The molecular biology revolution and research on how disease impacts quality of life are two of the most exciting advances in the field of medicine, , tells 51˶ in this installment of 10 Questions.
Frieden is a professor of dermatology and pediatrics, and director of pediatric dermatology at the University of California San Francisco and Benioff Children's Hospital. She has more than 30 years' experience in the management of a variety of dermatologic conditions including birthmarks, hemangiomas, eczema, and numerous other pediatric skin conditions. She is the founder and has served as director of the multi-disciplinary Vascular Anomalies Clinic at UCSF for the past 25 years. Frieden is an editor-in-chief of the journal Pediatric Dermatology, co-editor of the textbook Neonatal and Infant Dermatology, and a founding member and executive board member of the Pediatric Dermatology Research Alliance (PeDRA).
1. What's the biggest barrier to practicing medicine today?
The structure of the system itself is the biggest barrier. I feel like we in medicine live simultaneously in both the best and worst of all possible worlds -- there are so many exciting advances, medications, technologies. At the same time, the system for delivering medicine in the United States is a poorly functioning patchwork quilt that is a hybrid between free enterprise and single-payer delivery of care. Often it feels like we are incorporating the worst aspects of both.
2. What is your most vivid memory involving a patient who could not afford to pay for healthcare (or meds or tests, etc.) and how did you respond?
Rather than think of a particular case, I think about repeated scenarios which don't seem to improve. In my specialty, dermatology, there are huge geographic and delivery disparities. On a daily basis we see families drive 4 to 5 hours to get dermatologic care for their kids, even for common conditions such as severe acne or eczema. It is made even worse because children disproportionately have Medicaid insurance (called MediCal in California) and few if any local dermatologists will see them due to very poor reimbursement rates. And although the technologies definitely exist for us to be able to manage many of their conditions via telemedicine, there are huge bureaucratic barriers to being able to do this.
3. What do you most often wish you could say to patients, but don't?
"Believe me, I'm not lying when I say your child's eczema is NOT caused by a food allergy." I do try to get this point across but in more subtle ways. Many parents are convinced that if they cut out a particular food, their child's eczema will go away and they want me to figure out what food is causing it. Unfortunately, it is a multifactorial disease and almost never caused by a discrete food allergy.
4. If you could change or eliminate something about the healthcare system, what would it be?
I wish that the EHR were as elegant and easy to use as a smartphone. One problem is that the EHR is not just a medical record but simultaneously a compliance document. I wish that could somehow be changed. Its dual use means it gets bloated with tons of extraneous information and documentation for all kinds of things that don't fit into the narrative of the actual visit itself. This makes it more time-consuming and more difficult to focus on the central purpose of the visit. And when you read a visit note, you have to wade through tons of verbiage and skip from place to place to figure out what were the key findings and conclusions.
5. What is the most important piece of advice for med students or doctors just starting out today?
Try to stay in touch with the idealism and passion that drew you to medicine in the first place. Most people going into medicine are drawn to the field with a desire to help people, to do right by their patients, and to make a difference in people's lives. Retaining this sense isn't always easy, but a key is practicing what I like to call "realistic optimism." I don't think being cynical or negative is -- in the long run -- very helpful. Instead, it's best to try and look at the glass as half full and see what's really positive about what we do day in and day out, and not spend time and energy bemoaning the frustrating and stupid barriers that we face. Learning how to work in systems, including joining together with others to advocate for change, is also a good coping strategy.
6. What is your "elevator" pitch to persuade someone to pursue a career in medicine?
It's really a privilege to earn a living by doing something that's a mission-driven process where you can affect people's lives in a positive way. You get to help people and be a part of their journeys and lives just by coming to work. And you also make a comfortable living doing it! There aren't that many careers where that's the case.
7. What is the most rewarding aspect of being a doctor?
Being able to have a career where you can have a mission-driven life with a lot of potential for variety, not just always doing the same thing. I also love that I am able to participate in or be in close proximity to new knowledge. For example, the genomic revolution is so exciting and it directly affects our medical practices. When I started in medical school, Watson and Crick had already discovered DNA and scientists had some ideas about how the immune system worked. But the pace of discovery from those days (in the mid-1970s) to now is truly astonishing. As a physician, particularly working in an academic center, I get to have a ringside seat watching these advances and in many cases am able to incorporate them into patient care.
8. What is the most memorable research published since you became a physician and why?
Two things -- one is the molecular biology revolution including our understanding of immunology and genetics. The other is the formal study to understand the impact of disease on quality of life. That's something that wasn't really appreciated before.
9. Do you have a favorite medical-themed book, movie or TV show?
There are two nonfiction books I read recently that come to mind; one is the late Oliver Sacks's autobiography "," which recounts his career path as a neurologist and a writer. The other is Atul Gawande's book "," which I think everyone should read. He is not doing original research, but he synthesizes other people's research and tells stories in a way that really makes you think about death but also about living with purpose. Fantastic. In terms of fiction, I really liked "" by Abraham Verghese.
10. What is your advice to other physicians on how to avoid burnout?
I like to think about work effort as being analogous to aerobic and anaerobic exercise. You have to figure out if what you're doing is aerobic work -- if so, you can continue to do that for a long time and not feel you're doing something that's fundamentally unsustainable. Anaerobic work, on the other hand, is doable in sprints, but is fundamentally not sustainable in the long run.
A book I particularly like that addresses this issue is called "" It talks about managing energy, not time. Flogging yourself to keep going and going doesn't necessarily mean you get more done. It is better to maximize the use of your energy with great focus, but also to take breaks and nurture yourself in other ways. That said, I don't truly believe in work-life balance because I don't think you ever get to equipoise. It is always a work in progress.