When the doctor is the patient

Robert Klitzman’s resistance to his own depression led him to explore what happens when doctors get sick.

Robert L. Klitzman, M.D. ’85, expected the grief that followed the death of his sister Karen, who died at the age of 38 in the World Trade Center on September 11, 2001. But he did not expect that he would be unable to sleep and would suffer from persistent flu. Or that he would stop listening to music and take no pleasure in reading.

When friends told Klitzman that he was depressed, he rejected the idea. As a psychiatrist, of course, he knew that emotional depression often manifests itself in the body. “I’d read it in textbooks,” he acknowledged. Eventually Klitzman did recognize that it was depression, not flu, that was making him feel that his body had “given way” beneath him. “Going through it myself made me realize how much I didn’t know about what it was to be a patient,” he said. That realization, he said, was “a defining moment.”

Klitzman, a research scientist and associate professor of clinical psychiatry at the HIV Center for Clinical and Behavioral Studies at the New York State Psychiatric Institute and Columbia University, had already written five books. In fact, he’d gotten his start as a writer by reviewing books while a medical student at Yale—a starting point he recommends to students today. His role models included Richard A. Selzer, M.D., HS ’61; Sherwin B. Nuland, M.D. ’55, HS ’61; and Howard M. Spiro, M.D.—Yale physicians who are also prominent authors. Klitzman had already contemplated writing a book about doctors as patients. Now, however, “It was no longer an academic question.”

When Doctors Become Patientsis the product of interviews with 70 physicians of all ages who were facing cancer, heart disease, Huntington disease, bipolar disorder, HIV and other illnesses. Klitzman analyzes such common themes as denial of illness, doctors choosing doctors, “self-doctoring,” going public about one’s disease, overworking, coping and the role of spiritual beliefs.

Klitzman found that the doctors viewed themselves either as patients or as doctors, “as if individuals had a zero-sum identity.” In reality, Klitzman said, “They’re not entirely doctors and they’re not entirely patients.” Klitzman called this “odd hybrid form” the “doctor-patient”—one doctor-patient with a foot infection brought his own bag of opiates to the hospital. And as patients, Klitzman’s interviewees were often upset by the carelessness with which their doctors addressed their fears. A surgeon told one doctor-patient that a procedure carried a 5 percent chance of dying. The patient would rather have heard that he had a 95 percent chance of living.

Just as Klitzman resisted the notion of his own depression, his colleagues also denied that they were sick. They told him, “I feel like I have a magic white coat. Illness happens out there—not to me.” Klitzman noted that magical thinking is part of our everyday lives: “When we blow out the birthday candles, we all make a wish.” But doctors deny their irrationality, contending, “We do not engage in magical thinking. We’re trained scientists.”

Perhaps because doctors see themselves as scientists, they are reluctant to discuss religion or spirituality with their patients, as Klitzman’s research suggests. Yet “when patients are lying in bed, that’s what they’re thinking about,” he said. He advocates adding at least a lecture on the topic during medical school.

A reviewer wrote in the New England Journal of Medicinethat Klitzman’s book “goes to the very heart of the question of what a physician is.” In addition, When Doctors Become Patientsserves as a lasting memorial to Karen Klitzman.

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A Yale librarian upgrades Internet access for physicians in Uganda

When librarian Mark Gentry, M.A., M.L.S., set out to expand Internet access at a hospital in Uganda, he experienced déjà vu. “The speed of the Internet took me back 15 years to the beginning of the Web, when we had dial-up modems,” said Gentry, the clinical support librarian at the Cushing/Whitney Medical Library.

Gentry learned about the idiosyncrasies of satellite-based Internet service in Uganda when he joined the Yale-Makerere collaboration, a partnership that includes the School of Medicine, Makerere University and Mulago Hospital in Kampala. Since 2006 Yale attendings and residents have traveled to Kampala for rotations at Mulago Hospital, and Ugandan residents are now coming to Yale for clinical training.

While visiting Mulago Hospital in the spring of 2008, Gentry streamlined Internet use for physicians by setting up a home page that links directly to such often-used functions as e-mail and online journals. “Click: you go right to it. Because every time you get an intermediate page, you have to wait from 10 to 30 seconds,” said Gentry. Meanwhile a Yale resident compiled CDs that allow Ugandan colleagues to bypass the Internet—the disks contain copyright-free information on diseases such as HIV, tuberculosis and malaria.

Gentry next began building up the library for the Department of Medicine at Mulago Hospital, where the medical textbooks were 20 years old. Gentry collected 50 essential texts that were hand-delivered to Kampala. Up-to-date books are a godsend, said Ugandan resident Fred Okuku, M.D. During a five-month rotation at Yale last spring, Okuku discovered journal articles about research done in Uganda that he’d been unable to access at home.

While in Uganda, Gentry promoted a free Internet service called HINARI; sponsored by the World Health Organization for health care workers in developing countries, it provides links to nearly 4,000 journals.

Gentry said the Makerere collaboration has been a natural extension of his work on Cedar Street. “Part of my job as a clinical support librarian is to do what I can to support our people wherever they are.”

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