Interview: Dr. Larry Schwartz

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Dr. Larry Schwartz graduated from Wayne State University School of Medicine in 1975 and completed his Residency in Emergency Medicine at Henry Ford Hospital.  He has won numerous awards for his dedication to medical student education and humanism in medicine.  Dr Schwartz is a national leader in medical education.

Receiving: You are an icon in medical student education, how did you first get involved in this area?

Dr Schwartz: In 1989, while working at Beaumont Hospital, I started working a few shifts a month at the University of Michigan’s University Hospital. That lead to a stint as a physical diagnosis volunteer at U of M that I did for 1 or 2 seasons. I somehow became more involved in some other medical student teaching at the University of Michigan. In 1992, when I decided that I wanted to change jobs, I talked to Dr. Bock and told him how much I enjoyed working with medical students. At that time he was interested in establishing a mandatory EM clerkship and getting the EM faculty involved with physical diagnosis. It was a natural fit.

Receiving: What are some of the changes you have noticed in medical students from the 1980s to today’s medical students?

Dr Schwartz: I haven’t noticed too much difference. The students, by and large, are still energetic and idealist for the most part. They get excited by clinical medicine. They are caring to patients because they identify many times more with the patient than with the doctor. I find their enthusiasm contagious and they are like a breath of fresh air.

Receiving: In 2006, you were inducted into the Gold Humanism Honor Society.  With increased ED patient volume and the reliance on advanced technology (i.e. multi-detector CT) is “humanism in medicine” fading?

Dr Schwartz: Most patients go to the doctor to see the doctor not the CT machine. The problem we have is the decreased amount of time  we spend with out patients. We need to build up trust in the short time available,  The patient has to feel that the doctor cares about him and his well-being. As healers, we must be able to project a caring attitude. The patient doesn’t leave the ED saying, that state of the art CT machine was terrific! He or she states that the doctors and nurses were kind, caring, professional, and knowledgeable. I’d go back there if I  needed medical care in the future. Or, if unsatisfied with the care, I’d die before I’d go back to that dump again! They never praise or complain about technology, it is the providers and the cleanliness of the environment that make an impression on our patients.

Receiving: What are some of the biggest challenges that today’s medical students are going to face when they are practicing physicians?

Dr Schwartz: I think that the medical care system as we know it is going to change dramatically within 5-10 years. Today’s medical students are going to be at the vanguard of this change. Unfortunately, I don’t know what the changes are going to be. I think they will be imposed from without instead of arising from within Re-imbursement is going to be reduced. Students will come out of med school with huge debt and lower re-imbursement than we have been accustomed to. Unfortunately physicians have lost the role of managers of medicine. Our broken system is going to collapse and need to be rebuilt. That will be painful. Once rebuilt, however, I think it will be more just.

Receiving: Should emergency medicine be a core clinical rotation for medical students nationwide?

Dr Schwartz: YES! Every inpatient room in the hospital is an emergency room when the intern is called because the patient is having an emergency. The house staff must know how to handle these emergencies. Therefore a core EM rotation is necessary for all medical students.

Receiving: Can you tell us one of your secrets to being an influential teacher?

Dr Schwartz: Students have to feel that you respect them, your patients, and that you really care. They want a role model that they can look up to, one that can walk the walk as well as talk the talk. I have tried to meet the same standards I hold the students to. It is very important that we model the behavior we preach. If not, we have no credibility as teachers and mentors.

Receiving: Do you remember a time when “educational research” in medicine was unheard of?

Dr Schwartz: We’re finally realizing that although we may be good doctors, we may or may not be good teachers. I think that medical education research is growing exponentially because we have so many new modalities to study and ways to study them. The introduction of simulation and parts trainers into medical education is a huge new arena to study. Distance learning and interactive computer based training are also a new technologies. As we introduce things, we are studying them. This has opened the door to more and more educational research in medicine.

Receiving: Who is your role model?

Dr Schwartz: I have several. Our own Dr. Dayanandan, or Daya as we used to call him at DRH ED, was a great role model. He was always even-keeled, smart, and kind to everyone. He was well respected by all of the physicians, nurses, students, and patients.  Dr. V. Vaitkevicius, a retired oncologist, is another remarkable man. He is one of the most humanistic doctors I’ve known. He would give his personal telephone number to his patients and was available to them at all hours. Dr. Ronald Krome has been a mentor to me. He taught me about hospital administration and how to be a champion of emergency medicine, the emergency department, and emergency physicians. I learned an incredible amount from him.

Receiving: As the medical student clerkship director for emergency medicine, you were one of the earliest directors to employ “web-based” education by utilizing “Blackboard” and putting the clerkship “on-line”.  How will the web impact medical education?

Dr Schwartz: Dr. Rosh, you can answer that one better than I since you are using the web constantly in your work with the residents. I found that putting a multiple choice exam on Blackboard allowed for immediate scores, better images, and evaluations of the exam. What I didn’t know when I first put the exam on blackboard was about security. Our exam was purloined within the first month or two by a med student who copied, pasted, printed, and distributed it. I found this out about a year or 18 months later. The web is a great aid. However, I don’t think anything takes the place of face-to-face contact in  medical education. The web is a great addition, but it can’t take the place of the apprenticeship model where the more experienced teach the novice.

Receiving: If you were going to practice medicine in a remote village, what is the one medical textbook you would bring with you?

Dr Schwartz: A tough question! I like the Tintinalli book probably because I wrote a chapter in it. These days, I must admit that I go more to the web when I have to look something up. I guess I am going kicking and screaming into the 21st century.

“The Meeting Room” is devoted to interviewing leaders in Emergency Medicine.  Please email me with suggestions on people you would like to see interviewed or if you would like to conduct an interview.

Interview: Dr. Mark Reiter

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Dr. Mark Reiter has held multiple leadership positions in Emergency Medicine, including the Board of Directors for AAEM, AMA Council of Legislative Affairs, and President of AAEM Resident and Student Association to name just a few. Dr. Reiter is CEO of Emergency Excellence, LLC, a company whose aim is to improve emergency department processes through data analysis, benchmarking, surveying stakeholders, and the application of lean principles to optimize quality, efficiency, and satisfaction.  Dr. Reiter is a rising star in the field of emergency medicine and is sure to be a leader for this generation of emergency physicians.  Dr. Reiter currently practices emergency medicine at St. Luke’s Hospital in Bethlehem, Pennsylvania.

Receiving: You were involved in many leadership roles very early in your EM career, including serving on the Board of Directors of the American Academy of Emergency Medicine, the Board of Trustees of the Medical Society of New Jersey, and on the American Medical Association Council on Legislation.  How has your experience in these roles influenced you?

Dr. Reiter: I’d encourage all physicians, no matter what stage of training, to get involved with medical professional organizations or other organizations.  Active participation helps you to see the big picture, which allows you to advocate more effectively for your patients and for your colleagues.

Receiving: You strongly support AAEM, what is the big difference between AAEM and the other national EM organizations?

Dr. Reiter: AAEM takes a very active role in advocating for the individual emergency physician.  In particular, AAEM takes strong positions for workplace fairness (and combating workplace abuses) and protecting the value of board certification and residency education in emergency medicine.

Receiving: How has your MBA degree impacted your life as an emergency physician?

Dr. Reiter: My MBA has made me a more effective leader, both within professional organizations, or working within my ED to improve care.  In addition, my MBA has been invaluable in preparing me for the recent launch of Emergency Excellence, the emergency medicine benchmarking and consulting company I recently co-founded with Dr. Tom Scaletta.

Receiving: What are some of the toughest issues facing the specialty of emergency medicine?

Dr. Reiter: Unfortunately, there are many tough issues facing emergency medicine, and most we cannot solve on our own without help from outside of EM.  Overcrowding will continue to be a massive problem, as we have no national plan to deal with an aging, progressively sicker population, in the face of the fraying of our primary care system and a decline in staffed hospital beds.  The lack of action on tort reform or fixing our broken reimbursement system will continue to compromise our patients’ access to on-call sub-specialists, especially to our most vulnerable patient populations.  Physician autonomy is threatened by the continued consolidation of health insurers and the increasing corporate practice of medicine by for-profit non-democratic groups.

Receiving: How will emergency physician compensation be affected if this country adopts universal health coverage?

Dr. Reiter: No one knows.  Emergency physicians see more uninsured patients than any other specialty, so many expect to see an improvement.  However, in many areas, reimbursement from uninsured patients is on par with Medicaid or often better.  If uninsured patients were enrolled in a Medicaid-like plan, there would be little effect.  On the other hand, the federal government may decide to decrease reimbursement across the board to pay for the increase in the insured population, essentially putting the costs of insuring millions on the backs of the nation’s physicians, rather than the taxpayers.

Receiving: If you can change one thing today about emergency medicine, what would it be?

Dr. Reiter: Place a qualified practicing emergency physician in a position of power within the upper levels of leadership of every hospital, physician group, and relevant government agency.  Watch how quickly things could get done – does anyone make more important decisions a day than an emergency physician?

Receiving: When will you be President of AAEM?

Dr. Reiter: We’ll see….

Receiving: What are the biggest challenges of having two young kids and being a young emergency physician?

Dr. Reiter: Keeping my wife happy – she works harder than I do.

Receiving: Any relation to Dr. Reiter of “Reiter’s Syndrome”?

Dr. Reiter: Nope – some other guy.

“The Meeting Room” is devoted to interviewing leaders in Emergency Medicine.  Please email me with suggestions on people you would like to see interviewed or if you would like to conduct an interview.

Interview: Dr Lewis Goldfrank

Dr. Goldfrank is Professor and Chair of the Emergency Department at NYU/Bellevue Hospital Center and Director of the New York City Poison Control Center.  Dr. Goldfrank is a dedicated phyisican who has spent most of his career caring for the underserved population of New York City.  He is a civil rights activist and is committed to social justice.

Receiving: You have been practicing Emergency Medicine for more than three decades, what are some of the biggest changes you have seen?

LG: The development of academic departments, EM residencies, exceptional fellowships, devotion to academicity, the exceptional quality of faculty, resident, and students.

Receiving: What are some of the toughest issues we currently face in the medical profession?

LG: Lack of universal healthcare, inadequate access to primary care, corruption of the pharmaceutical and device industries in collusion with physicians.

Receiving: How did you first become interested in toxicology?

LG: The overwhelming demands in the ED population, environmental toxins, unintentional and intentional exposures and their vast societal implication all come to ED. Someone needed to study and develop responses.- antidotes,education and management strategies.

Receiving: Some of your recent work has been in disaster preparedness; are we prepared?

LG: We are integrating efforts, collaborating with more people than ever before and thinking about the unthinkable – all that makes us better prepared.

Receiving: You recently visited the African country of Guinea; how has that experience reshaped any of your views in Emergency Medicine?

LG: We are creating educational exchanges for faculty, nurses, residents, fellows and students so that young people can have a global educational perspective. The developing world must address problems that we no longer address – working together is a unique intellectual experience. The intellectual exchange includes members of many of the schools of NYU – Public Policy, Dentistry, Nursing, Medicine, Public Health. The opportunities for learning are unmatched.

Receiving: How can Emergency Physicians improve society?

LG: We must find jobs that make a difference to human beings. Achieving improved societal understanding of health and working with our communities, offers us the capacity to feel useful every day.

Receiving: Who is your role model?

LG: Probably no one individual – a composite of values and skills represented by Upton Sinclair, Pete Seeger , Albert Camus and Linus Pauling.

“The Meeting Room” is devoted to interviewing leaders in Emergency Medicine.  Please email me with suggestions on people you would like to see interviewed or if you would like to conduct an interview.

Interview: Dr. David Newman

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Dr. David Newman is the Director of Clinical Research and Assistant Professor in the Department of Emergency Medicine at St. Luke’s-Roosevelt Hospital Center/Columbia University in New York City.  In 2005, as a major in the army reserve, he was deployed to Iraq, where he received an Army Commendation Medal.  Dr. Newman recently published the book, Hippocrates’ Shadow: Secrets from the House of Medicine.  In this page-turner, Dr. Newman reviews research that refutes common and accepted medical wisdom. He cites studies that show how mammograms may cause more harm than good; why antibiotics for sore throats are virtually always unnecessary and therefore dangerous; how cough syrup is rarely more effective than a sugar pill; the power and paradox of the placebo effect; how statistics and studies themselves are frequently deceptive; and why CPR is violent, invasive — and almost always futile.  In addition to his penchant for writing, Dr Newman is a dedicated teacher and passionate clinician.

Receiving: What inspired you to write Hippocrates’ Shadow?

Dr. Newman: Hippocrates’ Shadow has been burning inside of me since medical school. My sense, in fact, is that it’s a book that’s been burning inside most doctors. It gives voice to a growing reality in medicine: the deepening divide between outsider and insider. On both sides of the stethoscope we frequently misunderstand the science of medicine, and in some cases we all seem to have forgotten its purpose. The book is an attempt to reconcile those two roles through transparency, to understand the science of medicine more completely, and to find a universal thread in our dualities — science and society, doctor and patient.

Receiving: Was Hippocrates the ideal physician?

Dr. Newman: Prior to the teachings of Hippocrates, physicians on the Greek island of Kos (where Hippocrates was raised and ultimately taught medicine) practiced in the ‘Aesculapian’ tradition. This was a mystical form of healing in which patients were brought to a sacred Aesculapian temple, given ‘medicinal’ sedative substances, and upon wakening asked to recall their dreams. These dreams were felt to be the key to their recovery, carrying messages that were to guide the healing regimens that followed. Hippocrates was unique in undertaking a more scientific approach. He documented his patient encounters assiduously, categorized the illnesses he witnessed, and was fanatical about recording and learning from his empiric observations. This was new. What is fascinating about him, and what appears to have endeared him to his peers around the world, was his ability to respect the power and traditions of the mystical while championing the power of the scientific.

To put it in classic philosophical terms, in medicine we have chosen logos (measurable fact) over mythos (tradition and emotion). Given the advances in our knowledge over the last century, and tremendous strides in technology, this makes sense to us. But our nearly blind faith in science has led us, in many cases, to ignore the data that our science generates. Hippocrates’ Shadow explores areas that are difficult for physicians to reconcile with the content and tone of our education, including the surprising limits of our knowledge, the profound and proven impact of placebos and mind-body connections, and the overuse, imprecision, and inaccuracy of most x-rays, EKG’s, and other tests. To discover these areas as a physician is humbling, and empowering. Hippocrates fused these two worlds in a way that maximized benefit for his patients. His ability to do this was very much the ideal that we should be striving for.

Receiving: You are an Army Reservist, how did your time spent in Iraq influence the way you practice Emergency Medicine

Dr. Newman: Combat medicine certainly impacted my practice, and it probably will for the rest of my career. Defining that impact is tricky because it’s more mental than practical. What struck me most about the experience was the sense of how unique a physician’s position is in a combat zone. The job of healing and tending without prejudice—to any and all comers—transcends the enmity and the violence of war. That’s a special gift and a privilege, and it gave me a real respect for how special our job is.

Receiving: Your book presents convincing evidence that some routine medical screens, such as mammography, colonoscopy, and PSA level, does not improve patient outcome.  Have you received any backlash for these statements?

Dr. Newman: Only those who haven’t read the book seem to object, at least so far. I try in the book to use plain language to untangle many of the statistical walls that have, I believe, made understanding data on these interventions difficult. Once these walls are gone the implications of the data become fairly clear. In the case of mammograms the existing evidence is strong, and it indicates that there is no identifiable life saving benefit to mammography as a screening tool in unselected populations. That’s something that most patients and most physicians aren’t aware of. What examples like this point out is that we have, in many cases, ignored scientific evidence in support of our science, and we continue to do so every day. The irony is hard to miss, and it’s a recurring theme in the book.

Receiving: You are the Director for Clinical Research at St-Lukes Roosevelt Hospital/Columbia University; is Emergency Medicine making a statement in medical research?

Dr. Newman: Emergency medicine is the frontier for innovative clinical research. As I point out in Hippocrates’ Shadow, the structure of our science means that on an individual level our greatest impact comes in the case of patients who are the most acutely ill, often at the earliest moments of their illness. Interventions like trauma surgery, and early goal directed therapy, and treatments for MI and cardiac arrest are all examples of how powerful our field, and research in our field, can be. The National Institutes of Health, the AHRQ, the CDC, and other major funding agencies are all beginning to catch on to this fact. As medicine begins to find itself and to value its most important resources many of the interventions with the greatest impact on human health will be developed and researched in emergency departments.

Receiving: Who is your role model?

Dr. Newman: Hippocrates, of course.

Receiving: What book are you currently reading?

Dr. Newman: ‘Sick’, by Jonathan Cohn, a brilliant, case-based chronicle of our health care system’s history and current state.

Receiving: Is a second book in the works?

Dr. Newman: I’m not sure yet. There certainly are many ideas swimming around in my head, but for now I’m going to work on getting the message of Hippocrates’ Shadow out.

Receiving: Thank you for your time.

Dr. Newman: My pleasure.

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Hippocrates’ Shadow: Secrets from the House of Medicine

“The Meeting Room” is devoted to interviewing leaders in Emergency Medicine.  Please email me with suggestions on people you would like to see interviewed or if you would like to conduct an interview.