’ll end up killing somebody because I won’t know enough stuff. And the patient is saying, I’m confident you’ll know enough stuff. I’m not so confident you’re going to listen. And it’s not just like mushy, squishy, feel good kind of stuff. The listening has a very, very powerful effect on that clinician’s ability to heal and on that patient’s healing.

Given the experiences that you’ve had in medicine overall of these years, Suzanne, how have you come to define what it means to heal, what healing is? How would you, in your own words, frame that

I’ve been thinking about this a lot lately because about a year ago, I had a pretty severe injury. I found myself writing about it recently, and what I wrote, Joan Didion said, I write to find out what I think, think she was right about that. This isn’t a thought I had until I went to write it. I wrote, I haven’t been cured, but I’ve been healed, meaning by various objective measures. I didn’t have a hundred percent restoration of function after my injury, which was a bad wrist fracture, but I feel healed. And I think what that means for me, and of course I can’t help but think of it, I can’t help but think of it in narrative terms, just the way I think is that for me, the story came to a kind of completion. I didn’t have a complete restoration of function. It’s not all better, but the story came to a sense of completion and I feel whole again. So by that standard, it’s possible that you can be dying and be healed, right? It’s possible that you can have a poor response to therapy and still be healed, which is why it’s so important that clinicians understand that when there is nothing left to offer, that there’s always something left to offer, can always heal even when we can’t cure or we can try to heal.

Absolutely. I could not agree with that more. And in some ways that’s kind of, to me, because I work or have worked a lot at end of life and with a lot of too that are in a process of dying, but also with adults, it’s amazing how sometimes it’s actually once nothing else can be done in terms of that curing perspective, that a whole other door opens up for healing that, especially with children, because there’s such a fight, fight, fight mentality for so long, because just the idea of the loss of a child is so hard for everyone to begin to even internalize that it often looks like a battle for a very long time until sometimes pretty close to the very end when there’s a moment of surrender and acceptance. And from that point forward is often when a lot of healing happens because there’s finally a portal to, okay, well then what more? What else is possible if the physical self cannot be cured? And so then it becomes often more about the family, the relationships, some of those really essential elements that arise for all of us if we have that privilege of a little window before we die, where we know we’re dying and we get to talk to others. And so a lot of the more heart-centered relational conversations can flourish, can happen once there’s that little transitional period between curing and then what’s left, which is healing in the face of dying, sometimes.

The word that comes to my mind in this context is integrity, not in terms of we talk of somebody having integrity if they’re honest or ethical, but in the other sense of it as in integral, as in a kind of wholeness that you are different than you were before you had the illness, for example, or the injury. But your whole, one of my favorite medical writers, late Oliver Sachs, a neurologist, is a wonderful quote about this. He was in an accident when he was in his forties. He was hiking a terrible leg injury. And when he thanked his surgeon, the surgeon said, well, you were disconnected and we reconnected you. And Sachs says, more needed to be reconnected connected than the muscles and the tendons, the spirit, the soul. Everything needed to be reconnected. And I think that my feeling about literature and bringing literature in the hospital is it reminds us of that other kind of reconnection, that other way in which we can make people whole, even when we can’t actually reconnect parts or make their parts healthy again.

Right. Well said. I so appreciate your taking the time to have this conversation, and I just always like to give a little pause at the end if there’s anything else that feels important for you to share that we didn’t get a chance to bring into our dialogue today.

I think we covered an awful lot of ground. I guess the main thing thing I would want to just reiterate is to remind both patients and caregivers that we’re on the same side and that these are very challenging times in healthcare in this country and in other countries. And that sometimes just kind of reminding ourselves that in that exam room at that hospital bedside that we’re two people, trying to do the best we can in a very challenging setting is worth remembering. And I feel like literature at poetry especially gets to the heart of what makes us human. That’s why we call it humanities, and reminds us that amid all of this noise, the interaction is very pure and can also be very beautiful.

It certainly can. You just reminded me of something, and it was so simple, but so beautiful. When my uncle was dying in the hospital some years ago, his oncologist, because he also had cancer diagnosis at that time, who he’d known for a period of time came in and connected with him knowing it would be the last time that he would see him. And they connected. They had a brief conversation, and as the oncologist walked out of the room he was crying, and I saw that my other family members saw that. And I remember being so touched by the humanity of that interaction. Two people who knew one another who’d gone through an experience together who cared for one another, and there was just real love, affection, connection, emotion, just happening from one human being to another. And it was beautiful and moving. And here he was. This was a doctor who’d probably been in the profession for at least 40 years, and yet his heart was open still after probably having seen thousands of patients.

Here was one, one that was dying on that day and he cared. And it’s remarkable how as you said, and I wholeheartedly agree because I’ve seen it, most people today that go into medicine, it’s because they want to help, right? There are things that you could do to make as much or more money that would be a heck of a lot easier. And I have witnessed many times that most people, they just do want to help and make a difference. And when you see that happening in real time, it’s really something quite remarkable to witness.

Yeah, I retired from my clinical practice a year ago, and I stayed on in the hospital in my teaching role, and one of the things I thought was, because I was in practice for over 30 years, I thought, well, gosh, what was that even all about? It kind of in some ways, it was really long time. In some ways, it went by in a blink of an eye, and it was my patients who told me what it was all about because I got a lot of notes and messages, and what they didn’t say was, oh, you remember that time that you made that smart diagnosis? Or You remember that time you gave me that drug that just knocked my infection right out? Though those things over 30 some odd years, those did happen. But they said things like, you remember that time I told you something that I had never told anybody before?

Remember when I was in the hospital and you came and visited me? And similarly, because I’m not perfect, I got a couple of comments about, gee, there was that time where I thought you weren’t as sympathetic as I wanted you to be, or maybe you were a little judgmental about a decision I made, but the people who were negative and there weren’t too many, but the people who were negative didn’t say things like, oh, you remember when you made that mistake? So this is really in a way, kind of an extension of what I was saying about the medical student orientation exercise. So what they were telling me was that what was important was connection and what it had been all about really was love. Now, I always feel I need to amend that statement by saying it’s not just about love. It’s not just about kindness. It’s not just about connection. Because if that were the case, then we wouldn’t need medical training. But it can’t only be the science. It has to be the kindness too.

Well, thank you so much for having this beautiful conversation on healing with me, and I really appreciate it very much.

It’s my pleasure, Shay.

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