Hope in Medicine: A Fireside Chat with Dr. John Rhee and Dr. Farr Curlin

Host

Hi and welcome to the Hippocratic Society Podcast. In this series of episodes, we break from our usual content to share presentations from the 2nd Annual Hippocratic Society Conference during which physicians, trainees and students from across our chapters came together to reflect on what it means to live out the virtue of hope in medicine.

Host

We hope you enjoy our esteemed President, Dr. John Rhee and Dr. Farr Curlin, who spoke earlier today,

Host

will be leading this session.

Host

Before this, John has some quick announcements about the QR code that you see on the board, but to give him an introduction before he starts speaking.

Host

John Rhee is a neuro oncologist and palliative care specialist at Dana Farber Cancer Institute and instructor of neurology at Harvard Medical School where he researches supportive care for brain tumor patients.

Host

John is a young member of the Pontifical Academy of Life and co founded the Hippocratic Society and he currently serves as its president.

Host

Please give a Warm welcome to Dr. John.

John Rhee

Great.

Farr Curlin

Thank you everybody. And you could finish up if you, if you want. But the next session is something that's core to what we do in the Hippocratic Society,

Farr Curlin

which is the Hippocratic fora discussions that happen at the local level,

Farr Curlin

which all of you, or most, most of you are familiar with. And it's dialoguing about a particular virtue that we're discussing here today, which is hope.

Farr Curlin

And we've defined hope as, you know, in the local chapters how we typically outline this as we come together in terms of a definition of hope that we have together,

Farr Curlin

go through a case and then talk about why it is important in the context of the practice of medicine and then how we could practically live that out together since we spent a lot of the morning discussing on different definitions of hope.

Farr Curlin

What I'm thinking is that we could have the case up and move directly into the case discussion.

Farr Curlin

And each table has a moderator that's already assigned who will help facilitate the discussions.

Farr Curlin

And we'll have about 20 minutes to share this time together thinking about hope. And we've had different aspects of hope that we've been talking about this morning. And this particular session we're going to be thinking about what it means to hope for sharing the good of medicine with both our colleagues and also with our patients.

Farr Curlin

And so that will be the focus of the discussions at the tables.

Farr Curlin

And then I will do a fireside chat with Farr Curlin about some of the questions that come up in the tables and then have a larger discussion. So just for the facilitators to know right after we read the case.

Farr Curlin

It'll be 20 minutes, so 20 minutes of discussion at the table and then we'll have about 30 minutes of this fireside chat and then maybe 10 or so minutes with the whole, whole group in terms of sharing some of the things that reflections that you may have.

Farr Curlin

Great. So I will read the clinical case out loud and then we'll go from there. All right, so Dr. Maya Chen is a second year attending in the outpatient internal medicine clinic at a large academic medical center.

Farr Curlin

And over the past two years, her clinic has shortened appointment times from 25 minutes to 15 and increasingly evaluates physicians through RVUs,

Farr Curlin

throughput documentation, turnarounds, screening, compliance and patient satisfaction scores.

Farr Curlin

Department leadership frequently emphasizes reducing barriers to care and respecting patient preferences.

Farr Curlin

One afternoon, Dr. Chen sees Mr. Alvarez, a 54 year old man with chronic back pain, obesity, depression and diabetes following a workplace injury several years earlier.

Farr Curlin

He has completed physical therapy, undergone back surgery and tried multiple non opioid medications with little improvement.

Farr Curlin

He lives alone, rarely leaves his apartment and has gradually withdrawn from friends and family.

Farr Curlin

Over the past year, Dr. Chen has begun to suspect that Mr. Alvarez's suffering is no longer primarily driven by physical pain alone.

Farr Curlin

During visits, he often speaks less about his back and more about losing work, routine, purpose and contact with other people.

Farr Curlin

Still, he consistently returns the same request. Opioid medications.

Farr Curlin

At today's visit, Mr. Alvarez tells Dr. Chen that he has started buying oxycodone from a former co worker because,

Farr Curlin

quote, it's the only thing that makes life tolerable. End quote. He says the pills help not only with pain, but with getting out of bed, leaving the apartment and feeling normal for a few hours.

Farr Curlin

Dr. Chen is unsure whether prescribing opioids would meaningfully improve Mr. Alvarez's overall condition or instead deepen patterns of isolation and dependence that already seemed to shape much of his life life.

Farr Curlin

At the same time, she knows refusing to prescribe will almost certainly lead him to seek opioids elsewhere, either from another clinic or illegally.

Farr Curlin

Mr. Alvarez becomes frustrated as she hesitates.

Farr Curlin

I know there are doctors who will prescribe this, he says. If you won't help me, I'll just go find someone else who will.

Farr Curlin

The appointment is already running behind and several patients are waiting to be seen.

Farr Curlin

Dr. Chen turns back to the computer screen,

Farr Curlin

where a notification reminds her that incomplete charts older than 48 hours negatively affect departmental quality metrics.

Farr Curlin

There's the familiar laughter there.

Farr Curlin

So yeah, we'll use this case. Obviously, as you know, in the local chapters, the case is also used to evoke Themes that are coming up in the life of the clinician, but also to share your own experiences with cases that you have as well.

Farr Curlin

But we'll have 20 minutes starting now then.

Host

Thank you, everybody. Our time is just about wrapping up, so if I can invite John and Far to come up to the front, that would be great.

Farr Curlin

Um,

Farr Curlin

but yeah, I think one of the. Sorry, one of the themes that came up at our table that maybe we could start with and this work or is work that you've been doing a lot or building a lot of, also academic thought around is this idea of pursuing the good,

Farr Curlin

especially with colleagues who might not share the perception of the good. And what does it mean to try to pursue this good in medicine or the end of medicine, that is health?

Farr Curlin

And what does it mean to look. What does it look like to try to enact or live out that good in the context of people who may be okay with just renewing the prescription of opioids because time limits, because that's what the patient says that they want.

Farr Curlin

This provider model of care.

John Rhee

What struck me in the,

John Rhee

in the case which rung very true. I mean, I've. I've been seeing many such patients in my line of work was that it really is challenging often to discern if, If.

John Rhee

If hope is this desire for love, for future goods that are difficult but possible to obtain.

John Rhee

Part of,

John Rhee

Part of our challenge is to discern what those goods are. And in this case,

John Rhee

you know,

John Rhee

at the heart of it is a question about what should. What are the kinds of goods that the medical practitioner, Dr. Chen, should pursue as a medical practitioner.

John Rhee

But even if we can agree, as I think we should, that she should be oriented toward Mr. Alvarez's health and not towards satisfying Mr. Alvarez's wishes or even simply minimizing his pain,

John Rhee

that still leaves this really challenging discernments about, well, how do we do that? Is it. To what extent is it even possible?

John Rhee

And if it's partially possible, what things would bring it about?

John Rhee

So it.

John Rhee

I think seeing that reminds me of again, what. Of what Hippocratic Society,

John Rhee

to my mind, one of its values is it's creating space to reckon with those kinds of challenges.

John Rhee

And it also gives me hope, John, for more directly to your question,

John Rhee

for our ability to invite colleagues,

John Rhee

any colleague into community into that conversation,

John Rhee

because as this case suggests, I mean,

John Rhee

treating pain, chronic pain with opioids was something that for years people took for granted, was a good thing to do.

John Rhee

But people have been able, across their ideological differences of all sorts of, to recognize that was a bad idea.

John Rhee

It doesn't mean, as his question suggests, that everybody recognizes it in the same way. But people have been capable of seeing that if we satisfy a person and they're happy with us, then but they go on to die of an overdose, or their kids to die of an overdose or whatever,

John Rhee

then maybe we need to re. Reassess this. So in that way,

John Rhee

in that way, I think the case reflects the fact that we can orient ourselves toward this professional aim of attending well to those whose health is threatened or diminished. People like Mr.

John Rhee

Alvarez, with all the complexity and it is a worthy, challenging, difficult,

John Rhee

needing hope kind of thing to do,

John Rhee

and one in which there is, there are things to us to dialogue with our colleagues about, even if they disagree with, about us, with,

John Rhee

about the overall framework or about any one particular ethical issue.

Farr Curlin

And I think that maybe brings up a question that I've heard from just, especially,

Farr Curlin

I think, just in individual discussions.

Farr Curlin

How have you approached these types of discussions with colleagues who may have different perceptions of the good? How do you practically engage with them? How do you kind of extend the desire to have dialogue with them and then also help them enter into dialogue, into the space of discussing what the good is in medicine?

John Rhee

So I'm in an academic medical center. I have trainees with me most of the time when I'm working clinically and I'm in palliative medicine. So for me, on a case like this,

John Rhee

I would just explain to my trainees,

John Rhee

well, first of all, I'd ask them, what, what do you think,

John Rhee

how should we think about this case with Mr. Alvarez?

John Rhee

What do you think we reasonably, reasonably aim for?

John Rhee

And they'll, they will probably, in a case like this, be able to say something like, well, he needs relief of pain,

John Rhee

but we also don't want him to die of overdose, et cetera, and then kind of draw out for them how they think about it. And,

John Rhee

and then explain how I think about it, which is to explain that I think about this in terms of trying to clarify what his health entails and then to think about what I can do to contribute to it.

John Rhee

And, and so I. There's that, there's that actually scriptural reference where we always be prepared to give a,

John Rhee

an answer for the hope you have.

John Rhee

In my case, I think about that, that concept in terms of always being prepared to give an answer for the way you act or the way you think, the way you reason within.

John Rhee

As a clinician and I found that committing yourself to,

John Rhee

to practice medicine oriented to health without apology,

John Rhee

but also without irritability,

John Rhee

I have I get many opportunities from trainees and colleagues to. To explain what do you. What do you. Why do you do it that way, why do you talk that way, why do you approach that differently?

John Rhee

And then you can. Then you can explain this approach.

Farr Curlin

It also makes me just reflect on some aspect of. So also from my own faith tradition too, if I could share. Just been reflecting on this idea of. I think it's in the Letter to Romans where Paul talks about how affliction results in endurance,

Farr Curlin

endurance results in proven character,

Farr Curlin

and proven character results in hope.

Farr Curlin

And I thought that. That even just from a literary standpoint, it's very interesting and in some sense the basis of what we're talking about here,

Farr Curlin

this idea of proven character both being tested through challenge,

Farr Curlin

not just grinding through it, but also seeing the challenge as a potentially transformative event,

Farr Curlin

and how the proven character or virtue is the basis for perhaps growth and hope and also perhaps the basis for how we interact with others and enter into dialogue with others about the idea of trying to hopefully reach a common sense of what the good is in medicine together.

Farr Curlin

Yeah, maybe we could shift also to the discourse about the patient.

Farr Curlin

And some of the questions that have been coming up in the Q and A have been about also perhaps practical questions around how do we help or accompany a patient who may be feeling hopeless?

Farr Curlin

And so chronic pain is something that probably the experienced clinicians in the room when they read this case,

Farr Curlin

they experienced Dr. Chen's and to quote the esteemed Dr. Brewer Eberly,

Farr Curlin

experienced her heartbreak in the context of practicing medicine. And also how challenging it is sometimes to go into the room of a patient who is experiencing chronic pain and feeling helpless herself about what to do for that patient.

Farr Curlin

And if we feel helpless about it, like, how much more might the patient feel an even deeper sense of hopelessness about it.

Farr Curlin

And so could you share a bit about just how to think through accompanying patients who are at this place of feeling hopeless about their condition improving.

Farr Curlin

Perhaps even in the case of, as a palliative care physician,

Farr Curlin

a patient who is at the end of life and perhaps feeling hopeless about the diagnosis,

Farr Curlin

thinking about how we can practically accompany patients who are feeling a sense of hopelessness.

John Rhee

A critical step, it seems to me, is for us to,

John Rhee

when the facts support this, that we acknowledge that medicine does not have what the patient hopes it will have,

John Rhee

namely, a means of alleviating their pain without harming them in a disproportionate way.

John Rhee

And it's kind of like that earlier conversation about telling someone who's dying of cancer that,

John Rhee

that communicating that our hope is not that we're going to overcome this cancer,

John Rhee

but then orienting toward, well, what can we do? What are the goods that are available for us?

John Rhee

And in someone like this,

John Rhee

I would just want to tell them,

John Rhee

I lament that medicine, the tools we have,

John Rhee

don't work for chronic pain. Otherwise we wouldn't have chronic pain. Right. We would just get rid of it. The reason we have chronic pain is because chronic pain is the sort of thing that medicine doesn't have the tools to resolve.

John Rhee

And I don't want to do harm further by giving you something like an opioid that the best I can tell is not going to.

John Rhee

Not in the long term, going to contribute to your health. It will relieve your pain now, but at the cost of your pain actually getting more complicated and harder to deal with.

John Rhee

And then just try to turn toward very. And I do this all the time with patients. So what. What can we do? And I think there are.

John Rhee

And invariably there's something good that we can work toward.

John Rhee

Like can. What can we. What are the steps? You can. I can meet with you. So part of this is a commitment. I will be with you, I won't abandon you.

John Rhee

But let's meet regularly over the coming months and let's together work toward you growing more capable of living with pain that won't go away.

John Rhee

And so that's kind of where I try to pivot that. Similarly, when someone has advanced cancer, it's less how do we get rid of the cancer than how do we focus on what's possible and how you live well.

John Rhee

And I want to contribute to this in the ways I can with the tools I have with a cancer that won't go away, that is going to take your life in the coming weeks.

Farr Curlin

Yeah, Just one reflection on that as well is as a non philosopher, I don't know where Allison is, but the idea of the perhaps primary object of hope that we were talking about, perhaps that it is or may have to be directed towards, like a question of whether hope exists after death,

Farr Curlin

that there may be secondary objects of hope that we can work on patients with in the sense that I find that even in my palliative care practice that patients,

Farr Curlin

when you ask them,

Farr Curlin

like, what is most important to you,

Farr Curlin

almost universally people say, talk about their relationships that they have and the people that they care for.

Farr Curlin

And that second, even if the kind of object of the primary hope is like for living forever and or afterwards,

Farr Curlin

there can be still secondary objects of hope that can be fulfilled within that period of Time. Whether it is the deepening of relationships,

Farr Curlin

whether it is a sense of getting to my, like, son's baseball game that he's having this weekend, or whether it is sharing a deeper moment with a loved one.

Farr Curlin

Actually, interestingly, just to share an anecdote of a patient last week that I had.

Farr Curlin

She was referred to me specifically to have conversations around medical aid and dying, assisted suicide,

Farr Curlin

so that we could. Because she was. She wanted to request it.

Farr Curlin

And, you know, in some sense, I see that request almost as despair that, like life cannot be,

Farr Curlin

perhaps that there is a sense of despair that one has reached to the point where one feels like it's better to end one's life.

Farr Curlin

And sitting with her.

Farr Curlin

It really had to do with this sense of hopelessness that she actually had about how she would be living her end of life as a patient with a brain tumor,

Farr Curlin

whether she would be able to enter into those times of intimate discussions, love, et cetera, with her family, which is most important to her.

Farr Curlin

And part of the work of the shared hope was actually to share with her as a physician, that I have taken care of hundreds of patients with brain tumors at the end of life.

Farr Curlin

And that actually, though I cannot guarantee in your individual case, the reality is, is that, sure, your cognition may be slower, the attention may be harder, but that people still have really deep moments,

Farr Curlin

closeness and shared relationships at the end of life in which they're interacting in that way. And I think in that way, we actually can restore the sense of hope by getting to the core of, like, what is the fear?

Farr Curlin

And maybe it is a secondary object of that hope, but that it is still, like, a very worthwhile object for the patient who is going through that or living through that.

Farr Curlin

Maybe also shifting a bit to this idea of,

Farr Curlin

again, coming back to this idea of hope for the profession as a whole and sharing this with our colleagues.

Farr Curlin

Similarly, last week,

Farr Curlin

just, I guess, a series of stories, but I have this young gentleman who is in his early 20s and has astrocytoma in the brainstem, unfortunate location.

Farr Curlin

And he is on a benzo and also olanzapine for his anxiety.

Farr Curlin

And he sent me a patient gateway message saying, I'm gonna go down on the olanzapine. And I told him no, because, well, I didn't say that to him. Sorry, but I wanted to say that to him.

Farr Curlin

But, well, we had, over a long period of time, done this, because every time he changes his medications on his own,

Farr Curlin

he goes into a spiral of anxiety and insomnia and then. Then reaches out with, like, all these pages and Saying like, you know, it's, it goes out of control.

Farr Curlin

And so we had agreed in our last clinic visit together that he would not change his medications without first us meeting about it. But he's very young.

Farr Curlin

He also wants control over the unfortunate circumstances in which he doesn't have control over, and in some senses is his reaction to try to gain control over the situation by demanding to me that he's going to come down on the medications.

Farr Curlin

And so of course, I gently told him, like,

Farr Curlin

hey, we agreed to this, like, let's meet and talk about it before you make any changes.

Farr Curlin

Then of course, he responded in a way that was very, very like, you're threatening me, you're holding this over me, et cetera,

Farr Curlin

which again, I understand where it's coming from, it's an emotional reaction.

Farr Curlin

But I do think that when we do have this sense where we're not able to share the good with the patient, even in this case of Dr. Chen,

Farr Curlin

there is the sense where the patient can just say, like, well, I'm just gonna go to another clinician and, you know,

Farr Curlin

whatever, like, that's, that's fine if you're not going to do this for me. And so how do we think about this hope for perhaps a finding, this common ground in the profession of medicine?

Farr Curlin

Because there is a sense in which integrity, as for the profession itself, is damaged when there are certain physicians who might be having a certain idea of the good, another physician having perhaps even contrary idea of the good for the patient, and that creating a sense of also a lack of trust for the profession as a whole.

John Rhee

I'm going to think of this in two parts. First,

John Rhee

what struck me in the case was the way that Dr. Chen is in certain respects in a parallel situation to Mr. Alvarez.

John Rhee

She's dealing with her own so called sort of chronic pain, chronic inability to get out of this tangle of the contemporary health care system in the way it seems to be,

John Rhee

you know, keeping her at home, so to speak, you know, unable to do,

John Rhee

unable to do what she knows she wants to do. And,

John Rhee

and I think the temptation is either to give up and just give in to the chart prompts and the,

John Rhee

the external forces and just basically get rid of Mr. Alvarez, which you can either do by writing a prescription or by just passing him on saying, find somebody else, you know,

John Rhee

but what this, I think what the conversation about the hope has reminded me of is the way that the challenge is really one, is hope related for us, it's, it's to,

John Rhee

to help each other when we are Dr. Chen or when Dr. Chen is our colleague,

John Rhee

see the goods that are still available in this situation. So in the same way that Mr. Alvarez, I want to tell him,

John Rhee

I don't think you're ever going to be free of pain. That's what I would tell him.

John Rhee

At least if you are, it won't be because medicine brought it about.

John Rhee

It'll be because things have happened in your life such that this pain just gradually fades in the way it dominates your life.

John Rhee

But I do think you can get better, you know, or in the case of Dr. Chen, I don't think you're going to get to a situation in this system anyway where you're not getting those prompts.

John Rhee

But there are steps that you could take probably to try to be an agent for change in your context. You could join the Hippocratic Society chapter at your institutions.

John Rhee

You could together start thinking about things that are possible. And you can also, you know, there are.

John Rhee

You have to look for the goods that are available to you there.

John Rhee

Second part, the second part of the question is kind of, what about these disagreements in the profession about what medicine is for?

John Rhee

And, you know, this is actually a, this case doesn't bring that out too much because there is, I think, a shared sense that we shouldn't be treating chronic pain with opioids.

John Rhee

At least it's a rapidly growing consensus among physicians.

John Rhee

But we have other areas.

John Rhee

I mean, just to put one that's rarely talked about in academic medicine on the table, something like gender medicine,

John Rhee

where for a good while we've been in a situation not unlike an era where people said the right dose of pain medicine for a patient is the one they say relieves the pain, period.

John Rhee

I was taught that, you know, and everybody nodded their head.

John Rhee

We all agreed that, that who are we to say what a person needs for their pain?

John Rhee

You know, they know what's right for them, it's their pain, et cetera. We all nodded our head and then a million people died of opioid overdoses over the course of about, you know, 20 years.

John Rhee

And then,

John Rhee

and then we kind of thought, oh, that wasn't not a good idea.

John Rhee

But I think there's,

John Rhee

there is this,

John Rhee

we have this, we have this incredible resource with medicine and that we keep getting faced with the concrete reality of people,

John Rhee

humans who are body, soul, you know, unities, who come to us and they get sick and they're, and they get injured. And so even, even whatever ideological thing is swinging through medicine will be exposed eventually by the reality of people's lives and their, and their, and their bodies and their health.

John Rhee

And so I think we always are.

John Rhee

We always have this resource to be able to come back to with our colleagues. Like, how's this working?

John Rhee

I'm seeing that we always do this. And it seems to me that it doesn't really fit with our orientation that we normally take toward this is I've had these conversations all the time.

John Rhee

We're never going to lose that resource, I don't think, because we're never going to stop facing people who are sick. So that's something that makes me hopeful going forward.

Farr Curlin

Yeah, I love the also the parallel that you drew with what Dr. Chen is experiencing, also in a sense of despair or hopelessness in the system that she's working in.

Farr Curlin

And from our discussions this morning,

Farr Curlin

I've also just been reflecting on this idea of how when we experience aspects in our profession that we do overcome in the setting of affliction, how that adds to in some sense a lived practical wisdom of the sense that, like, we have gone through these things.

Farr Curlin

What I mean by that is the role of also remembering or memory and how that helps preserve hope,

Farr Curlin

that sometimes in a moment of cognitive negative reframing, we could sometimes forget the fact that there are many times that we have been in very difficult situations as clinicians or even as patients, ourselves,

Farr Curlin

and we're able to get through that difficult situation and how important it is to also remember those things,

Farr Curlin

to find hope in the role of memory, perhaps in finding hope. And that some of that also would be important for Dr. Chen, especially in a day where everything seems to be coalescing together.

Farr Curlin

And then the just the second idea was this idea of,

Farr Curlin

again, why community like this is so important in sharing the sense of hope with one another.

Farr Curlin

Because sometimes in a midst of negative frames, what we need is for somebody around us to be able to remind us or help us to re remember the times that we have been able to get through this together and in that sense share that sense of hope with.

Farr Curlin

With each other.

Farr Curlin

I think maybe what we can do is we could shift also now to engaging with all of you and again, we could have the microphones open.

Farr Curlin

But the two themes that we've been talking about here is this idea of hope for finding also common ground and the good of medicine, of health with our colleagues, and then also sharing that sense of hope with our patients.

Farr Curlin

So if people have any questions or comments, also based on the discussions that you had that may have arisen in your table discussion,

Farr Curlin

then I would, yeah, I'd love to hear and share that with you.

John Rhee

As people are getting up, I just want to add,

John Rhee

you asked earlier, how do you have these conversations? And I want to make sure I say this, I think, because I think it's really important for trainees.

John Rhee

If people see that you are committed to being a good physician,

John Rhee

that is,

John Rhee

it breaks down the opposition to,

John Rhee

to you that they would ordinarily or, or naturally have if they see you rather being committed to keeping your personal values.

John Rhee

So I just encourage people to, as a practical matter,

John Rhee

don't talk about your personal values. It's also not talking about your personal values as the reason you don't think you want to give this guy opioids, for example, or,

John Rhee

or, or refer somebody for gender to a gender affirmation clinic is actually not an accurate way of describing your reasons. Your reasons really are professional ones. They're, they're or they're related to what you think medicine is for.

John Rhee

And so if you frame your,

John Rhee

your disagreement as a matter of two different persons with personal values, it seems like you have nothing to bring you together.

John Rhee

And then it becomes a matter of who has power. And it seems like you're imposing.

John Rhee

But if you frame this as I'm committed to being a good physician or becoming a good physician,

John Rhee

but this practice,

John Rhee

as best I can see, it doesn't seem to be consistent with that.

John Rhee

Help me understand how you see it consistent with that. Then you're. Now you're talking about your shared work.

John Rhee

And I think that that's a really helpful way to lean in.

Farr Curlin

Yeah. And just one comment about that is I think one of the beautiful things that we're is this sense of true open dialogue. And I hope that that's something that we could also emulate here,

Farr Curlin

that even in the times that you're discussing with one another at meals to try to,

Farr Curlin

with a sense of genuine curiosity, understand the other.

Farr Curlin

And in that way we come to, I think, truly understanding being at the basis of, of love or relationships that we come to really know each other and where, where how we think about these things and understanding that.

Farr Curlin

Right. Because I think especially in a place where sometimes things are framed around so much around personal values, then it could be, it could come off as whenever you're talking about anything that is coming from also an understanding of trying to reason together what the good of medicine is,

Farr Curlin

that it might just be like an imposition or some type of battle for values, but rather coming from a place of like, I really want to understand, like how you're thinking about this and why you're thinking about this this way.

Farr Curlin

I Think also being an important practice for how we then come to understand our patients.

Farr Curlin

Because I do think that there's something good about medicine where we're able to make quick judgments about what's happening in a room, because that's also important, because maybe there's a patient who's escalating, and you have to know quickly, like, if that's a safe place or not.

Farr Curlin

Right.

Farr Curlin

And at the same time to suspend at times in the right moments or judgments in order to truly understand whether this is not just another chronic pain patient that I have to deal with, but rather, like, what is at the root core cause of, like, what is driving the suffering behind this patient as well.

John Rhee

William.

Audience

Yes, Maybe. Maybe more. More in. In that direction than I. I've come to appreciate. I'm betting far came up with this title because you've Ital. Italicized four,

Audience

and that helps me understand that there's more than one use for that.

John Rhee

That.

Farr Curlin

That word there.

Audience

So by my count, there's hope directed towards medicine with use of 4. Hope could be within the medical practice. Hope could be as a prescription.

Audience

You can give, hope as a treatment you could be. This could be hope for medicine as what is medicine about? What can medicine do? What can do maybe in the future?

Audience

And then hope is a. Like, maybe a virtue informing medicine. So I think probably you're meaning to make us ambiguous here.

Audience

I was struck by the contrast in this case because I felt really bad for Dr. Chen.

Audience

But isn't it the patient who has the problem?

Farr Curlin

Right.

Audience

So what is the medical encounter for?

Audience

And my point is, I think a lot of our dissatisfaction with medicine may come from our own misappropriation of what this encounter really is.

Audience

It's not about me.

Audience

It's. It's about the patient. So I wonder if you would just sort of.

Audience

Y' all are.

Audience

Y' all were touching on this, but really drill into like.

Audience

Like,

Audience

this is very harsh, and I don't mean it to be harsh, but in this case, why should we care about Dr. Chen?

John Rhee

Well, cause we are, Doc. We are.

Audience

And that's intentional.

John Rhee

We are doctors.

Audience

Yeah.

John Rhee

I mean, it seems to me that the reason we care about the doctor is because we care about a practice without.

John Rhee

Without practitioners of that practice being able to do their work well in a way that's sustaining,

John Rhee

then they're not gonna be able to offer whatever that practice offers to their patients.

John Rhee

It seems to me what the re.

John Rhee

What's. So what's powerful about these cases is that. And what makes them difficult is that, yes, this Whole encounter is about Mr. Alvarez.

John Rhee

The point of medicine is health.

John Rhee

And it's not health in the abstract.

John Rhee

It's not the health of populations, it's the health of the people,

John Rhee

the individuals that the physicians see. So in this case, it's about the health of Mr.

John Rhee

Alvarez. The reason it's a painful interaction is because the reality is chronic pain like his is something that medicine just has very little power to heal. So in effect, what the doctor does here is, I think, expression.

John Rhee

The ancient,

John Rhee

the ancient role,

John Rhee

painful role, as I take it. Throughout history,

John Rhee

Brewer talks about this, of being a docere, one who teaches. So you teach Mr. Alvarez as best you can, within a limited time,

John Rhee

the character as best you can of what he's experiencing, namely chronic pain.

John Rhee

You teach him,

John Rhee

hopefully with success, that medicine does not have. I know you, I know you, Mr. Alvarez, hope that we will have something to relieve this pain, but we don't.

John Rhee

And you know, doctors have had to do that all throughout history.

John Rhee

Help people see that they have a problem that medicine can't solve and then combine that with,

John Rhee

I wish it weren't so. I'm going to be with you. You know, I will walk alongside this with you. I'm not just kicking you out the door.

John Rhee

I care about you and I want to know you and I want to figure out what we can focus on that contributes to your health.

John Rhee

But that,

John Rhee

that seems to me why that, that's this. Yes, it's about Mr. Alvarez, but it's about Dr. Chen because he's looking to her with an expectation that she needs to be able to help him reorient because if she doesn't, if she just goes off chasing what he hopes for, she'll make him worse off.

Farr Curlin

I think maybe one other concept that I would add there is how the physician conceptualizes hope in a particular clinical encounter is crucial to how the patient understands hope.

Farr Curlin

And I guess to take another example, like if you are a surgeon and you were consenting a patient for a surgical procedure to remove a cancer,

Farr Curlin

that how you frame the discussion might be that maybe you would,

Farr Curlin

if, if you wanted to in some sense be more kind of self facing about it, maybe you would want to emphasize the risks because then if the surgery turns out well,

Farr Curlin

then it actually makes you look better.

Farr Curlin

But for the patient, actually that might be more harmful or painful or whatnot. Right. And so I do think that there's actually a lot of internal reflection on how we also present these things to patients in terms of how they then also have hope or frame hope in that situation.

Farr Curlin

And if the doctor is in a place of despair about the health system or all of these things, then I do also think that it affects directly the hope of the patient as well.

Audience

Just to build on this conversation about why should we care about Dr. Chen in the relational field?

Audience

And what stands out to me is that these affective states are contagious.

Audience

When we have a patient before us in a visit that's hopeless, helpless, demoralized, depressed,

Audience

those affective states are contagious. And if we're really leaning into the encounter,

Audience

we will experience that too in our countertransference, in our own being.

Audience

And I think that there's a reframe to this discussion because we often think about this dilemma of a case as a me, the clinician, who holds the keys to the opioid cabinet,

Audience

and you, the suffering patient, as sort of a direct conflict rather than a shared relational reality where the two of us together are oriented toward the good or the secondary goods.

Audience

And so often in a visit like this, we were talking about at our table,

Audience

I'll even reorient the way my body positioning is with a patient rather than staring at them as saying, this is what I'm gonna with.

Audience

I'll actually sort of sit a little bit more beside them and look out before us almost like I'm looking out at a horizon, and say something like,

Audience

Mr. Alvarez,

Audience

acknowledging everything you're going through,

Audience

and you deserve the best care possible, the most optimal care possible. I know that we would never want to compromise that in our visits together.

Audience

And these are the things that I think can get us there, can get you there toward that more meaningful flourishing. These are the things that aren't going to get us there with a lot of we lacking language to really lean into the relational connection.

Farr Curlin

That's great. Yeah, I love that. Thank you.

John Rhee

Kari.

Audience

Hi, I'm Nico.

Audience

I'm a undergrad at bc, so I obviously don't have the experience as a clinician, but I do have a lot of experience as a patient for a long time. And so I just wanted to shift the conversation, too, towards, like, I think what everyone's pointing towards, which is that even physicians are imperfect beings.

Audience

Right. Like, we have our own desires.

Audience

Yeah.

Audience

But, yeah, like,

Audience

you know,

Audience

we're also within the structure that we're given within a hospital setting or whatever it is. And so I was thinking also with my experience as a patient, thinking about how we structure, incentive, structure incentives for our physicians and how we can, like, formulaically make sure that we actually are doing what's best for the patient.

Audience

Cause we're talking so much about,

Audience

you know,

Audience

what can we do so that we're thinking about their outcome, but also managing the given situation and the fact that they could go to another clinic and receive care.

Audience

And so there, there seems that there needs to be a way so that we can just help physicians to have like a metric of like, okay, what are my biases?

Audience

Like, I, I'm a finance major at bc. I just finished up organizational behavior. And a lot of the things we talked about was what is a. A bias? It's something that you can't fully see.

Audience

And so if, if we have, you know, if you're a psychiatrist and you need to meet a certain amount of medication that you're going to give to patients,

Audience

like,

Audience

in that situation, can you actually do what's best for the patient if it doesn't fit that metric? And so what, what can we do? What formula can we give physicians so that they can better take control of what they can do and do what's best for the patient?

John Rhee

Well,

John Rhee

you know, we talked about this. To what extent is our focus,

John Rhee

even in Hippocratic Society, on the individual clinicians and fostering character and so on?

John Rhee

A kind of not enough. If we're, if we live in broken systems that are disordered and have all the incentives misaligned and don't we need to change the system?

John Rhee

You know, Anna talked about, I think it was Anna earlier. Do we need a revolution?

John Rhee

And it seems to me, of course, at times revolutions are necessary.

John Rhee

And you, of course, can have different kinds of revolutions. But Ben is an example of someone of a group of people, namely the direct primary care community,

John Rhee

many of whom are examples of kind of doing them,

John Rhee

detaching from the current conventional structures to create new structures.

John Rhee

But most people still have to work in these missiles in systems that are where the incentives are misaligned. And even if we have a revolution, as human history suggests,

John Rhee

we're going to need,

John Rhee

the new thing is going to be corrupt in its own way.

John Rhee

And so if you look back at the history of medicine and you look at physicians writing, they're always writing about corruption.

John Rhee

All the memorable exemplar physicians are writing about corruption in their profession.

John Rhee

And they're aware of how there's all kinds of structures that are leading away from good medicine and temptations away from good medicine.

John Rhee

I just read the Citadel,

John Rhee

for example. Forget the author's name.

John Rhee

D.S. cronin. A.J. cronin.

John Rhee

But it goes way back. I mean, Hippocrates and his movement was responding to what they saw as corruption. So I think this is going to be an endemic part of which is why hope is a fitting thing to talk about.

John Rhee

It's going to be endemic that we find ourselves in structures that are not very well aligned with what we take to be the good that medicine is properly oriented to.

John Rhee

And yet these structures are good. I mean, we have hospitals with all these resources to take care of sick people. That's an amazing thing. So we,

John Rhee

you know, we have to figure out for us what are the goods that are available,

John Rhee

future goods,

John Rhee

difficult but possible to obtain.

John Rhee

How do we align with those who can help us see them, pursue them,

John Rhee

including, as Carrie said, with our patients, Helping our patients see the goods that are actually possible to obtain and fitting to pursue.

John Rhee

And I think this is what makes part of what makes medicine such a really interesting line of work.

Farr Curlin

Maybe the only thing that I would add to that is this idea that though in the Hippocratic Society we are focusing on the formation of the individual clinician trainee,

Farr Curlin

that one of the things that I thought was really interesting when we were first starting off,

Farr Curlin

the very first at the time, Hippocratic forum meeting,

Farr Curlin

which was like during the first wave of COVID on a zoom meeting on a Sunday night monthly with a group of basically my friends who were trainees and residents across the country.

Farr Curlin

And at the end of the year of doing that monthly together,

Farr Curlin

people said that the thing that they really loved the most was that they felt that where they were,

Farr Curlin

they were very alone in trying to live the ideals that brought them to medicine in the first place because of this kind of negative frame in which they were at.

Farr Curlin

And people just complained about what they were doing, and they themselves got sucked into that complaining feel. And they kind of lost a sense of even if they wanted to do what was good for the patient, it was almost like, belittled at times as to, like, why are you doing that?

Farr Curlin

Or like, that's kind of useless or a waste of your time. And to be with a group of people that were striving to live those ideals gave them a sense of strength and hope as to where they were in their individual communities.

Farr Curlin

I think that that is what we are also trying to do. That, sure, maybe like the direct work of the Hippocratic Society is not to go, like, dismantle institutions,

Farr Curlin

But I think there is strength in the formation of community and even at local chapters and also this trying to reclaim as a whole profession then the sense of the good so that we together,

Farr Curlin

in this beautiful practice of medicine can try to renew and rebuild a sense of the deeper meaning of what we're doing for patients. And so,

Farr Curlin

in that sense, I do think that there is something perhaps more systematic about that, but that is intrinsic to bonds and communities that we build with one another,

Farr Curlin

that we also then become kind of a core group of people that allows or awakens in people the desire to see those higher ideals and to also encourage people to live up to the ideals that our profession also asks of us.

Farr Curlin

Time. Okay,

Farr Curlin

last question. Okay,

Farr Curlin

last question.

Audience

I guess not really a question, but I'm Angela. I'm a rising fourth year at Ohio State.

Audience

So, like, one of the things that my table group was talking about is that, you know, there is stuff where we call this perfecting the art of medicine.

Audience

But, you know, one of the phrases that one of my dear, like, colleagues say was that you do not have to be perfect at every moment.

Audience

I know that with Dr. Chen, there is a,

Audience

you know, higher power, aka hospital admin,

Audience

counting all your metrics and saying to you that you need to be fitting these billing hours every single day and making sure you are on top of it. But in this scenario, it can be a chance for you to be a little imperfect and maybe not meet that metric and use that opportunity to get to the point core of.

Audience

You know, I know that, Doc, that Mr. Alvarez is coming to me with this problem, wanting to get opioids for pain and maybe instead of focusing more about,

Audience

you know,

Audience

not really focused about how can I fix all his social dilemmas currently,

Audience

but maybe even getting to the root of Mr. Alvarez, how much do you trust me at this moment? How much do you trust our medical system?

Audience

And why do you feel that,

Audience

you know, where some, like, disagreements or lack of trust that you have that I can currently fix, Maybe even, you know, probably Dr. Not Dr. Chen, probably Mr. Alvarez is feeling that, you know, this doctor will just prescribe me this medication because they don't really care about me.

Audience

But what if that doctor, Dr. Chen, says, hey,

Audience

you know, I'm so sorry that you feel that I do not care about you or that our medical system has failed you,

Audience

but I want to tell you why I can't prescribe you this medication,

Audience

because I do care about you, and let's work together so that at least I cannot alleviate everything that's going on outside of your life, but I can at least help you through this one problem, and maybe tomorrow we can focus on a different problem.

Audience

And if you're having some other issues outside of that, feel free to, you know, contact my office because I'm assuming this is like a clinical practice and not really like an inpatient.

Audience

Very like short, limited time.

Audience

You know, create like more follow ups to be like, I know it was really difficult for you to not get opioids this week. How do you feel even sending? I know there is a little bit like a chart message nowadays to use, or if he doesn't have that option to schedule a follow up in two weeks and ask them,

Audience

how was that going for you to just let him know that you do care? I think those are the moments. Even if you didn't meet that metric of finishing your chart and saying, oh, problem solved,

Audience

I think that really makes bigger strides on the patient care itself.

Farr Curlin

Thank you, Angela.

Farr Curlin

Well,

Farr Curlin

I guess, yeah, we'll end there, but it's a nice way to end.

Farr Curlin

Reflecting on also the virtue of trust and perhaps humility, but both related to hope.

Audience

Great.