Interview with Julian Seifter, MD

After The Diagnosis

Julian Seifter, MDthirdspace sat down with Julian L. Seifter, MD, Senior Nephrologist at Brigham and Women’s Hospital, Associate Professor at Harvard Medical School, and author of After the Diagnosis: Transcending Chronic Illness, to talk about his experiences being a medical student, physician, professor, and author.

Dr. Seifter, tell us about your medical education.
I entered medical school at Albert Einstein College of Medicine in the Bronx, New York in 1971. It was a very traditional medical school in that there were two years of basic science. First year was normal anatomy, biochemistry and physiology; second year pathology, pathophysiology and pharmacology; third year the clinical clerkships; and fourth year clinical electives. I enjoyed the atmosphere, the collegiality, and the principles that the school stood for, and my father, who was a brilliant biochemist and chairman of his department, was one of the founding faculty members there. I started school about 15 days late, because I was employed on a merchant ship that could not return to the US from Southeast Asia because of a major Longshoreman strike. As a result, I missed the head and neck dissection in anatomy, so I never did learn that topic very well. Thank God it wasn’t the kidney!

What did an ordinary day at your medical school look like?
It was very compact. We had lectures from 8 AM to 5 PM every single day. I took the boards before I had pharmacology and pathology. At the time, some vocal students were demanding pass-fail grades in the basic sciences. I never got into those kinds of debates; that wasn’t important to me. I also didn’t object to being taught diseases that other students thought were “irrelevant” for a physician in the US. In my view I considered everything relevant, the real problem was that we couldn’t learn everything. That was the frustration.

Can you give us an example of these student protests?
Yes. At one point students boycotted the parasitology course. They thought they’d never see a case of this or that. Not in the Bronx. Why learn the life-cycle of various parasites, when there was hardly enough time to learn about rheumatic heart disease? When you look back to this era before the growth of immunosuppressive therapy for organ transplantation and cancer, with the AIDS epidemic and the interest in international health for US students yet to come, this argument could not have been more myopic. But I loved that course. One of the influential moments for me was when one of the parasitologists brought to class a bottle with a tick inside, and he passed it around the entire auditorium. Every student had to look at the tick. The parasitologist said: “I’ll tell you a story about this tick.” He was at a hospital in eastern Long Island where there was an 18-year-old woman who developed rapid-onset of total body paralysis, requiring intubation and ventilation. Nobody knew what to do for her, or what the diagnosis was. She was clearly going to die. This parasitologist went to see her and he examined her scalp very, very carefully. He found this tick buried in her scalp. The tick was giving off a toxin and causing paralysis. He removed the tick, and she recovered. He told us: “This is very unusual, very rare, and you could put that under the category of ‘not relevant.’ But to this 18-year-old woman, this was the most relevant thing in her life: that somebody knew about this was extremely important.”

“Being a doctor is, in a sense, a way to underscore that ‘I’m OK, you’re not OK.’ Sickness is not us, it’s other people. In my years on the admissions committee at Harvard Medical School, I read numerous applicant essays that described growing up with an ill or dying family member. The personal brush with disease is often the driving force in the choice of medicine as a career, but it can be a double-edged sword. There’s pain (and sometimes revulsion) in the past, somewhere. Donning a white coat may represent, in part, a wish to keep safe: I’m OK, even if you’re not.”
(Excerpt from After the Diagnosis )

What are some other memorable moments you recall from medical school?
I remember my experiences as a student very well, most good, but some were quite bad. For example, I remember asking a question, on my obstetrics rotation in the old Lincoln hospital in the south Bronx, and the attending said to me: “That’s a stupid question.” I never asked her another question. That did teach me how not to treat students. By the way, Lincoln hospital was built in the 1840’s as a home for runaway slaves, and was condemned for destruction in the 1940’s. Yet there I was in this relic of a hospital, in an underserved neighborhood, overcrowded and anachronistic in the 1970’s. A place where the windows were open for ventilation in the operating room during the summer. A place that admitted mostly Spanish-speaking patients with few official interpreters. On my OB rotation, I took a history from a family member of a young woman on the OR schedule for tubal ligation. It was only then that a mistranslation came to light; she didn’t want sterilization—she was concerned about infertility. The most incredible experience to me by far was moving from the classroom to the clinic. I always showed up at the lectures and at the labs, and had some of the most amazing teachers. But to be able to follow physicians around the wards and to learn from them was most gratifying. I went to a city hospital in New York City for residency. That was one of the best decisions I ever made. And then I went on to training in nephrology.

How was your learning of medicine in the seventies different from medical learning today?
The 1970’s were a very tumultuous time in history. I would come back home after class and turn on the Watergate hearings. Carrying on from the civil rights and peace movement of the 1960’s, I became involved in some of the political issues at the time. I co-chaired a committee with a woman professor who first identified the insulin receptor as a tyrosine kinase. We were against the use of some of the anti-personnel weapons that were being used in Vietnam. We protested the school’s purchasing equipment from the same companies that were producing these weapons. Another hot issue had to do with children at the Willowbrook State Hospital in Staten Island who were being given hepatitis intentionally in order to understand two types of hepatitis: “infectious” (hepatitis A) and “serum” (hepatitis B). We were opposed to the use of children in that way.

What are some of the differences you see in medical students today from students 30-40 years ago?
I think that students today are learning in a more humanistic, but still imperfect, medical world and in a society that for better or worse involves more public discussion. Today we’ve made advancements in recognizing patient’s rights, and in privacy, confidentiality, and human research ethics; but we’re also in an era of increasing complexity, with new diseases, more drugs, greater technology, better molecular understanding of genetics. These developments have raised new issues concerning privacy and disparities in health care. There is just as much to do as there ever was. And students are interested in these causes. However, during training, it’s common to have difficulties understanding “the other side”; sometimes it’s tempting to blame people-- for their illnesses, for poor self-care, for emotional demands, or for “the pain that won’t go away.” I remember when I was in an organic chemistry lab during the Vietnam War and a graduate student wanted a draft deferment, so he asked me if he should enroll in medical school. He said: “The only problem with going to medical school is you have to listen to people’s problems.”

“I’m sitting in a darkened ward next to the bed of a man in distress. He’s in his sixties, though he looks much older, with a lined face and salt-and-pepper hair; his chart says he has heart failure. He’s sitting propped up on pillows, his face blue under the fluorescent light. His breath comes unevenly, and he struggles to get words out. He is Italian, he tells me. I nod. He’s been a cabdriver his whole life. He’s driven the streets of New York; the map is up here, he says, pointing to his head. He’s driven some important people around the city; Mayor Lindsay, one time. I nod. He gulps for air; his lungs sound wet. He has a little garden on the roof of his apartment building, I should see his tomatoes. I nod.
His breath grows raspier. He looks at me. I hold his hand. A shudder runs through him, his eyes close, he slumps forward. His body is still. It’s my first night as an intern, 11:00 p.m. I pronounce him dead.”
(Excerpt from After the Diagnosis )

What made you decide to write After the Diagnosis?
In the past 10 years I gradually stopped hiding an invisible illness, diabetes. I had it throughout my medical career. I gradually decided to talk about myself with students at Harvard Medical School. It was at a time I was having my first eye problem, and I felt it was better for me to talk about it rather than not talk about it. I wanted to discuss choices I made between career and self-care, and how there are many ways to juggle both. I wanted to reflect on how my disease affected me not only as a patient, but as a doctor. I think my own experiences with sickness helped me be a better doctor, and my patients helped me be a better patient. When you’re healthy and young, you separate yourself from “them” - the patients and the old. You want to be healthy. You don’t want to be the one in the hospital bed.

In your book, you write: “Forget about teaching empathy to medical students; we should teach them etiquette instead.” Can you expand on that?
Maybe it’s strong to say “instead,” but I say this to second year students who are going on to their third year, because what they’re often concerned about is what’s the best rotation schedule they should have. And I say to them: “Really what you’re saying is that you’re worried about doing well. But what will determine how well you do is not just how many facts you have at your fingertips, but really how you behave and how you are with people.” I believe very much in respect for the person. How you are with nurses, with your peers, with patients, with patients’ families, how you are under stress - those are the qualities that matter most. Additionally, taking initiative, taking the responsibility, being a reliable person, being kind, and being generous with your time - these characteristics, including curiosity, and etiquette, are the most important things for being a good physician. You don’t have to know everything at the start. You have to be willing to learn and work hard to learn. Nobody knows everything. Nobody will ever know everything.

What was the process of writing the book like?
I tend to view my life in stories. I organize things as to their meaning. So, there’s a narrative. I’ve always thought in this manner. The book was really a matter of writing things down. My wife, whom I married the first week of medical school, is a writer gifted in organizing narratives. Often I would just talk with her. We would be driving on a trip. I would drive and talk, and she would take notes. We wove the stories and put them into chapters. The bullet points were the idea of the publisher, because marketing research shows that the public likes to have bullet poin“Thou shall… Thou shall not…” It wasn’t difficult to make these stories fit that format.

How did sharing your journey with illness affect you?
I was nervous about putting this information out there. There was a lawyer at the publishing house who told me that nobody was going to be unhappy with this book, because it isn’t mean-spirited. I have had tremendous positive feedback. Every once in a while someone will say: “This is a story about a doctor who didn’t take care of himself. A doctor should not ask patients to have a perfect A1C hemoglobin if he himself is having a snack of chocolate chip cookies,” or something like that. For me, that really misses the point. As I discussed in an interview for the New York Times, I never wanted to be a pancreas. I have others things in my life that I want to do. I am not a disease. I am a person who has an illness.

What advice do you have for our readers?
Young students today know the guidelines, know what the disease is like and how to take care of it ideally. But now is the time to incorporate that knowledge while moving on to real patient visits —which means realizing that a patient is a person who has to walk the dog, go shopping, and has a lot of other things that they’re doing and should be doing. It’s not all about the A1C hemoglobin. That to me is the message, and most people get it. And we doctors, like all people, are waiting for our illness. If we don’t have a chronic illness, it’s coming. One out of 3 people has a chronic illness and everybody knows someone who does. People have a lot of stigma, shame and fear about being sick. I see it all the time. “Am I going to lose my job if I tell my employer that I’ll be starting on dialysis?” If you are judgmental, very often the patient will not want to come back and see you. I don’t think it’s my place to judge. After all, I went to medical school, not law school.