COMMENTARY

Heart Doc Writes About His 'Front-Row Seat' in Medicine

; Haider J. Warraich, MD

Disclosures

December 19, 2019

This transcript has been edited for clarity.

Eric J. Topol, MD: Hello. This is Eric Topol, editor-in-chief of Medscape. I'm thrilled to have a session today with Haider Warraich, who is an incoming faculty at Brigham and Women's in heart failure, and the author of three books at the ripe old age of 32. Welcome, Haider.

Haider J. Warraich, MD: Thank you, Eric, for having me.

Medical Training and Early Writing Career

Topol: It's a pleasure. I wanted the medical community at Medscape to get to know you because you are lighting up the medical world and the public. First, let's go back. I know you are an immigrant from Pakistan; can you give us a little bit of color about your background?

Warraich: I grew up in Pakistan. My mom was a dentist, but both of my parents were in the military so I changed schools 11 times. I went to medical school at Aga Khan University. Being enrolled there for my education was one of the foundational experiences of my life. It was only after I finished medical school that I left Pakistan for the first time and came to the United States. So I had never really been to the outside world until I was pretty grown up.

Even though they were both in the military, they were kind of misfits in that they both valued and loved reading and writing. They wanted nothing more than to see us surrounded by both. I have a daughter myself now, and I think about how I can mimic what they did. I grew up in a great environment which I think has everything to do with where I am today.

Topol: Did you start writing when you were in the crib? When did you get your writing career off the ground?

Warraich: It's interesting; I first started writing comic books. I used to draw and figured that this seemed great. In fact, I remember the first comic book I drew. I drew a whole notebook with a story and gave it away to my best friend—never to see it again. So I have no proof that I ever wrote it, but it's still a vivid memory.

I thought of myself as a writer way before being a medical student. In medical school, I used to write short stories and would try to get my friends to read them, but no one wanted to. Everyone would just start running away as soon as I had written a new story. That was also the time when I wrote my first novel, and none of those [stories] had anything to do with medicine. I almost felt like I had this other life that may never have anything to do with what I was actually doing on a daily basis. It's interesting to be able to merge those now later in my life.

Topol: Your first book, Auras of the Jinn, was published in 2010. There are not too many physician writers. Of course, you're reminiscent of my friend Abraham Verghese, who has written both fiction and nonfiction. In fact, he's about to finish a new fiction book. But not too many have crossed the back-and-forth, and you're one of them. Tell us a little bit about your first book.

Warraich: I used to write primarily fiction. Auras of the Jinn is about this kid growing up in Pakistan who develops temporal lobe epilepsy and starts having hallucinations. The society he lives in thinks that something supernatural has come over him. This diagnosis starts a journey where not only does he discover a lot about himself, but he becomes a "periscope" for readers to be engrossed in what it was like to grow up in Pakistan as a young person.

It was only published in India and Pakistan. It was very hard to write fiction. When you're writing fiction, you are so vulnerable, and I felt extremely emotionally vulnerable all the time. It was a very taxing exercise, and now that I think about it, I don't know if I can ever embark on it again. Nonfiction is much easier on the soul.

Residency in the United States

Topol: That's interesting. How did you wind up in the United States?

Warraich: My medical school was a very "elite" medical school, where most of my mentors had trained in the United States and then had come back. Many of them were alumni of that university and inspired me to want to be the best in my field. But when I looked around and saw what American medical training offered, I wanted that experience for myself. That is how I embarked on this journey, which has been extremely rewarding.

Topol: That's for sure, and also for all of the people that you've been working with and writing for. Initially you went to Beth Israel in Boston for your residency and then to Duke for your fellowship—is that right?

Warraich: That is exactly right. I went to Beth Israel and did my residency there, stayed on for a year as a hospitalist, which was a great experience, and then moved on to Duke, where a couple of weeks ago I finished my cardiology fellowship and an extra year of advanced heart failure training.

Modern Death

Topol: Congratulations. And in the middle of all that, you wrote another book, Modern Death. How did you write a book during residency and fellowship while also having a daughter? Are there two of you or three of you?

Warraich: Well, there is one more of me and that is my wife, who has been the rock in my life and so much more than a partner. None of this would have been possible without her help. But the second book was interesting: By this point, I didn't see medicine and writing as two separate worlds but really as one. I felt that I didn't have to go into sort of dark crevices of my soul for stories; I could just show up to work and the stories would be right there for me like they are for any other clinician. I started writing up some of these encounters for The New York Times, and a lot of my stories would gravitate toward people's last moments, in part because that was what internal medicine residency has become. So many patients spend their last few days, weeks, months, moments in the hospital under the care of residents like myself and so many others.

I also felt like this was not a story that could be told in an essay; it needed something much more extensive. Part of it was that I was an outsider. Medical school trained me very well for things like managing myocardial infarction or pneumonia, but end-of-life care was totally unique for me. In Pakistan, because of how the medical health system is, we didn't have many of the [end-of-life] discussions or types of prolonged life-sustaining support that we have here. I was curious about some very basic facts of how we came to be where we are, and I knew that was not something I could wrap up in 1200 words. So I decided to take a deep dive and look at all of the history and research, and talk with as many people as I could to put together this picture.

Writing for The New York Times

Topol: It's quite an accomplishment. How did you start writing essays for The New York Times in your 20s?

Warraich: I was one of those persistent people who just kept writing things and sending them in. I just had a thick skin. That is one of the things that my medical school prepared me for; rejection didn't bother me at all. I just kept sending in pieces. I have yet to go to the office of The Times and I have never met any of my editors at the op-ed department there. But this is also a testament to what is great about this country: As long as you can tell a story, they will take it, even if it's from a kid like me from Pakistan. It was a fascinating journey.

Topol: There are two things you are being quite humble about. One is that you write really well and the second is that you are damned persistent. Like you said, you just beat them down and kept sending in essays. When they finally realized that this Haider guy can write and has some things to say, what did you do? Did you keep a journal about all of your patients so you would have the details? How do you keep track of it all?

Warraich: If I'm in the middle of a book project, I will write things down. But most of the time, I don't like to put things down on paper. A lot of these incidents are seared into memory and there is nothing you can do to get them out of your system. I think one of the reasons why I started writing them down is because it made sense to be able to process them in a way that I could learn from them and perhaps others could as well.

State of the Heart

Topol: You just published State of the Heart and it's an extraordinary book. I had a chance to read it and write a blurb for it which I still feel is true: "What struck me about State of the Heart is the state of the author―how a young cardiologist could have such an astute, wise perspective of the field and be an extraordinary storyteller."

The history of heart disease is nowhere crystallized better than in the struggle of women.

I thought we'd delve into this book because I'm sure not everybody has had a chance to get hold of it yet. It's rich. You have chapters that cover things like the dance of cancer and heart disease and stenting, and many historical aspects, but also things that have been somewhat misconstrued. One chapter I felt was especially worthy of note is the chapter on women and heart disease. Can you get into that a bit, because there are so many misconceptions and there is such a long, deep storyline about women and heart disease.

Warraich: It's the longest chapter in the book, it's my favorite, it's probably the best, and it could have been a book in itself. I think I wrote 11,000 or 12,000 words, and I felt like there was so much more to say. My own grandmother died of a cardiac arrest, and the day she died was the first day she had ever been in a hospital. I don't think that it would have happened if she were a man. I don't think that the symptoms she had been having would have been brushed under the rug.

The history of heart disease is nowhere crystallized better than in the struggle of women. I have spoken with people and gone through their stories. Nanette Wenger, one of the most well-known cardiologists in our country, does not end her job after seeing patients; she advocates for the profession and for the patients. I also see that in my patients. One of the patients I interviewed, Katherine Leon, described how after she had given birth to her second child, she had to go repeatedly to the emergency room for chest pain until someone took her seriously. She had spontaneous coronary artery dissection (SCAD), a diagnosis I was well trained to recognize and treat as a fellow. But 10-15 years ago, no one even knew what this thing was.

I felt that all of the stories I came across and shared, and also a lot of the research that has been done in this area, were so reflective of the state of our field at large. I always go back to how hormone replacement therapy for reducing the risk of heart disease so artfully expressed the value of the role of observational studies versus clinical trials. But yes, many of those misconceptions are still there. Fifty percent of the women in this country don't know that heart disease is the leading cause of death in women. This knowledge is even lower among ethnic and racial minorities.

There is a long way to go. We've made a lot of progress in heart disease over the past century, but if we don't do better at treating women with heart disease, then it might all be for naught. I feel very strongly about that.

Life Support

Topol: A common thread between Modern Death and the current book is keeping people alive in an artificial way, whether with extracorporeal membrane oxygenation or by other means. Obviously, this is a bioethical dilemma. Our ability now to sustain life artificially in a way is increasingly on collision course with things like economics and, no less, ethics. What are your thoughts on that?

Warraich: I think my training as a cardiologist, and then later on as an advanced heart failure transplant physician, has prepared me not just to focus on being able to do everything we can to help people prolong their lives, but to also think about what some of the tradeoffs might be. I have seen technology such as the left ventricular assist device (LVAD) or mechanical heart pump provide people with the sort of life they never could have imagined. I have seen people be able to live through important life milestones that they had almost no chance of being able to do if this were happening 10 years ago.

But at the same time, I've seen that when people go ahead with these therapies and are unprepared, complications can have a very lasting and sometimes brutal toll, not just on the patient but on their entire care network, including clinicians, nurses, and physical therapists.

Our goal should be getting the best treatment for the best patient. For a lot of patients, that might be an LVAD. I have joined a social media group called LVAD Warriors, but more as a fly on the wall. It has thousands of members. These are people who have had LVADs, and I get to see the highs and lows of what life with an LVAD is like. It's a remarkable experience for me, and I wish others could experience something like that as well. But at the same time, I do think we can better prepare patients before they embark on these journeys so that even if they still go ahead with it, they will be ready for what might happen. But there is a tension because of the economics of all of it. We still live in a fee-for-service world, and unless payment models change and unless we are incentivized to give good care rather than more care, I do think that the tension is going to continue.

Topol: It's a really vital issue, not just currently but also for the future of medicine. What you are bringing up is so apropos with respect to understanding, both from the patient-family side as well as the treating-care-team side.

Making Time to Write

Topol: Storytelling is a special talent of yours, and I'd like to know how you found the time in the midst of residency and fellowship training to write these two books. Also, what are your recommendations for all of the latent-talent people out there who have not done something like this before? How do you fit this in? Do you go without sleep?

Warraich: I need my sleep; I need all 8 hours. Seven hours and 30 minutes just does not cut it for me. I tell this to a lot of people—it's like anything else. I give the example of exercise: If you're going to run a marathon, then you need to be training every day. So if you're going to think of writing something that is long or more in-depth, you need to have worked up that muscle memory in some way. Consistency is really important.

The other thing is, as physicians, if we are writing, we can't afford to be inefficient. I don't think we can afford to be spoiled. What I mean is that I can't afford to take time to write in a rented villa in Southern France. Sometimes I need to write at midnight, sometimes early in the morning, sometimes during lunch break. Or if not write, then at least read and research, because like so much of what we do, writing is easy when you know what you're talking about, when you're confident—especially in nonfiction. I feel that 90%-95% of the time I spend is actually just researching, because once you have done that and you are prepared, the page is not as intimidating.

As for advice for people who [want to write], I tell people that I was surprised by how interested people are in this country and around the world in the stories that we get to tell. Just because you think your experience may be ordinary, that experience may not be ordinary to someone outside of medicine. There is a real curiosity among the public about the work that we do, and there is so much space. There are so many stories that have been untold. Just because I have written a book on heart disease does not mean that no one else can write a great book on it. In fact, I think many more can come in and look at the same thing from different angles.

I do think having a thick skin is important. Being able to write for places like The New York Times has become so hard after November 2016 because we are not just competing with our peers; we are competing with what happened today in Washington, DC, or somewhere else. But there is nothing better than being well prepared. So if a story breaks today and you are prepared to write a good piece on it, you can put something together today or tomorrow, send it in, and have a chance to be part of the news cycle.

Preparation is very important, persistence is important, but also important is just knowing that what we see is not ordinary. What we see is something that is extremely special. We are extremely privileged to be able to be part of people's lives, and there is a real appetite for our experiences out there.

Topol: I want to pick up on that because I like to encourage young physicians like yourself to pursue writing—whether essays or books—because, as you say, we have a front-row seat. We see things that are remarkable and we take a lot of that for granted. And if you can tell stories not just to fellow people in the medical domain but also to the public, it can be illuminating, especially when you can capture the emotions and human factor, which you do so well.

I love to see that, and in fact, if I look back in my career (because I'm on the other end), trying to capture thoughts and put a few books together is the most important thing I have been able to do. Of course, being able to communicate with the public is not something you get in medical school or in your residency or fellowship, but in order to be a really good researcher and writer, you need to be able to do that. That is one of the reasons why you're a standout. It's an opportunity. A lot of the people listening or reading this will know that there are a lot of untold stories and lots of things that we can all relate to the wider community of people.

Where do you go from here? You have these three books. You are so young, with decades in front of you. Have you already worked on the next book?

Next Steps

Warraich: Right now I'm focused on the job that I have been given by Brigham and Women's and the Boston VA. The Boston VA is starting an advanced heart failure program to provide this service to veterans of New England, and that is my top priority now because it gives me an opportunity to put into practice all that I have seen and learned and all of the skills that I have developed. The VA is a great setting to be able to implement that, and I'm really excited.

From a writing point of view, I'm really interested in what is happening with the rural hospitals in America. As I mentioned, I'm between jobs right now and I'm getting to work at some rural hospitals. And it's a very different world. I had only ever worked at places like Beth Israel Deaconess or Duke University, and I have very skewed views of the world. It's given me more perspective on how they are struggling, so that is one story that I think we will have to figure out as a health system, because rural hospitals in America are under stress.

The other thing that I think needs a deep dive is pain. We thought we knew pain and we thought we knew how to treat it, and that is one of the reasons why we have the opioid epidemic. Really, we were wrong about one of the most essential sensations of the human being, of the human experience. There are so many cultural and historical differences around it. Pain is political. Like with heart pain, it is very [gender-specific]. It's a rich area where I can see myself taking a deep dive, because I do think that, like so many other things, it can use a broader lens. It can use a wider view—to think of it not just [as something] in the moment but about what it means in the entire spectrum of our existence.

Topol: That's great. We will be looking forward to reading about your experience in the rural hospitals, about pain, and many other things that have not even come to mind yet. We're wishing you the best at your new post at both the Boston VA and at Brigham, which you will be starting in a couple of months. Thanks so much, Haider, for helping us get to know you. Hopefully a lot more people will get to read the things you are writing, not just in books or things published in The New York Times, but in many other periodicals. Congratulations on a fantastic career, and we'll be cheering for you as you go forward.

Warraich: Thank you very much. I'll need all the cheers.

Topol: Thanks to everyone at Medscape and to our community for tuning in to this One-on-One with Haider. We look forward to bringing you more interesting people in medicine and beyond. Thank you.

Warraich: Thank you.

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