The Importance of Caring in Caregiving: An Interview with Sandeep Jauhar
INTERVIEW BY HART FOGEL
It is no secret that the field of medicine has undergone a number of profound changes in the recent past both for better and worse. As procedures and technologies have become increasingly advanced and medicine has continued to become more commercialized, the human aspect of healthcare has often been overlooked. Dr. Sandeep Jauhar, a cardiologist (who also has a PhD in physics) and the director of the Heart Failure Program at the Long Island Jewish Medical Center, has written extensively about the challenges faced by contemporary caregivers and why it is vital to put people first in the process of providing care. He is an op-ed contributor for the New York Times and has written two books: Intern: A Doctor’s Initiation (2007) and Doctored: The Disillusionment of an American Physician (2014). His third book, Heart: A History, is scheduled to be published later this year.
Senior Editor Hart Fogel recently interviewed Dr. Jauhar by telephone to gain insight into his perspectives on a number of issues involving caregiving and the training of health professionals.
Hart Fogel (HF): Obviously, the heart is your specialty considering that you are a cardiologist, but you have also written extensively about heart in a more figurative sense -- namely that physicians need to have heart when interacting with their patients. In a July 2017 op-ed for the New York Times, you discuss "empathy gadgets," devices that help healthcare professionals gain a more visceral understanding of conditions like Parkinson's Disease by simulating symptoms. Why is promoting doctor-patient empathy important, and how can we better train healthcare professionals to develop connections with those whom they care for?
Sandeep Jauhar (SJ): Most of the complaints that patients have about the healthcare system center on the doctor-patient divide and feeling misunderstood by their physicians. Even complaints about the time that a physician spends are mostly focused on how a lack of time is an impediment to understanding the patients and where they’re coming from. A lack of understanding by their healthcare providers is probably the most widely voiced complaint in the healthcare system today.
In the [New York Times] piece I talked about a patient of mine who had developed end stage kidney failure. He had been started on dialysis and he had been told that dialysis might potentially be temporary. He’d asked his physician, “How long do you think I’ll be on dialysis?” The physician clearly didn’t even know how long he’d been on dialysis. He wasn’t really invested in his care. The physician responded with a flip remark like “How long have you been on dialysis?” and the patient said, “Oh, a few days.” And the physician said, “Well, I think you’re going to be on it permanently. I don’t see you coming off of it.”
The way the patient relayed the conversation later [was that] the way the physician responded was almost as grievous and injurious to the patient as the fact that he was going to require hemodialysis for the rest of his life. He wanted to feel that his physician cared. There is plenty of evidence to show that when patients feel understood, and they feel that their physicians care, their outcomes, their relationships with their physicians, their relationships with their other healthcare providers, their compliance with care – all of that improves.
Promoting empathy is critically important to delivering good care and getting patients to buy in and adhere to medical advice. What I was fascinated by with this SymPulse device was that it specifically reproduced symptoms that I had thought about for so long because my mother had Parkinson’s disease. She died with Parkinson’s disease and I had always wondered what [it was] that she [was] experiencing. Even though she didn’t have a lot of tremors, she had a lot of the characteristic Parkinsonian symptoms of bradykinesia (slowing of the movements). When I experienced this device, it was moving for me to at least get a glimpse of what my mother had been going through and the fact that she had a disease that she couldn’t just turn off like I was able to turn off that device. It’s experiences like that that I think really help caregivers build understanding and empathy for the people they’re caring for.
HF:In addition to empathy, are there other often overlooked qualities that we should be encouraging in healthcare professionals?
SJ: There are so many. Healthcare professionals – doctors, nurses – they have one thing in spades. They’re by and large very committed, detail-oriented people who work very, very hard, are very motivated and, generally speaking, provide excellent care in a system that many consider broken.
There are some things that I think all healthcare professionals could improve. One thing is cost-consciousness. When we order tests, are we thinking about how much they cost? Do we order labs on a Friday for the entire weekend, and if so, why? Why are we checking blood counts that have been stable? Why are we checking them every day? There’s a bit of that but by and large, I think that doctors and nurses do a very good job in a very, very tough profession.
HF: You’ve written extensively about how tough the profession is and how challenging the experience of going through a medical internship and residency -- as well as practicing medicine -- can be. Could you talk a little bit more broadly about this topic? In your opinion, what are some of the primary issues with the current system of medical education?
SJ: If you look at the way the system evolved, most people would agree that there was an implicit contract between young doctors and hospitals; which is, we’ll provide you patients to learn on and you provide us cheap labor to keep our institutions running. In the past, what young doctors were providing hospitals, say a hundred years ago, was very different than what young doctors are providing hospitals today. A hundred years ago, there [were] a lot of manual chores – drawing blood, transporting patients, stuff that most hospitals today have other personnel doing. Today, the exploitation, if you will, is really focused more on maintaining hospital volume – getting patients in and out the door to generate a hospital profit. That is not necessarily in the educational interests of interns, but it’s something that they have to do. So that is a big part of what young doctors have to contend with today.
Now, the density of work has increased even as the number of hours has actually decreased. When interns are working they may work fewer hours in the week, but when they’re working, they’re really on. They’re working non-stop. I think that can lead to burnout. The solution historically has been [to] cut the number of hours, but that has its own problems. Increasing numbers of shifts means increasing handoffs, and decreased hours means less experience…that would enable you to be a competent physician.
There are a lot of tradeoffs at play. No one is arguing for keeping interns in the hospital for 100 hours a week like I had to do when I was training in New York. In my CCU [Coronary Care Unit] and ICU [Intensive Care Unit] rotations I was on in the CCU every third night and it was horribly fatiguing. I think the situation was unhealthy for me, but also for my patients.
No one’s arguing for that, but I think that enforced work hour limits have gotten a little bit excessive to the point where there’s no flexibility left. If interns want to stay in the hospital to attend a conference, for example, after a work shift…they should be allowed to do so. We have to individualize the training process -- obviously not to the point where things become excessive and interns are staying too long for their own health as well as for the proper care of the patients. But the individual has a better sense of what they can do than the ACGME [Accreditation Council for Graduate Medical Education]. Blanket regulations are not in the interest of medical education. I would argue for more flexibility in the training of young doctors and probably different pathways within residency – and even in medical schools -- so that the people who are committed to primary care may not need to have the same research requirements as people who are going to go into sub-specialty training or go to the lab.
I think that we need to individualize the curriculum more as we go forward. That’s going to be the best and safest way to get competent doctors in the future.
HF: So you envision a solution starting on a more individual scale rather than with sweeping systemic changes and regulations?
SJ: I think that regulations are very blunt instruments and they have their own costs associated with them, not least of which, with work hour regulations, is the fostering of an almost shift-work mentality among young physicians which I don’t think is compatible with the kind of doctoring we want as patients.
HF: Changing gears a bit, another topic that you’ve covered frequently in your writing – and you mentioned it earlier in the interview – is the commercialization of healthcare and all the various challenges that this trend brings along with it. You talked about some ways that people working in healthcare can address these challenges. What can also be done on the parts of people in the general public to help with this issue?
SJ: I think patients need to advocate for themselves. They need to be better educated about medical procedures – what works and what doesn’t. We need to involve the patient more. [Cardiologist] Eric Topol in his last book [The Patient Will See You Now (2015)] said – he may have been quoting someone, but there was a line in his last book that said – “the patient is the most underused player in healthcare.”
There’s a lot of truth to that. We need to inform patients that there are certain procedures that are going to have very little benefit even though they may be lucrative for hospitals and doctors. Most surgery for lower back pain is not going to be helpful. Doing routine stress testing in someone with coronary artery disease in the absence of symptoms is not necessarily beneficial. Stress testing plays a big role in my second book, Doctored, and unnecessary testing [also] plays a very big role in that book, both echocardiography as well as nuclear stress testing.
I think that we need to inform patients. The ABIM [American Board of Internal Medicine] has created lists of procedures that don’t benefit patients. It isn’t just doctors who should get those lists; it’s [also] patients so they can better advocate for themselves.
We need to move away from a mentality of “doctor knows best” because doctors are buffeted by many different forces, some of them more positive and some of them negative. There are financial motivations. There is care that’s delivered through habit or through local cultural practices that have very little evidence behind them. I think you need patients to get into the mix and advocate for themselves and not always just do what the doctor ordered.
HF: What prompted you to begin writing about your experience in and perspective on medicine? Has the process of putting your thoughts on paper been illuminating or changed the way you view your profession?
SJ: Absolutely. I’ve always been interested in writing from an early age. I grew up in a family where my parents were both scientists. [My father’s] favorite saying to me growing up was “non-science is nonsense.” He was very scientifically minded. I was always interested in writing but it never seemed like an option as a career.
I gravitated toward science but was always interested in writing, and medicine provided such wonderful opportunities to reflect on my experiences, to better understand human behavior and impulses, and to use that understanding in my writing. Of course, there’s a long tradition of writing in medicine, from Somerset Maugham to [Anton] Chekhov to Oliver Sacks, so this was something that was also very attractive to me as someone who was very interested in eventually writing about his experiences. Before I went to medical school I actually worked at Time magazine, and that sort of whetted my appetite for writing. Then when I started my internship, I was offered an opportunity to write for the New York Times for a column called Cares, which is in the Health section, and I started doing that back in 1998. I wrote several pieces just during internship and then during residency things ramped up, and by the time I was done, I was writing about eight to 10 pieces a year. Then the offers came to write books and so on. It all started with an interest in writing about my experiences and thinking about [them].
I was always attracted to situations or experiences that bothered me. That was my gauge for what I should write about. For example, when I was an intern, there was a patient who was always aspirating when he would swallow. He would swallow through his lungs. They were getting ready to put a feeding tube into this guy, and the thing is that he didn’t want a feeding tube. He actually wanted to taste food because eating was one of the great pleasures of his life. I remember thinking: why are we doing this to this poor guy who doesn’t want a feeding tube? He was asked, “Do you want to die of pneumonia?” and he would say, “I don’t care. I just want to eat food. I don’t want to be fed through a tube.” The fact that he was making what we thought was a bad decision seemed to render him incompetent or give him a lack of capacity in decision-making for some of my colleagues. This is one example of something that bothered me, that I thought about and then eventually wanted to write about to sift through what it was about the experience that was bothering me.
I’ve found that in writing about medicine, I’ve been able to reflect on experiences and think about them and come to some sort of deeper understanding – a more subtle understanding – of the issues at play when I actually put my experience down on paper and think about things that way.
HF: Speaking of writing, you have been working on a book chronicling the history of the human heart that is set to be published later this year. You have studied it throughout your career, but what is it about the heart that has captured your imagination? Has anything in particular that you’ve researched or reflected on in the course of composing your book surprised you?
SJ: There are many things about the heart that are absolutely fascinating. There’s probably no other object in the human experience that is so imbued with meaning as the human heart. Not only was it thought to [contain] the soul, it was the locus of emotions, the source of courage, of love…the source of life. People still equate life with a beating heart. Even when patients are brain dead, but whose hearts are beating, families still ask: “His heart’s beating, how can he be dead?” We think of the heart as such a central player in the human experience, the religious experience, the spiritual and, of course, the medical experience.
Also, the story of the development of cardiovascular medicine is absolutely fascinating for me. As of the late 19th century, every organ in the human body had been operated on except the heart. The brain had been operated on, but the heart was considered beyond treatment for many reasons. It beats. It moves. You can’t stop it. It’s filled with blood. You cut it open and you bleed to death. There were so many challenges that [had] to be overcome to develop the kinds of therapies that we have today.
These are all reasons why I was attracted to it. What I’ve found through the course of my work both as a cardiologist and as a writer is that there is a real intersection between the metaphorical heart that you mentioned – the source of emotions – and the biological heart. In other words, our emotional lives have such a profound impact on our heart health. I think that that piece of medicine is going to become more and more important as some of the technological advances start to cap in terms of their effectiveness.
We’re going to make the kinds of advances [we’ve been] used to making over the last 50 or 60 years where the mortality from heart disease has dropped significantly. It’s still the number one killer in the world. It’s still the number one killer in America. But there’s been a dramatic drop, so we know that our treatments work. But in making those advances I think we need to pay a lot more attention to our emotional lives, and that’s a central theme of the book.
HF: What is one piece of advice you would give to students who are planning to pursue careers in medicine or other health-related fields?
SJ: Don’t be dissuaded by all the negative talk. Ultimately a career is a very personal decision and it involves much more than the environment in which you’ll be practicing. It should speak to your heart, your interests, your skills, your predilections.I always find it sad when students I know really want to be doctors but then they go and shadow a doctor – maybe a community physician who is overworked [and] feels like he’s underpaid – and he discourages them from going into medicine.
Medicine has so many different pathways that it can accommodate virtually any set of interests. I know doctors who were architects in previous lives, physicists, lawyers, economists, policy wonks, English majors…There are so many different domains within medicine, niches that will accommodate the whole variety of interests. You can see patients. If you don’t want to see patients, you can go into pathology or radiology. There’s an increasing need for people with a background in healthcare economics and health policy.
My advice is just to follow your interests. Be introspective. Think about what it is you really want. I’m optimistic about medicine and I’ve encouraged my own kids to become doctors if that’s what they want to do – my second book, Doctored, with the subtitle, The Disillusionment of an American Physician, notwithstanding. That book was written at a different time in my career path. I think we still work in a wonderful profession that has ample rewards both emotional as well as financial.
I really think we’re lucky to be in this field.