EP. 45: THE PAIN OF OTHERS

WITH HAIDER WARRAICH, MD

A cardiologist discusses how modern medicine neglects the psychosocial dimensions of pain and how we can better make sense of suffering.

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Episode Summary

Storytelling, pain, rage, and cultural competency are just some of the themes we will explore in this episode. Our guest, Dr. Haider Warraich, grew up and went to medical school in Pakistan before completing residency at Harvard Medical School and fellowship in cardiovascular medicine at Duke University Medical Center. Today, he is an assistant professor at Harvard Medical School and the associate director of the Heart Failure Program at the VA Boston Health Care System. A prolific writer, he contributes regularly to the New York Times, Washington Post, and others. He is the author of three books on medicine for the general audience, most recently 2022’s The Song of Our Scars: The Untold Story of Pain, which examines the nature of pain not only as a physical, but also a historical and cultural experience. Over the course of our conversation, Dr. Warraich compares his medical experiences in Pakistan and in the US, discusses why he strives to incorporate palliative care into his cardiology work, and offers an impassioned critique of how modern medicine fails to address patients' suffering.

• GUEST BIO

  As a physician, writer, and clinical researcher, Dr. Haider Warraich wears many hats. He writes frequently for the New York Times and the Washington Post, and has also written for the the Atlantic, Wall Street Journal, LA Times, Guardian, Vox, Slate, Boston Globe and Stat News. He has more than 120 peer reviewed research papers including mutliple papers in the New England Journal of Medicine and the Journal of the American Medical Association. 

  Dr Warraich completed internal medicine and cardiology training at Harvard Medical School and Duke University and is the Associate Director of Heart Failure at the VA Boston Healthcare System, Associate Physician at Brigham and Women's Hospital and Assistant Professor at Harvard Medical School. He has appeared on CNN, Fox, CBS, PBS, and on NPR shows like Fresh Air with Terry Gross, The Diane Rehm Show, The World, Marketplace and the BBC World Service. His research focuses on end of life care, heart disease, disparities and inequities in medical care, health care costs and policy. 

• HIGHLIGHTS/RECAP

  In this episode, you will hear about: 

  • How Dr. Warraich went from thinking of his medical training as an “arranged marriage” to loving the career - 2:10

  • How Dr. Warraich stays connected to his patients and his work despite the intense pressure and responsibility he experiences on a daily basis - 7:03

  • What drew Dr. Warraich to cardiology and end-of-life care - 13:22

  • Dr. Warraich’s reflections on the gaps in the care of patients with heart disease and how he now strives to reform the practice of cardiology - 17:33

  • A discussion of how the medical culture of Pakistan differs from the United States and how they can be shockingly similar - 22:06

  • How Tom Brady, the football quarterback, inspires Dr. Warraich to stay connected to the emotional core of his practice - 28:49

  • Why it’s important to stay in a field if you care about it, especially if you hope to change and improve it - 35:37

  • Dr. Warraich’s reflections on the nature of pain and how he hopes to change our cultural conversation around it - 41:38

• EPISODE TRANSCRIPTION

  Henry Bair: [00:00:01] Hi, I'm Henry Bair.

  Tyler Johnson: [00:00:03] And I'm Tyler Johnson.

  Henry Bair: [00:00:04] And you're listening to The Doctor's Art, a podcast that explores meaning in medicine. Throughout our medical training and career, we have pondered what makes medicine meaningful. Can a stronger understanding of its meaning create better doctors? How can we build health care institutions that nurture the doctor-patient connection? What can we learn about the human condition from accompanying our patients in times of suffering?

  Tyler Johnson: [00:00:27] In seeking answers to these questions, we meet with deep thinkers working across health care, from doctors and nurses to patients and health care executives; those who have collected a career's worth of hard earned wisdom probing the moral heart that beats at the heart of Medicine. We will hear stories that are by turns heartbreaking, amusing, inspiring, challenging and enlightening. We welcome anyone curious about why doctors do what they do. Join us as we think out loud about what illness and healing can teach us about some of life's biggest questions.

  Henry Bair: [00:01:02] Storytelling, palliative care, pain, rage, and cultural competency are just some of the issues we will explore in this episode. Our guest today, Dr. Haider Warraich, grew up and went to medical school in Pakistan before completing residency at Harvard Medical School and fellowship in cardiovascular medicine at Duke University Medical Center. Today, he is an assistant professor at Harvard Medical School and the associate director of the Heart Failure Program at the VA Boston Health Care System. A prolific writer, he contributes regularly to the New York Times, Washington Post and others. And as the author of three books on medicine for the general audience, most recently 2022 "The Song of Our Scars The Untold Story of Pain," which examines the nature of pain not only as a physical, but also a historical and cultural experience. Over the course of our conversation, Dr. Warraich compares his striking medical experiences in Pakistan and in the US, discusses why he strives to incorporate palliative care into his cardiology work, and offers an impassioned critique of how modern medicine fails to address patients' suffering. Haider, Thank you so much for being here and welcome to the show.

  Haider Warraich: [00:02:16] It's great to be here speaking to you all.

  Henry Bair: [00:02:19] You've written so much about death, dying, heart failure, and pain. So there's a lot there that we can explore. But first, can you tell us what initially drew you to a career in medicine?

  Haider Warraich: [00:02:31] When I was growing up, I was pretty undifferentiated, and if I had to pick, I was probably a a writer and a storyteller before I kind of knew what I wanted to do with my life. I somehow ended up in medical school almost by accident, if you believe that. When I finished college, I had applied for medical school, dental school and engineering school. And in the end, I ended up picking medical school not because of any fancy inspired reason other than the fact that that college is probably the best institution for an education in Pakistan. And it would keep me closer to my friends as well. So, you know, I ended up in medical school with very poor reasons, and it really held me back in a pretty significant way because, you know, medical school is no joke. Unless you're inspired, unless you have a purpose, it can really be a pretty daunting place. And so my first few years in medical school were really a struggle from from an academic perspective, even though my writing was really flourishing and I was able to really see life and my environment in a way that I hadn't done before. But the medical school experience itself was really, really hard until I began to find the reason, until I, you know, almost like a like an arranged marriage. I began to sort of pay a lot more attention to medicine than I had in the past. And it was only when I got past some of the superficial nature of what we do as physicians and as clinicians that I really fell in love with medicine. But it wasn't something that was pre-planned. It was almost by accident, but something that I am very lucky to have experienced now.

  Tyler Johnson: [00:04:15] That's a very interesting metaphor, that it was an arranged marriage for you. But once you discovered a reason to love medicine, what was it that you discovered?

  Haider Warraich: [00:04:26] I think it was for me, the most fascinating piece about medicine has always been that any random day in our lives is probably one of the most important days in the lives of our patients, and that we kind of get dropped into these really important situations for patients where they're oftentimes scared, oftentimes unsure, oftentimes just confused about what's going on. And they look to us for guidance. They look to us for not just technical guidance, but really moral guidance and ethical guidance. And that, to me, is something that still never gets old. And to me, as someone who was always interested in exploring spaces or exploring people or exploring new worlds, medicine is an opportunity to explore a new world every time you meet a new person, and the responsibility that is placed on us, no matter what our specialty is or no matter what you're doing, is just so immense, but also very rewarding. And I think it is because of those interactions that I have with patients that really brought me in and pulled me in into medicine and then keeps me glued to this day.

  Tyler Johnson: [00:05:47] Before we get to some of the other bigger topics that Henry was mentioning a minute ago, I remember having a light bulb moment when I was in college in a physics class, and I learned that the reason that a pin can puncture something is not because of the amount of force that's applied with the pin usually, but rather because all of that force is applied to a single point. Right. There's this very narrow contact point and then you can apply not that much force and it will still puncture something because all of the force goes concentrated to that one contact point. I think about that sometimes in medicine, because as you correctly, I think point out, when patients see us, oftentimes whatever they're seeing us for is like that pin point, right? Where they have this enormous amount of emotional energy, Sometimes literally their life is hanging in the balance or their limb or they're not having a disability or a life changing diagnosis. Whatever it is, it concentrates an enormous amount of moral and emotional and psychological force onto this encounter with a doctor or health care professional that may last for 5 minutes, 10 minutes, 30, 60, depending on the encounter.

  Tyler Johnson: [00:07:03] But but all of that is to say that on the one hand, as you correctly point out, that's what part of what makes medicine so meaningful, right, is that we are there to help them through this and to be a witness to whatever it is that that passes over them in this time. But by the same token, it is also true that it's a lot to be on the receiving end, in a sense, of these pinpricks day after day after day after day. Right. It's just it's a it's a heavy emotional burden. And it's no wonder in some ways that if we're not careful, you can get burned out because, in effect, you're getting punctured over and over and over and over again. And so I guess I'm curious from a practical perspective, as you make your way through a medical practice day in and day out, how do you keep yourself in a headspace, in a space where all of that remains, I don't want to say exciting but, meaningful and keeps you curious rather than just feeling burned out and apathetic?

  Haider Warraich: [00:08:10] You know, I do agree it can be a lot to take in and the responsibility can feel overwhelming. But what I tell myself and what I tell others is that I always try and focus on the process. You know, the outcome isn't always in our control. I mean, it starts with something quite as basic as when you're performing CPR. I mean, you cannot actually control if the person you are performing CPR on is going to live or die. But what you can control is how deep are your compressions or are you doing it at the right rate or are you thinking about all the sort of different differentials or diagnoses that could be at play? And that's that's what I focus on. That's what I work on. And I feel like if I can get that right and again right doesn't mean perfect, then then I can then I can feel like I played my part. I lived up to my responsibility. But I think the moment we start to tie ourselves to outcomes, I think that's when we start to get into trouble. And in my mind, the folks who get burnt out in medicine are also the folks that we need to take the most care of, because oftentimes they're the ones who are the most empathetic, the most detail oriented, the ones who have a difficult time getting over errors or forgiving themselves. And so I think just as a as a profession, but also as individuals, I really think that we need to take care of each other and especially those who are likely to feel the weight of what we do more than others. And in some ways, when I see that it does give me it is something important because we need I feel like we all need to realize that what we do is special. But that it also does come with special responsibility. But the way that I've gone through life and my life as a physician is by focusing on what I can control and then taking whatever remains I can get along the way.

  Tyler Johnson: [00:10:17] That especially resonates with me because I know as a young trainee, like you mentioned, the process of dissociating yourself and the work you're doing as a physician from the outcomes that come from your work. But I know that as an early physician especially, and still sometimes that's really hard, right? Like, I know that the first number of patients that I had die in the hospital, which as I take care of advanced cancer patients, that happens with a sad frequency. It was almost impossible for me to not feel like it was my fault, to feel like if I had done something better, if I had caught something earlier, if I had given a different combination of antibiotics at a different time or whatever it was that I and even though I knew the person was really sick and whatever, that I could have made things turn out differently if I had just been a better doctor. And obviously there's an appropriate way to reexamine your steps and to make sure that there wasn't something that you missed. That's part of that kind of self evaluation is part of being a doctor. But but everyone is going to die. And some patients with advanced, whether it's advanced heart failure or advanced cancer or whatever, that is going to happen sometimes. And I think that learning that acceptance piece is difficult. But I agree with you really, really important.

  Haider Warraich: [00:11:34] So in some ways it's sort of like when you first have to give pass off and you have to sign out your patients to the night resident. And it can be hard at times because you feel like you've been with the patient through time. Oftentimes it happens when you've been through a difficult time together and it can be difficult to just say, okay, now I'm going to go home. And now, you know, the sort of the night team is responsible. And I remember when I first had to do that, it didn't it just didn't feel right. And, you know, but over time, you know, the way I think about medicine is that you really have to take a very long view of the profession. You can expend all your energy right at the beginning. I mean, you have to I mean, for me, I mean, I think if medicine is a profession and I see myself doing this late into my life. And in some ways you do have to pace yourself. In some ways you do have to. Part of what allows has allowed me and others to have done that is that as much as it's really important to be all in when you're on, but it's also really important to disconnect. And again, I think finding what is what is going to help you through that- is it going to be your relationships? You know, is it going to be a hobby? What is that thing outside of medicine that's going to help you sort of even things out, whether writing or reading is that thing? For some people it's research and it can be it can be a whole lot of different things. And I think that's part of what what all of us have to figure out if you're going to have- if you're going to be able to do what we do for a long period of time.

  Henry Bair: [00:13:22] Yeah, absolutely. Thanks for offering your perspective on that. Haider. So going back to a personal level, back to your path. So as a happy accident, you find your way to medicine and then you eventually find your reason, your meaning in this career, in all the, all the deep patient relationships that you get to form. I'm wondering what in particular drew you to cardiology and not just cardiology, but also this this interest that you've you've had and explored in end of life care and palliative care?

  Haider Warraich: [00:14:01] I mean, for me, going through medical school and then residency was hard because there was so much of medicine that I really liked. And it felt like every time I was doing a rotation that, oh, this was going to be it. You know, when I was doing psychiatry, I was so sure I was going to be a psychiatrist. When I was doing pediatrics, I was all in on pediatrics. I signed up for all my electives in pediatrics. And then over time, I came to medicine, internal medicine, in part because I felt like, well, this is going to allow me the broadest possible experience of medicine. And it would really kind of place me at the heart of the entire specialty. That in some ways is connected; Internal medicine in some ways is like the beating heart of medicine, and it touches every specialty. And if you want to sort of know what the larger story of sickness and health and what the health care system looks like and how it interfaces with that, then internal medicine is the best way to sort of be on that journey and have that viewpoint.

  Haider Warraich: [00:15:07] You know, cardiology was attractive to me in a way, because I, I felt that, I mean, cardiac disease can be so dramatic and it can be dramatic both in its onset, but also in what we can do for folks who have cardiovascular disease. I felt like unlike many other conditions, it was a condition that was very common. And for me that was what made it interesting and exciting, that it wasn't just a niche condition that very few people will have, but it was something that a lot of people will experience with both personally or amongst their relations or amongst their loved ones. And so the experience of the person with cardiovascular disease is going to be something that it's not going to be experienced by just a few people, but it is going to be a big part of what we do in medicine and health care.

  Haider Warraich: [00:16:00] But because I had so many other interests and a lot of my interests in medicine and in narrative and in writing began with my experience as an internal medicine resident, often with people at the end of their lives, it just made sense for me to really figure out, well, why are we not as good at studying care that people receive at the end of life when they're dying of heart disease or heart failure as opposed to other conditions? You know, why is this a conversation we're not having? Why as a field are there are so many unanswered questions? Which is ironic because cardiac cardiology is a very science based field. I mean, the clinical trials that we have that guide our practice in cardiology are second to none. And yet when it comes to the end of life experience that patients have, it was not really even part of the conversation. And so I felt that that cardiology and then within cardiology, an emphasis on palliative care, end of life care, serious illness care, whatever you want to call it, was really something that that fulfilled so many different sides of me. And gave me something to do, which was that can I be part of a change in the culture of cardiology? Can I, through writing and through research and through advocacy and mentorship and building collaborations, you know, can I change the sort of care that people with heart disease receive, especially when they need us most? And heart failure really, I think, incorporate so much of that.

  Henry Bair: [00:17:33] So you talk about how you saw this need for us to change the conversation around death and dying. Can you be a little bit more specific in terms of what the problems you see are on the ground as a cardiologist dealing with patients with very serious illnesses of the heart? What are the problems you're seeing and what do you hope to see change?

  Haider Warraich: [00:17:58] Well, where do I start? But I go back to this instance where I was taking care of a patient who had heart failure, and he had had heart failure for decades. And now he'd come in with septic shock and had gotten better from that perspective, but now had end stage heart failure. And he had a pacemaker. He was on all these medications. And so I really wanted to sort of see, well, what does a patient understand about their disease? What do they understand about their prognosis? And so we did what anyone else would do in that situation. We put together a family meeting and the family meeting started off. And I said that, well, we are infections better. But your heart failure is quite severe and the patient and their wife stop me right there. And they're like, What is heart failure? No one's ever told us that he has heart failure. And they were completely shocked. And I had to take a big step back and essentially- the meeting ended up going quite, quite poorly. And it made me think that a lot of patients who have heart disease or serious heart disease, their understanding of what that disease means or how that might change their experience, and especially how their experience at the end of life was very, very limited.

  Haider Warraich: [00:19:23] And, you know, people know about heart attacks, people know about stents, people know about all that stuff. But when heart disease evolves into heart failure, as it invariably does for many people with advanced cardiovascular disease, there seemed to be a disconnect between how the conversations we, the physicians were having and the understanding that many patients had. And really, that's reflected in the data. That patients with cardiovascular disease are much more likely to see palliative care closer to the end of life than patients with cancer, or that patients with cardiovascular disease are much more likely to die in a hospital or in ICU than in hospice or a hospice facility or at home. That patients with cardiovascular disease are much older at the time of palliative care referral. That many of them are getting inappropriate therapies right until the last few hours to days to weeks of life that the average patient with cardio heart failure in this country lives only for about 11 days in hospice after they're referred to hospice, and that a quarter die within the first 48 hours.

  Haider Warraich: [00:20:31] So the problem was always there. And to me, there are two ways that I could change the conversation. One was through storytelling, one was through writing about this in ways that could really engage not just other cardiologists and physicians, but really also engage the larger public into thinking about heart failure, not just as as sort of a mechanical breakdown. I think a lot of times we get carried away with our metaphors in cardiology and so people come to think about heart disease or heart failure as essentially collateral damage that they pick up just by being old enough rather than think about as potentially catastrophic, often fatal conditions. And so storytelling was a big part of that. But then it had to for me especially, I felt that this was important, but that it had to also be paired with actual research. And it's showing in very clear ways what the gaps were, what the current state of affairs was, so that I could build a case that was based on appealing to people through both storytelling and narrative and but as well as through data and figures. And so that was how my writing and how my sort of my clinical experience informed my writing. And then that informed my research. And so and when everything came together, that's when I knew that this was in fact a happy accident. But, but it took a while to get there.

  Henry Bair: [00:22:06] So most of our clinician guests have trained and worked pretty much entirely in the United States, myself included. I'm currently in medical school in the United States, but I did not grow up in this country. I grew up in Taiwan, and I'm always curious to see how different cultures treat their patients. And I'm wondering, since you spent some of your early medical training in Pakistan, did that in any way inform your perspectives or your approach to caring for your patients when you came to America?

  Haider Warraich: [00:22:47] It almost certainly did. I went to medical school at the Aga Khan University Medical College in Karachi, but like many other -if not all other similar settings- the patient physician relationship was very...The power dynamic was completely off when I essentially saw many physicians really bullying their patients. The patient was often at a huge disadvantage. There are moments of empathy that I saw. But the overarching experience was pretty disheartening. And so to come to a place where patients were, you know, really at the center of the conversation, it was kind of like being in a time machine. You know, going to medical school in Pakistan was in some ways what it was like practicing medicine here in this 1960s. I mean, there is a paper in JAMA, it was in sixties or seventies, in which 80% of physicians did not think that patients with a cancer diagnosis should be told that they have cancer. And the reason was that they felt that that the patient will have no use of that piece of information or that they may not respond to it appropriately as they saw fit, or that it may take away whatever hope they might have. Et cetera, etc.. So for me, in some ways, it gave me a lot of perspective, but also in some ways medicine was very simple there. As far as end of life care, for example, is concerned. There were very few conversations about "do not resuscitate" or "do not intubate." In many ways, the health system there was simple because many people didn't have health insurance.

  Haider Warraich: [00:24:38] Many people are just paying out of pocket. And so decisions about medical care were often driven by finances. There is so much inequity in care that I saw there, and there are so many things in my medical school experience that I thought I would never need when I came here, because I felt like, "Well, I'm coming to the richest country in the world and everyone's going to have great health care, and all the physicians are going to be incredibly empathetic and that there is not going to be any inequity or injustice." But so many of those issues have just followed me here. I mean, I will say that the first hospital that I worked at in the United States, I was an elective student was the Cleveland Clinic. And the Cleveland Clinic is kind of like this monument of American health care. You know, there was like the suite of Mercedes S-classes always park in the front and these infinity pools and all the art and stuff. And and so I truly believed it. And yet there's so much it's really sad to see that so much of what I saw when I was in medical school in a place that had not even a fraction of the resources that we have here, but that so many of those issues are so universal, that so many patients here are as burdened by their medications here as they were back in Pakistan. And they were making some of the same financial and economic and health decisions that patients back there were making, that people were rationing medicines, that people were, you know, going bankrupt just to just to stay alive, really, that how patients were treated had less to do with their medical conditions than with where they grew up or how much money was in their their bank account.

  Haider Warraich: [00:26:29] And so in some ways, you know, growing up in that setting, I was oftentimes anger and rage was my driving force. I mean, I grew up listening to Rage Against the Machine, and that really was a sort of ethos that I brought to my work as a medical student as well, because the cruelty that I saw happening because of the system was just so unmistakable and it was so difficult to forgive. And now that I'm here that so much of those same forces kind of drive me when I think about. How we can do better. Because it is infuriating that we live in the richest country in the world, that we train the best doctors in the world, that we have the best nurses in the world, that we have so much going on for, so much going for us, and that yet so many of our patients are not getting what they deserve. And so, yes, it was very different in many ways growing up in Pakistan and going to medical school in Pakistan. But there are also so many parallels as well, which is which is really unfortunate, but also, as far as I'm concerned, really give me a lot of inspiration about wanting to do better.

  Tyler Johnson: [00:27:48] I'm hoping, if nothing else, at some point in the future, you'll write a book called Rage Against the Machine, My Reflections on Fury and Medicine, or something like that.

  Haider Warraich: [00:27:58] Yes, I it's a very powerful force. And again, I think that we're at a moment in time where there is so much rage about the injustices in this society. And the question is, how do we channel it for change? How do we take that into and transform that into meaningful change, not just so that we can make nicer billboards and not just that we can have more self congratulatory tweets and social media outputs, but how can we actually change things for patients who really need that the most? So I think that anger and rage, which are an incredibly powerful emotion that can be used for good. And so part of me is always thinking about how do I channel that and how do I find avenues for that that is actually going to help help the people who need it.

  Tyler Johnson: [00:28:49] You know, one of the things that I think is one of the kind of the threads that stitches together many of the episodes on this podcast is this idea that most people who go into medicine have a sense that it's a pretty steep price, right? If nothing else, when you go in, you probably know you're going to be studying for many years. There's going to be a lot of financial sacrifice for the first decade and a half, etc. and yet people go into it anyway. And for most people, not everyone, but for most people there is a very idealistic sense behind that. And you are the first person, I think, who who we've had on the show who has talked about rage or fury as being that driving force, but as you mention, rage that arises from a sense of fury about injustice. Can be a powerful catalyst for change. Right. And rage against violence or against discrimination or against even in kindness. All of those things in all of those cases, it can be a powerful motivator. But what we hear so often, I just in the last couple of weeks have sent to Henry a list of recent op eds from national newspapers where people are explaining their reasons for leaving medicine.

  Tyler Johnson: [00:30:11] Right. And in effect, what we hear over and over and over and over again, both from specific anecdotes and from larger survey sets and everything else, is that it's as if the. Whatever that righteous passion is, whether it's fury or altruism or something in between, it's like it just evaporates or dissipates at some point, either during your training or once you get into practice, there's just so much. People have different words for describing why bureaucratization or corporatization or depersonalization or whatever you want to call it. But I guess all of this is to say that whether it's fury or rage or something else, how do you, on a practical level, keep touch with like how do you keep feeding that fire so that that can be a meaningful component, sort of driving you to do what you do so that you stay connected with your deeper reasons for being in the profession?

  Haider Warraich: [00:31:07] I mean, that's just such a wonderful question. And I think just a really important way to think about it. Any any sort of powerful emotion is necessary I think if you're going to do something important. Maybe not necessary, but I think especially for people who are motivated in that certain way, I think having having this sort of sense of mission and then having an engine driving that is, I think for many is really, really important. But then the question is how do you how do you keep running that engine for a long period of time? I mean, one of my one of my inspirations in many sort of different ways is Tom Brady. And why I bring up Tom Brady is because in Tom Brady always you know, he is what, in his 19th or 20th year. And how do you how I always think about him. How does he motivate himself to come in every season, you know, take a beating to be on a good team or on on a bad team, and to really just give it us all knowing that he's already achieved everything that he could have possibly hoped for. I mean, they keep going back to the fact that he was drafted 199 to the draft, but that was a long time ago. That was before he had, I don't know, six or seven Super Bowls. But I think that that's what that's really what I go back to. And I think about these these these athletes like who've had long careers like Tom Brady or LeBron James.

  Haider Warraich: [00:32:39] And I think about how do they keep themselves motivated to keep getting better, even though they're at their they're performing their best. And part of it is that you that is that sense of being slighted. Right. And that that chip on their shoulder that that they use and recycle to keep going. But in our profession the way I think about it is. What are the causes you're going to connect yourself to? How what are the instruments of change that you have at your disposal? And sometimes those instruments are fairly boring. Sometimes an instrument is doing a study or doing a writing an essay or writing an op ed, or writing a prospective piece or giving a talk or designing a project. It's not the same as anything that any of these athletes are doing, but those are the means that we have at our disposal to enact change. Now we have social media as well. And if you look, there are so many great examples of individuals taking it upon themselves that there's that using that sense of injustice to really bring about really lasting change in medicine. But I think that the way to do that is by finding. A broad enough host of instruments that you're going to use to channel those emotions that if you just if you burn out too quickly, then it doesn't help anyone. It doesn't help the individual. It doesn't help whatever cause or mission or movement that you were inspired by. So in some ways, you do need to have the sense of balance and you need to have the sense of.

  Haider Warraich: [00:34:16] If you want to be a revolutionary, you have to make sure that you go along. It has to be within the system as well. A part of it does have to be within the system. You can't just decide that you're going to, leaving the system -It's hard to change from the outside. And so part of I mean, if you think about, for example, cardiology and end of life care is part of it. Part of the reason why I think I have a bit more legitimacy to talk about this is because I'm a cardiologist myself. If I'm coming from the outside, if let's say if I was a palliative care physician or if let's say if I was a primary care physician, but I still had the same passion and I still did the same work, my message would not have been that powerfully received because there would be this sense that, oh, this is an outsider, that he or she doesn't know what we have to go through. So so I think that there is value in being a part of the system if you're going to enact lasting, meaningful change. But that's where I think you need mentorship and you need guidance and you need a crew and you need a tribe and you need you need stuff outside of medicine to keep you engaged so that you're not going to expend all your energies all too quickly and that you're going to pace yourself for what will hopefully be a long and fruitful career.

  Tyler Johnson: [00:35:37] One thing I just wanted to say with that there was this one wonderful article written probably five years ago or something by David Brooks, who's the columnist for The New York Times, where he was talking about I want to say it was Richard Rohr, but I could have I could have that reference wrong. But anyway, a religious author and maybe activist is not exactly the right word, But in any case, who had coined the term "the edge of the inside." And what this person was saying is that the people who end up making the most change within an organization are not the people who are from the outside throwing stones, because those people usually get ignored and the people inside the organization just kind of shrug their shoulders and move on. But it's also not the people who are so deeply inside of the culture that they just kind of go along to get along and just do things the way that they've always been done. The people who really push change and become catalysts for change are the people who are on the edge of the inside. So in your example, you are a cardiologist, but because you're at the forefront of palliative care within cardiology as a sort of trusted insider, you're able to push and expand the boundaries in a way that a palliative care doctor or let alone someone who's not a physician, would never be able to do, even if they were making really, really good points and had good evidence and all the rest of it.

  Tyler Johnson: [00:36:58] Right. And I think I had never thought about that framing in terms of being a doctor. But in a sense, one way that that is potentially helpful is just as you were saying, as an argument for why to stay, right. If you're thinking, well, I'm just, you know, this whole thing has just gone to the dogs and so I'm just out of here and I'm going to, you know, and then I'm just going to, I don't know, write op eds as somebody who's not a doctor anymore. Not that, you know, judgment on people who choose to do that. But I'm just saying your efficacy and actually making medicine and by extension the lives of patients better is going to be pretty limited. As a person who has to open every up and saying, well, I'm no longer a doctor, but here's what I learned when I was, right? Like there is something to be said for like there is a productive friction that comes from being someone who sees how a thing, i.e. medicine can be better and yet owning up to staying so that you can try to bring that about.

  Haider Warraich: [00:37:57] I certainly feel that way. And I will say that in medicine has changed as a profession. But I think the core I mean, the strength of the profession, the reason why I think I would still do this all over again, despite all the ups and downs in this. And I still think that I still think that it's the best profession in the world. I mean, I think part of why there is so much attention on people leaving the profession is in some ways because there there is a disconnect between, I think, expectations and and reality. You know, in so many ways, part of why medicine has changed is because what we do has changed. 30 years ago, cardiology was what? No one no one had heart failure because you either had a heart attack and you lived or you died and you never got well enough to develop heart failure. Today, we live in an age where most people die of chronic disease and we manage chronic disease, and by definition, we're not able to make those types of big changes in people's lives just simply because of the nature of what we're dealing with from from a disease perspective has changed so much.

  Haider Warraich: [00:39:10] You know, and I think the other thing that makes things hard to change in medicine is because it has grown so much bigger. When we were in the hospital, when we were training. We feel like this is the center of medicine that we physicians, nurses, patients; that's it. That's all of medicine. But there's a whole big world outside of medicine that has its hands all over what we're doing. That is at times pushing for change, at times resisting change. And for me, the most effective leaders in medicine are the people who can who can take everyone together, who can take everyone along together. It's very easy to take an extreme position that is going to rile people up and and that. But in the end, if we're going to make any type of meaningful change, we have to understand the world that we live in and we have to make sure that we find a place where we're most of the stakeholders can agree on the right way forward.

  Haider Warraich: [00:40:11] You know, for example. I have written strongly about the influence of the pharmaceutical, the drug and device company in the work that we do. But we also have to realize that it will be very hard to make change without getting buy in or without on our own. That in the big world that we live in, that is of medicine, that is a fifth of our economy and beyond. If you're going to make change, it has to be in a way where it's collaborative. Having an approach that is exclusionary or that is extreme is just not going to cut it. I mean, in the long run, that's that's my own belief. And that's something that I've learned over time. I mean, sometimes I've let the anger do the talking and sometimes it is important to make people uncomfortable. Sometimes it is important to put the truth out there, whether it's whether it makes everyone look good or not, whether it even puts your own career on the line. But it can't be all you do. It can't be the core of what you're about. If your goal is not just to be not just to gain attention or to be to gain notoriety, but if your goal is to enact change, you can't just you can't sit it out. You have to be in it.

  Henry Bair: [00:41:38] Early on, you talked about how it's important for you to use the tools and resources at your disposal to channel the things that you care deeply about in medicine. And you talked about how a convergence of your passion for storytelling and your scientific mind was the reason that you found medicine to be the happiest accident that you could find yourself in. And yes, you've written many books over the past five years, and your most recent book, published earlier this year, was about pain and the nature of pain and suffering. And in a sense, that's so much of what clinicians do is alleviate and address our patients pain and suffering, suffering as very broadly defined. Can you tell us what the genesis of your book on pain was and what you hoped to explore about what pain and suffering are?

  Haider Warraich: [00:42:42] The genesis of the book, it began many years ago, I just didn't know that it had already begun. And it happened really after I suffered a really brutal back injury in medical school. I was lifting weights and I just had this- I got pinned under a bunch of weights. I was sitting in an emergency room. I had I developed back pain that just never got better. Well, I mean, it did get better, but after years and years of physical therapy, exercise and a whole lot of good luck, and it was around this time as I was getting better that I came to the United States to train. And when I started residency, it was then that I was exposed to opioid prescription for chronic pain, which at that point was really at its height as far as national prescription rates were concerned, even though we never even considered that to be a problem at that point. And as I began to get more curious, I realized that there is such a big story to be told here, not just about my sort of own journey with pain, but of the millions of Americans who live with pain. And the more I read, there is this huge disconnect between what the science of pain was and what our understanding of pain was at a clinical level and how we were treating it.

  Haider Warraich: [00:44:01] The other thing about pain is that it is so connected to so many of the greater forces that exist in our society in regards to how we assess the value of a human being, how do we trust one another? So much of what people say makes the assessment of pain difficult is because of its subjective nature. And yet, to me, that is really the essence of medicine. So what I wanted to do was really to write a book that used my own personal story of having lived with pain and then becoming a resident, really, at the height of the opioid prescription pandemic, to really challenge people and connect the science with both society, but also with other physicians to think about what the nature of pain really means. And what are the what can we learn from the opioid epidemic as a profession? And then really think about how can we do better for the person in pain? And in so many ways, I think it connected so many of the different themes that we've already touched upon in this conversation. So I just had a blast writing it. And really it's been the start of a journey that continues and really grows every day.

  Henry Bair: [00:45:17] So given your exploration of the the interplay between the subjective interpretation of pain and suffering, what advice can you give to clinicians and medical trainees on how to help our patients address suffering?

  Haider Warraich: [00:45:39] I think there are a couple of couple of big things that I would love to share. One is that the assumption that chronic pain is simply acute pain, prolonged is completely incorrect. And so the way we think about chronic pain is that, oh, chronic pain is just pain that lasts for three months or more. And and so what then happens is that then we assume that, oh, whatever works for acute pain is going to work for chronic pain as well. Both of those things are not true. I mean, if you look at really all the research that's been done in chronic pain, including the work done using, using fMRI, etc., what really becomes true is that acute pain and chronic pain might feel the same way because they both hurt, but really are can be very different processes. And so thinking that we can just take a treatment for acute pain and use that for chronic pain and assume that it's going to work is actually totally incorrect. I mean, this is really at the heart of what happened with opioids. I mean, opioids are excellent treatments for acute pain but are really, really bad therapies for chronic pain. So I think that that's one sort of broad message that I would like to share. I think the second message that I'd like to share is that especially I think starting in the nineties there, this movement called The Pain is a fifth vital sign movement. And really the essence of the movement was that it was a push for physicians and health systems to treat pain as a physical phenomenon, just like heart rate or blood pressure.

  Haider Warraich: [00:47:14] But but the fact is that pain is not just a physical sensation. In fact, pain is as much an emotion and as much a traumatic memory as it is a physical sensation. And the longer and the more chronic the pain condition becomes, the less of a physical sensation it becomes over time as well. And it really takes on the contours of the sort of sort of emotional traumas that we are, I guess, well versed. And if anything, I think the closest condition to chronic pain that I can think of is probably PTSD. And the connection between memory and chronic pain is also extremely interesting and very closely tied. And the factors that that predict the transformation of cute into chronic pain are not biomechanical features. And the intensity of the initial injury or imaging abnormalities and on your MRIs are not predictive of who will go on to develop pain or not. And really so so I think capturing pain as not just a physical sensation, but an event in someone's life that is connected to who they are, what they've been through and how they perceive the world is really, really important. Embracing the complexity of pain rather than trying to reduce it to a simplistic physical sensation is, I think, really, really critical. And then the role of empathy in pain is is so important, partly because empathy is actually hardwired into the experience of pain as a community because there's been a ton of research done in this.

  Haider Warraich: [00:48:55] But when you as an individual or even if an animal witnesses another organism in pain, you actually reproduce those same signals that account for the experience of pain in yourself just by being witness to it in another individual. Which is why physicians who are empathetic their patients have much better outcomes from pain, in part because empathy is really one of the strongest bonds for pain that we have as physicians, but also as a community. And so, these patients with chronic pain can be really, really hard to treat. Oftentimes their illnesses are invisible. Oftentimes they've been prescribed opioids and now they're struggling as much with opioid use and opioid tolerance and as they are with chronic pain. So I think I think the role of empathy in the treatment of patients of chronic pain is probably more important than any other condition I can think about. But I think that that's really what we need to do, is that we need to create a system that allows for empathy to be practiced. I mean, if you have a health system that is entirely based on fee for service medicine, what incentive is there to be kind? If you have a health system that is all based on efficiency and trying to see as many patients and bill as many RVUs as possible, why will you do the right thing? And so, you know, again, these questions that pertain to how we talk to the individual patient in the clinic or how we sit across and spend time with our patient in the ward is affected by big decisions that are being made at the policy level that are much more boring and much more mundane, but really are the instruments through which we can allow for those interactions that we have with our patients to become more meaningful, for us to have more time with our patients, for the incentives to be aligned such that what is best for us is also what's best for the patient.

  Haider Warraich: [00:50:53] And so that's really, those are, I think, some of the. I mean, key messages of the book. And my hope is that, You know, it's ironic to me that pain and pain is the number one reason why patients seek health care. The two most common reasons for people coming to the emergency room are abdominal pain, followed by chest pain. If you look at primary care visits, hospital visits, etc., pain is one of the most common reasons why really anyone will come seeking help from us and the fact that we understand it so poorly and that our treatments for pain have done arguably more harm than good really should be a wake up call for us that we really need to own pain, not just as a subspecialty, but all of us in medicine need to really sort of think about pain in a more serious way than we have done before.

  Tyler Johnson: [00:51:44] Your discussion about empathy with those who have chronic pain reminds me a little bit of there's this beautiful passage near the end of Bryan Stevenson's "Just Mercy" book, which is his memoir of fighting for patients on death row, where he talks about coming home one day after he's just lost a case in his and his prisoner- Well, his client, who was a prisoner- has been executed and he just breaks down crying. And then he at first he thinks he's crying because of the problems of this person who just died, but then pretty soon realizes that while that's there is truth to that, it's also because the epiphany that's cracking open inside of him is that it's actually that all of us are broken and that he, Bryan Stevenson, the author, was also broken along with this much more obvious from the outside broken person who is an inmate on death row and who ended up being executed, and that it's that shared brokenness or the shared vulnerability is the thing that although it was a sort of a devastating realization in some ways, that was the thing that ended up giving him the wherewithal to continue in his fight for these people on death row, many of whom had been unjustly imprisoned or unjustly sentenced to execution. And that's just to say that I think his version of being an attorney shares with our job this privilege of witnessing or accompanying people in their most difficult moments. Right. He talks eloquently about sharing the last moments and hours of people on death row with them. And I think there is a resonance with what we do. And I find that passage to have great resonance with with what you were sharing just now.

  Tyler Johnson: [00:53:21] We have kept you over time, Heather, and we so much appreciate your your willingness to to stay and chat with us. We appreciate your writing and all of the good that you do. And we thank you so much for for being on the podcast. And we wish you all the best.

  Haider Warraich: [00:53:36] Well, thank you so much for having me on. It was such a pleasure talking to you all. And I will say that I'm a I'm a big optimist. I think that we've made so much progress in medicine. That's one of the one of the joys that comes out of studying medical history is just knowing how far you've come. And I think that medicine allows us a great position to act as agents for social change. It equips us with all the tools that we need to be able to do so effectively. And it provides us so many different avenues to do that, not just through writing, but there are so many different ways that you can you can employ the social skills we have as physicians and the place we have in society to be able to improve the lives of people who are like us and also people who aren't like us, people who are sick, people who are really across the spectrum. So it's a real pleasure to talk about you, about some of the things that I'm super passionate about.

  Henry Bair: [00:54:29] Wonderful. Thank you so much for those delightful parting thoughts.

  Henry Bair: [00:54:34] Thank you for joining our conversation on this week's episode of The Doctor's Art. You can find program, notes and transcripts of all episodes at theDoctorsArt.com. If you enjoyed the episode, please subscribe, rate and review our show available for free on Spotify, Apple Podcasts, or wherever you get your podcasts.

  Tyler Johnson: [00:54:53] We also encourage you to share the podcast with any friends or colleagues who you think might enjoy the program. And if you know of a doctor, patient or anyone working in health care who would love to explore meaning in medicine with us on the show. Feel free to leave a suggestion in the comments.

  Henry Bair: [00:55:07] I'm Henry Bair.

  Tyler Johnson: [00:55:08] And I'm Tyler Johnson. We hope you can join us next time. Until then, be well.

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LINKS

Dr. Haider Warraich is the author of several books, including The Song of Our Scars: The Untold Story of Pain, Modern Death: How Medicine Changed the End of Life, and State of the Heart: Exploring the History, Science, and Future of Cardiac Disease.

In this episode, we discuss the article “At the Edge of the Inside” by David Brooks, for the New York Times, and the book Just Mercy by Bryan Stevenson.

Follow Dr. Warraich on Twitter @haiderwarraich.