The Surprising Lesson from My Cross-Country Book Tour

It’s been two and a half months since the publication of my book, When Doctors Don’t Listen: How to Avoid Misdiagnoses and Unnecessary Tests, and I’m exhilarated and exhausted. Since January, I have been traveling around the country to talk about why it’s so important for doctors to listen and how patient empowerment can transform medical care. The reception to these messages has been excellent, and I’m very grateful to my colleagues around the country for inviting me to speak.

Having given dozens of talks on When Doctors Don’t Listen, I can predict most audience questions. Invariably, someone will ask about medical malpractice: aren’t doctors just protecting themselves by ordering more tests? (My response: the primary cause of malpractice is lack of communication, and tests don’t replace communication.) There will be another question about how the medical profession has reacted to the book. (My response: quite well—who wants to admit that they’re the doctor who doesn’t listen?)

There is one more question that is consistently raised, from Boston to Los Angeles to St. Louis to Cincinnati, one that I wouldn’t have predicted. What do you think about integrative medicine, someone will ask. Why don’t doctors advise patients on other options beyond pills and CT scans? What about treating the whole person, and preventing disease from occurring in the first place?

This question surprised me, as did my lack of knowledge of how little I actually knew about integrative medicine. Even though I was born in China, a country steeped in combining Western practice with Eastern philosophies, my medical training has been exclusively from conventional Western institutions. I cannot recall one course during medical school or residency that focused on complementary medicine or holistic care, or anything other than the disease-oriented model of Western medical care.

In fact, it wasn’t until I was asked this question during my book tour that I began looking into the concept of integrative medicine. I learned that integrative medicine is not synonymous with complementary and alternative medicine, but rather is “healing-oriented medicine that takes account of the whole person (body, mind, and spirit), including all aspects of lifestyle. It emphasizes the therapeutic relationship and makes use of all appropriate therapies, both conventional and alternative.”

This sounds like the type of medicine that all doctors should all strive to practice, and all patients strive to receive! In the words of physician and noted humanist Dr. Abraham Verghese, integrative medicine isn’t “wedded to a particular dogma, Western or Eastern, only to the get-the-patient-better philosophy.” Indeed, millions of patients in the U.S. and around the world embrace this holistic medical practice, and the pioneers of integrative medicine, such as Drs. Andrew Weil, Bernie Siegel, Deepak Chopra, and Dean Ornish, are widely revered.

Yet, from my own experience, I know that integrative medicine is not something we are teaching future doctors. I can also see that, based the persistence of this one question asked around the country, patients are hungry for knowledge on what they can do that goes beyond our Western concepts of disease. Instead of prescribing a pill for blood pressure and cholesterol, what is an exercise regimen that I can try first? Is there an alternative to surgery for my back pain, including yoga and massage? How can doctors coordinate my care with more “traditional” healthcare providers like nutritionists and physical therapists, as well as more “alternative” providers such as acupuncturists and naturopaths? Health is not just about illness, but about prevention and maintaining wellness—how can patients partner in all aspects of their health?

I am in the midst of writing a series on medical errors that occur in the hospitals. We know that conventional Western medicine can save lives, but we also know that medical error happens far too frequently. We also know that 30% of all tests and treatments are unnecessary. Patients are seeking an alternative approach to health. They want information about prevention and natural approaches to health. They want to talk to their doctors about it, but are finding that their doctors—like me—know precious little about integrative care.

During my research in China last summer, I spent some time observing the practitioners of Traditional Chinese Medicine, who were adept at integrative medicine. Unfortunately, this, and my brief but educational visit to Emperor’s College, an oriental medical school in California, is the extent of my interaction and knowledge of integrative medicine.

Now that the book tour is coming to a close, I am looking to learn more about the surprising topic that has emerged and to think more about how to educate conventionally trained doctors like myself to practice a holistic approach to patient care. Please reply with your suggestions for resources. Include links. Recommend books. Suggest places for me to visit, virtually and in person. Contribute your experiences. I’ll post more from my journey in this blog.

A Young Emergency Physician Appreciates the History of U.S. Emergency Medicine Through the Lens of China’s ERs

I’m a young emergency physician, part of the “new breed” that’s always known emergency physicians to be residency-trained and emergency medicine (EM) as a well-respected field. Being a leader in the American Academy of Emergency Medicine, I often hear of our organization’s leaders speak about the struggles they had in establishing our specialty, but I didn’t have a sense of what they actually went through. Why is that they so dislike the term “emergency room” and cringe at the reference to “ER doctors”?

It took a visit to China for me to even begin to understand the reasons. In August-September 2012, I traveled back to the country of my birth to study the current state of medical education here. My trip traversed 9 provinces and involved visits to 14 medical schools and over 50 hospitals.

Being an emergency physician who is interested in healthcare systems, I was particularly curious to visit the Emergency Departments there (we prefer this term and the abbreviation “ED”s to ERs for reasons I’ll speak about later). What I found is quite far from the EDs I know. In fact, everywhere I visited, from rural provincial hospitals in Inner Mongolia to major inner-city teaching hospitals in Beijing, had an emergency ROOM. That’s because patients were literally seen in a giant room, with beds pushed against walls and (if they are lucky) a curtain to divide the rooms. Extra patients were lined up along hallways, often six-deep.

Many places had triage to service, meaning that patients were triaged to a specific area to be seen by specialists who came through the ER. So internists would see patients designated as having medical problems, surgeons would see patients thought to have surgical problems, etc. If the patient turned out to a different problem than was initially decided, a long discussion would take place before the patient was transferred to the correct part of the ER.

Since China is a densely populated country, many hospitals had serious issues with overcrowding. Not surprisingly, the biggest problem seems to be with patients waiting for a hospital bed—basically, boarding.

“Do you often see patients waiting for a bed for 24 hours?” I asked a doctor in a major Beijing hospital.

“24 hours? We are lucky if there’s a bed in 72 hours!” He went on to describe the difficulties he had with admitting an elderly woman with heart failure, diabetes, kidney problems, and liver cancer who came in with difficulty breathing. The cardiologists refused the patient, saying the problem was the kidney. The nephrologists declined, saying diabetes or cancer was the underlying problem. Oncology and endocrine stated the chief complaint was not mainly their issue. General internal medicine said the patient was too complicated. As a result, the patient stayed in the ED for the entirety of her care—a total of 30 days.

The emergency physicians I met attributed the problem of boarding to the lack of respect for the specialty. Though EM is a specialty in China, and there are EM residency programs in some cities, it is considered to be a specialty of last resort—for those physicians cannot make it in other fields. Most EDs are divisions that exist only under the auspices of “real” departments such as surgery and medicine. Attendings working in the ED are scorned by others, and fights over airway, chest tubes, and other procedures are frequent occurrences.

Hopefully, my fellow young American physicians are wondering what kind of backwards environment I’m describing, but many reading this column are probably thinking that this description is not too far from the reality they knew. Indeed, the road to becoming a specialty involves predictable stages. My generation takes it for granted that we are part of excellent training programs and will be specialists in a well-respected medical field. But it wasn’t long ago that our predecessors fought the same battles that China faces now, of specialty recognition, admission privileges, scope of practice, etc.

We young emergency physicians need to thank those who came before us for making our specialty what it is and paving the way for us. For creating the emergency DEPARTMENT (rather than the ER) staffed by emergency physicians (rather than ER docs). For ensuring safer and better care for our patients.

We must also recognize that while many problems have been resolved, many remain. Overcrowding and boarding continue to be problems in EDs across the U.S. There are continuing challenges to our scope of practice, and other specialties still question our abilities. Vocal groups still insist that there are other ways to become “certified” emergency physicians through alternative boards. The corporate practice of medicine remains a real issue for practicing physicians.

It’s imperative for young emergency physicians like myself to continue to find value for our specialty. China’s EM leaders have found creative solutions around their overcrowding and scope of practice by starting “E-ICUs” (emergency ICUs) and transitional care units (transition from E-ICU to home) and staffing “emergency inpatient” and observation units. As we look to the future of EM, we should be aware of our history, work to overcome ongoing problems, and continue to advance our specialty and improve healthcare, in the U.S. and internationally.

This article was initially published in AAEM’s Common Sense magazine. I welcome your comments!

How a Stubborn "Western" Physician Came to Appreciate Eastern Medicine

As a child growing up in China, I was always aware of Traditional Chinese Medicine (TCM). TCM is what we refer to as Eastern medicine, in contrast to the Western medicine we know from U.S. hospitals. I never understood much about TCM, only that it somehow involves herbs and that many Chinese people believe in it. The more I progressed in my medical training in major U.S. academic centers, the more distanced I felt from TCM. Why should I learn about something that lacks evidence, when there’s so much to know about for which there is good research?

For the last month, I have been in China studying its medical education system. While my study is primarily on its Western medical system, I have been so fascinated by what I learned of Eastern medicine that I spent many free evenings observing TCM practitioners. There is so much I didn’t know. For example, I had no idea that many TCM doctors in China undergo rigorous medical training, and actually take the same courses as Western medicine doctors in addition to courses in herbs, acupuncture, cupping, etc. As a discipline, TCM is far too complex for me to understand in my short observation, but there are some very important “lessons from the East” that are applicable to our Western medical practice:

#1. Listen—really listen. The first TCM practitioner I shadowed explained to me that to practice TCM is to “listen with your whole body”. Pay attention and use every sense you have, he said. I watched this doctor as he diagnosed a woman with new-onset cervical cancer and severe anemia the moment she walked into his exam room, and within two minutes, without blood tests or CTs, sent her to be admitted to a (Western) medical service. I’ve seen great emergency physicians make quick diagnoses and disposition decisions, but this was something else! “How could you know all of this?” I asked. “I smelled the cervical cancer,” he said. “I looked and saw the anemia. I heard her speak and I knew she could not care for herself at home.” (I followed her records in the hospital; he was right on all accounts.)

#2. Focus on the diagnosis. I watched another TCM doctor patiently explain to a young woman with long-standing abdominal pain why painkillers were not the answer. “Why should we treat you for something if we don’t know what it is?” he said. “Let’s find out the diagnosis first.” What an important lesson for us—to always begin the diagnosis.

#3. Treat the whole person. “A big difference between our two practices,” said one TCM doctor, “Is that Western medicine treats people as organs. Eastern medicine treats people as a whole.” Indeed, I watched her inquire about family, diet, and life stressors. She counseled on issues of family planning, food safety, and managing debt. She even helped patients who needed advice on caring for the their elderly parents and choosing schools for their child. This is truly “whole person” care!

#4. Health is not just about disease, but also about wellness. There is a term in Chinese that does not have its exact equivalent in English. The closest translation is probably “tune-up to remain in balance”, but it doesn’t do the term justice, because it refers to maintaining and promoting wellness. Many choose to see a TCM doctor not because they are ill, but because they want to be well. They believe TCM helps them keep in balance. It’s an important lesson for doctors and patients alike to address wellness and prevention.

#5. Medicine is a life-long practice. Western medicine revers the newest as the best; in contrast, patients revere old TCM doctors for their knowledge and experience. Practicing doctors do not rest on their laurels. “This is a practice that has taken thousands of years to develop,” I was told. “That’s why you must keep learning throughout your life, and even then you will only learn just a small fraction.”

#6. Evidence is in the eyes of the beholder. Evidence-based medicine was my mantra in medical training, so I was highly skeptical of combinations of herbs that are supposed to have some curative effects. But then I met so many patients who said that they were able to get relief from Eastern remedies while Western treatments failed them. Could there be a placebo effect? Sure. Is research important? Of course. But research is done on populations, and our treatment is of individuals. It has taken me a while to accept that I may not always be able to explain why—but if it helps the patient, that’s what’s important. “In a way, there is more evidence for our type of medicine than for yours,” a TCM teacher told me. “We have thousands of years of experience—that must count for something!”

There is so much I have not covered about TCM. Its practices vary regionally, and no doubt, there are more and less capable practitioners (as there are in Western medicine). More research into TCM methods will be important. However, regardless of whether we Western doctors want to prescribe TCM treatments, we should recognize there is much to learn from Eastern medicine, including what it means to be a physician to really care for our patients. A month into my China trip, I, for one, have a newfound appreciating for Eastern philosophy and medical practice.