Editorial

Rebecca Kowaloff, DO

I can honestly say that a book changed my life. I received “The Lost Art of Healing” by Dr. Bernard Lown from a high school teacher as a gift, and while I read almost exclusively fiction, I happened to read the book years later just after graduating college while applying to medical schools. As the daughter and niece of primary care doctors, I knew the humanistic side of medicine with longstanding and deep patient relationships was one of the most appealing aspects of becoming a doctor. But reading Dr. Lown’s work gave that impetus direction and form. Thinking that medicine was primarily about staving off death, I had not conceived of a role for a physician other than treating with the intent to cure. Dr. Lown’s book made me see how much care there is in treating people facing life-threatening illness and how much our actions as doctors in that sacred time can impact patients and their families. Later, in residency, with a plan to apply to palliative care fellowships, I met Elizabeth in my primary care clinic. She was a thoughtful former high school math teacher who loved to tease me and her daughter-in-law at our visits. Her worsening COPD landed her in the hospital, and her chronic back pain debilitated her increasingly over the months I cared for her. She entered the hospital shortly before Christmas with excruciating back pain such that she couldn’t walk. I sat with her, holding her hand, and looked her in the eyes and gave voice to what she already knew. She was dying. The next words out of her mouth were, “thank you,” and I had never felt more like a doctor. She died at home a few weeks later.

The concept of continuing medical education is one that has been central to our craft since before formalized medical education, as the Worcester District Medical Society’s long history as a repository of medical literature and lecture sponsor illustrates. There are some of us who relish the arrival of a medical journal to pore through the latest research advances and collegial debates within. But many of us, like myself, have our favorite topics, and have a stack of journals that we peruse to keep nominally abreast of new developments relevant to our practice. But are not serious illness care and end of life care relevant to all our practices? Leaving aside specialties that deal almost exclusively with serious illness, rheumatologists treat patients with sometimes debilitating chronic illnesses that leave them vulnerable to serious complications as they progress. Gastroenterologists diagnose cirrhosis which limits prognosis and can cripple quality of life. Interventional radiologists emergently treat life-threatening problems, often on patients who are too sick for traditional surgical approaches. We all need to have formal training in how to talk to patients about their illness frankly, honestly, and compassionately. This is not inherent in being a doctor. We all spent part of our education rotating through specialties so that the psychiatrists among us remember snippets of gynecology or the orthopedic surgeons have had some experience with Crohn’s disease. Unfortunately, even obstetrics and pediatrics are not immune from the realities of serious illness and death. Even if we do not think these skills relevant to our practice, they are at the core of being a doctor.

If the pandemic has shown us anything, it is that politics and bureaucracy aside, the public still holds our profession in noble regard. There is at least a kernel of reverence for the knowledge and skills we have refined and for our dedication, sacrifice, and selflessness. As serious illness and death are the foundation of medicine, I believe we are obligated to develop our ability to discuss these matters with our patients to be worthy of society’s esteem and of our titles. There are not nearly enough palliative care clinicians for all specialties not to be having these conversations with their own patients. To be a provider devoid of the most basic form of these skills would be like a primary care physician who cannot manage routine hypertension or a surgeon who cannot close an incision. Our patients honor us with a trust above all others and we must match that trust with competence and commitment. We all chose specialties that suit us, but we all chose medicine with its central themes of illness and suffering first. Everything we do is to stave off death, but its inevitability is implicit in all our interventions. As we intervene, we must acknowledge that our power to prolong life is not limitless, and demonstrate that our power to be present is.

To be a physician we must be able to address these issues directly with our patients. To be a good physician, we must be able to support them along their illness journey and guide them to the end of their life compassionately. I encourage you to connect with the humanist inside of you who chose medicine and with an open heart and mind to discover your role in delivering the much needed changes in our approach to serious illness in America.

Dr. Rebecca Kowaloff, DO, is board certified in palliative medicine is a member of the inpatient Palliative Medicine team at UMass. She loves to educate lay people and medical providers in palliative care and can be reached at Rebecca.kowaloff@gmail.com.