This transcript has been edited for clarity.
Robert A. Harrington, MD: Hi. This is Bob Harrington from Stanford University, here on theheart.org and Medscape Cardiology. On these podcasts, we delve into current science topics and health policy topics. But we also try to introduce you to some of the people in cardiovascular medicine who may be approaching the world of medicine from a different vantage point as opposed to a strictly scientific/research vantage point or a clinical observation standpoint. I'm really looking forward to today's conversation because it's an opportunity to talk with a cardiologist author who I greatly admire and whose work I've enjoyed reading over the last several years.
I'm honored to have Dr Lisa Rosenbaum join me today. Dr Rosenbaum is a national correspondent for the New England Journal of Medicine (NEJM). She is also an assistant professor of medicine at Harvard Medical School and a practicing cardiologist at Brigham and Women's Hospital in Boston. Lisa, thank you very much for joining us here today on Medscape Cardiology.
Lisa S. Rosenbaum, MD: Thank you so much for having me.
On Becoming a Writer
Harrington: As you heard in my opening remarks, I'm very intrigued by cardiologists who either became authors or authors who became cardiologists because it's a special skill set they bring to the world of medicine. Can you tell us about your background? Where did you grow up and go to college and medical school?
Rosenbaum: I grew up in Portland, Oregon. I am the daughter of physician parents. My sister is also a physician. My father is a rheumatologist and studies ocular inflammation or uveitis. My mom is a cardiologist and my grandfather was also a physician.
Harrington: I have to disclose that your mom and I are good buddies, but that is not why you are here. You have tremendous accomplishments on your own, but your mother is someone who I admire greatly so thank you for mentioning her.
Rosenbaum: You have good taste; I love her, too. I went to Stanford for my undergraduate education. I always wanted to be a doctor, so I did not really think about doing anything else. Then around my junior year, I had probably my first real heartbreak, and in order to deal with it, I took a fiction writing class. I totally fell in love with writing. It was cathartic, and I made all these amazing friends. I got obsessed with writing and fiction and the short story. By then, I had done most of my premed requirements. On a whim, I applied to do a master of fine arts in fiction writing and went to Columbia for that right after I graduated college. I got there the week before September 11 in 2001.
It was a really hard year. I got depressed and spent a lot of time just trying to make sense of the world. I literally did not write a word. I was finally in this program where writing could be my life, and I could not do anything. So, I dropped out of the program and went to the University of California San Francisco for medical school, which was wonderful. But I still sort of had this itch to be creative. At some point in that process, it became clear to me that medicine is so rich with stories to tell that it didn't make sense to keep trying to invent stories when I could be talking about the real world.
During this time, my grandfather, who was a rheumatologist in Portland, decided he wanted to write a book with me. When my grandfather was 70, he got a cold that would not go away. Six months later, after being told his illness was all psychological, he was diagnosed with laryngeal cancer. He underwent treatment and radiation therapy, which was successful. He returned to practice and was really disappointed by the state of medicine, having been on the other side. So he wrote a book about it called A Taste of My Own Medicine: When the Doctor Is the Patient, which was published in the late '80s. Then in 1992, Disney made it into the movie The Doctor, starring William Hurt.
Harrington: Oh, wow, I didn't know that. I remember that movie.
Rosenbaum: My dad and I always joked that it was the best movie not to win an Oscar. I watch it every few years. It's really good.
My grandfather had real success and lectured all over the world about meaning in medicine. There are six grandkids on the Rosenbaum side, and at that point, I was the only one in medicine, even though my sister became an endocrinologist, and three of his sons are also doctors. The fourth is an attorney.
The day I got into medical school he started writing me letters. He had this idea that we were going to fix medicine through this exchange of letters about ethical issues and challenges in medicine. That was incredibly meaningful to me but also not coherent in terms of something that I could publish. During this time, he was in his 80s. He ended up getting Parkinson disease and got progressively worse. He lost his ability to write. I have these binders he sent me with my name scrawled in his writing. Then he hired somebody so he could dictate and keep telling me these stories. The point of all this is that there was an inherent meaning in writing for me because it was focused on my relationship with him and knowing that he was not going to be around forever. He died at age 94, about a month before I finished my residency.
Harrington: That is really fascinating, Lisa, because it's reminiscent of books like Letters to a Young Doctor. But here, it's the grandfather to the granddaughter who is a medical student. That is incredibly powerful.
Rosenbaum: All I would ever do was write about my grandfather. It was ridiculous, honestly, and at some point, my dad, who loves him as much as I did, said, "You might want to move beyond the whole topic." He was right and that that was an important thing to do at some point. Now I have all this material, and I never could figure out how to bring it all together. I realized that I was trying too hard to figure out what the theme of each story was and that all that mattered was that the stories existed. These were stories he carried about patients for 50 years. He held onto them and his legacy was passing them along. To me, that is also an aspect of medicine that is now missing. I've been saying that I have this idea to write a book for years. Now I'm really committed to doing it and framing the book with that theme so I can write about him and share some of his stories, but also, in the middle, figure out what happened. What happened to medicine? Why can't we practice like that anymore?
'Writing Is Work'
Harrington: I'm good friends with my colleague, the author Abraham Verghese. I've interviewed him before. Something he and I talk about a lot reminds me of what you said, which is that writing is work and that you have to constantly work on your craft. It sounds like you were honing your craft during the early days of your writing back and forth with your grandfather and while writing about your grandfather. You developed your voice and a style of writing that that has served you going forward.
Abraham is very envious of his colleagues who can turn out a book every July. He says, "I just can't do that. It's work for me, and it's going to take, 3, 4, 5, or 8 years." I think Cutting for Stone took 8 years. Do you feel like it's work?
Rosenbaum: Yes, intensely it feels like work to the point that I prefer seeing patients—not that that is not work. It's a different sort of work, but it's a work that gives you such utter clarity in that your sense of purpose is clear. Your day is going to be busy, but you just go until you can't go anymore. With writing, I'm constantly battling the sense of" Should I keep going? Is this good?"
If you talked to my mom, she would say that I do this with every essay I write. I send it to her at some point and say, "Should I just quit?" She says no, and then says, "You do this every time." And it's true, I do. I may never get to the point where I say, "Okay, I got this." I have not written a book yet, and I've been saying that I'm going to. The challenge for me is figuring out the arc. I don't know exactly what it's like for other people, but I often find that I don't know the point of the essay until I get to the end. So, the book challenge for me is also wondering whether I just need to write the book to figure out what it's about. That feels like a massive project.
Harrington: Obviously, I don't write as you do. I write in the science literature. I write a lot of viewpoints and editorials and those sorts of things. I stick to my lane. Abraham says a lot of similar things to you, which is that he often does not know where the story is going until he tells it. It is a process. A lot of medical students and college students come to see him. Sometimes they come to see me to talk specifically about internal medicine or cardiology. And sometimes there is a sense that you can just dive into this. I'm always glad to hear how hard this is from people like you because it is work you have to practice over the years, isn't it?
Rosenbaum: For sure, and I don't mean that as a complaint. I would pay to get to do this. It's thrilling. As you said, I was honing the craft in medical school. My whole fourth year, I just remember getting up as early as possible, going for a run, and then going to a coffee shop and just writing forever. I didn't publish any of that; it was so bad. But it felt like the right thing to do and what I wanted to be doing.
Harrington: You felt like you had to do it, and that this was part of who you were. Several years ago, one of my colleagues at Stanford asked me to meet his Stanford undergraduate daughter to talk about her future. She was thinking about medical school, but she was also thinking about writing. He and his wife both are basic scientists. He thought they would send her to me, and I would disavow this notion of writing and set her straight. She was a very enthusiastic young woman who was interested in creative writing and I said, "You should do that." She started laughing and said, "My dad sent me to see you for you to tell me I should do biology." I said, "No, you should write, and if you want to come to medicine later or as part of that, that is great, but don't feel constrained by it." I said that medicine needs more people who tell stories and who can help us all deal with issues in medicine through storytelling.
Rosenbaum: I think so, in a very self-aggrandizing way. I agree.
Becoming a National Correspondent for the New England Journal of Medicine
Harrington: How did you start writing for the NEJM? In our world of science, we have NEJM and JAMA as our big general medicine platforms, and you are writing for one of the biggest.
Rosenbaum: I got extremely lucky. I did my residency and fellowship, and then I spent my third-year fellowship at the NEJM. They offer an editorial fellowship every year. This was 2012, 11 years after I had that failed year of misery. But now I had training in medicine under my belt and was a little more grown-up, so it was an opportunity. I said at the outset of the process that I wanted to write perspectives that year, and I got really lucky to be paired with Daniela Lamas. Do you know her dad, Tony Lamas?
Harrington: Yes, I know Tony pretty well.
Rosenbaum: Daniela and I happened to be the two fellows that year. Daniela had been the editor at The Harvard Crimson and she had reportorial skills that I completely lacked. She is an incredible human and so funny and smart. We spent a lot of time together and we wrote together. I learned so much from her in terms of how to think about reporting and investigative journalism, and it was fun. But I also learned, in terms of my own life and ambitions, that I could structure my life around writing, and that it could be fruitful instead of miserable. I had already matched at that point for the Robert Wood Johnson Clinical Scholars program at the University of Pennsylvania. I was still pretty conflicted about whether or not I wanted a research career or a writing career. I ended up working with one of the behavioral scientists at Penn, Kevin Volpp.
I was and still am deeply interested in emotion and risk perception. Intellectually, it had always interested me how physicians deal with risk, how patients perceive risk, how we communicate about risk, and how we talk about risk to the public. I worked on a project on how to improve medication adherence among patients who had a myocardial infarction. My role was to do this qualitative study that entailed talking to these patients about what medication taking meant to them. It was transformative for me because I found that I just wanted to tell people's stories. There are methods for qualitative research, which are universally accepted, but I still felt a little constrained by that. I had to make a table, and what I really wanted to do was write an essay. So I did. I realized that I was always going to be looking for the stories. Why was I trying to pin myself to this research career when there was something else I clearly love so much that also seemed to reveal things we didn't understand? In this case it was how people feel when we tell them to take medicine and what it's like to have a heart attack. All these things are hard to measure.
In the second year of this fellowship, I ended up writing for The New Yorker online. It became another year where I spent a lot of time writing. It was also really exciting just to be at that office and focus on writing. I wanted to keep going and extend the fellowship, but my parents were like, "You've done three fellowships. It's time to get a job." I didn't know who would hire a cardiologist writer; I didn't see any jobs that made sense. I emailed Jeff Drazen who had just retired from the NEJM and said I needed advice. He called me the next day and said, "Why don't you come work for us, and you can take an academic cardiology job wherever you want." I thought I wanted to go to New York, and then I thought I wanted to keep doing research at Penn. But in the end, Jeff said, "Just interview with the Brigham." I did and fell completely in love with it. I have this visceral reaction to being in this division where everybody is just so talented. I feel this awe and so here I am.
Harrington: That is a great story, and there are a lot of good lessons for people thinking about how they want to put a career together. You got good advice. There is a saying, "chance favors the prepared mind." You were certainly prepared when the chance offered itself.
Rosenbaum: I definitely feel like I was in the right place at the right time.
On Burnout and Joy in Practice
Harrington: You are very interested in the important and serious topic of clinician burnout. You write a lot about meaning, joy, and sometimes the not-so-joyful experiences of practicing medicine. And you are willing to take on what seems to be mainstream thought around conflicts of interest and the less-is-more movement. Let's go through those and start with burnout.
Rosenbaum: Jeff used to joke with me that I was burned-out on burnout. How do you not talk about burnout right now if you're writing about medicine? It's on everybody's mind. I try to write about it in a way that seems to get past "let's do yoga and Pilates or create another task force" and look at what this is really about. My fundamental sense about burnout is that we are caught in this vicious cycle of thinking that if we put people in roles where they may be in the hospital less, they are consumed by more administrative tasks.
I think we've completely lost sight of how people derive meaning in caring for patients and giving them the space to create relationships. It sounds so obvious, but I don't think we are restoring that. That feels like the most important issue to me in medicine today. We talk about quality and ways we can measure it. There is so much effort and money invested in improving quality. There are clear ways to improve quality, such as guideline-directed therapy for heart failure. But overall, physicians and patients sense that something so fundamental is missing. I don't know how to get that back, but it is the core of the burnout problem.
Harrington: You have articulated something I have thought about for a long time. I'm a quantitative researcher and a clinical researcher. But in my clinical practice, although I enjoy the application of evidence to practice, the older I get, the more I enjoy in-practice sitting and talking to patients about their life and the meaning of what they are going through. It's my job to help them navigate some of the decisions they are making. The joy I get is not from the application of evidence to practice but from that relationship and just holding someone's hand and hearing about their grandchildren. In some ways I have the luxury of doing that because of the job I have. But I'm with you. We need to figure out how to make this the routine practice of medicine because this is what medicine is at its core. I tell our students, "Medicine is not a science. Medicine is a human art built on scientific principles. And if you want to do science, do science. But if you want to practice medicine, it's a different type of thing."
Rosenbaum: I so agree. What worries me and why I feel this obligation to write about it is because I feel like I carry the torch of my grandfather and my parents. In my home, medicine was a way of life; it was not a job. For so many, we've made it a job. And if you don't have that inside of you because you have not seen it or experienced it, how do you pass that on? How do you live your life like that? That is what worries me.
Taking on Tough Topics
Harrington: You have been willing to take on some pretty big issues such as conflict of interest and have sort of gone against the grain. You have also been willing to take on the less-is-more movement and write about it articulately. You get criticized, so why do you take these topics on?
Rosenbaum: I don't mind getting criticized. I know that I will get criticized when I take these issues on. I take them on because they are important. They are shaping the dialogue. I listened to your American Heart Association presidential address, and it was beautiful. There were so many parts of it I loved. One thing you talked about is trust. Trust between society and the profession is so precious and so important. What worries me about the dialogue around some of these issues is that they ostensibly are about improving public trust, but they consistently compromise it.
The reality is that both of these issues, conflict of interest and less is more, completely ignore the complexity of medicine, of uncertainty, and of what we don't know of the scientific process. I do it because restoring trust in the profession is also part of what will help us be more effective doctors and part of what will mitigate burnout. Someone has to take this on, and I don't mind being criticized about it. When I wrote both series, I wanted to start a dialogue. It's not because I'm not a sensitive person. The thing that feels worst to me in the world is when I feel like I've made a mistake that hurt a patient. That is the worst feeling in the world. But if I write something and somebody disagrees with me, who cares? It's just part of this job. And it's important.
Harrington: I'm glad you phrased it that way. I operate under the principle of my friend and colleague, Rob Califf, who told me when I was a fellow in his research group, "If you're not ticking off somebody, you're probably not saying anything or doing anything interesting." I agree with you—you need to be willing to take on some topics that might make people uncomfortable. My whole issue is making sure we can do that in a culture of civility and respect, which I worry about a lot. What I really enjoy about your writings is that you are willing to take on difficult topics, and you do it in an articulate, civil way, which should make us all pause and think and reflect. Kudos to you for helping us in the public dialogue on some really tough issues.
Rosenbaum: Thanks, and kudos to my editor Debbie Malina and all the editors who edit me. They help tone me down sometimes.
Harrington: It's important to have a trusted editor. Lisa, I could talk to you all day. This was a great conversation and I really enjoyed it. I want to thank you for joining us. My guest on Medscape Cardiology has been Dr Lisa Rosenbaum who is a national correspondent for the NEJM, assistant professor at Harvard Medical School, and a cardiologist at Brigham and Women's Hospital. Lisa, thank you so much for taking time out of a busy day to join us.
Rosenbaum: Thank you so much for having me.
Bob Harrington, MD, is chair of medicine at Stanford University and current president of the American Heart Association. (The opinions expressed here are his and not those of the American Heart Association.) He cares deeply about the generation of evidence to guide clinical practice. He's also an over-the-top Boston Red Sox fan.
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Cite this: A Cardiologist's Search for Medicine's Lost Heart - Medscape - Feb 10, 2020.