Chapter 02: Turning to the Human Side of Medicine:

Title

Chapter 02: Turning to the Human Side of Medicine: "An Impeccable Diagnosis is Not Sufficient"

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In this chapter, Dr. Bruera begins to sketch his medical education. He begins by explaining his selection of a medical school and the education he received (MD conferred, 1979; Universidad de Rosario, Rosario, Argentina). He also speaks about professors who had a great impact on him and how he keeps their influence in mind through keepsakes in his office. He describes this as an important kind of ritual and symbolism he integrates into daily life. Next he describes shifts in his interest in medicine. He began, he explains, with a fascination with disease and how it causes processes to break down in the body. However, as his clinical experience deepened, he became more interested in 'the person around the problem.' He tells several anecdotes from his oncology training that inspired him to shift his focus (Certificate of Specialist, 1984 or 1982, Medical Oncology, Universidad del Salvador, Buenos Aires, Argentina). He explains that his director cautioned him against focusing on what was a 'fringe area' at that time.

Identifier

BrueraE_01_20180806_C02

Publication Date

8-6-2018

Publisher

The Making Cancer History® Voices Oral History Collection, The University of Texas MD Anderson Cancer Center

City

Houston, Texas

Topics Covered

The Interview Subject's Story - Educational Path; Personal Background; Faith; Character, Values, Beliefs, Talents; Personal Background; Inspirations to Practice Science/Medicine; Influences from People and Life Experiences; Professional Values, Ethics, Purpose; Healing, Hope, and the Promise of Research; Human Stories; Offering Care, Compassion, Help; Professional Practice; The Professional at Work

Transcript

Tacey A. Rosolowsi, PhD:

So tell me about your choice of medical school. Let’s see, you got your MD in 1979, so tell me about going to the Universidad de Rosario, is that correct?

Eduardo Bruera, MD:

Right. That was the only medical school really, so I had no other option and no other major choices.

Tacey A. Rosolowsi, PhD:

Was that where your dad went?

Eduardo Bruera, MD:

That is where my dad went. The same place in the same town. It was the only medical school, and so basically I went there without having to make any choices. It was a six-year medical school, so you entered, it was combined with what the U.S. experience would be, the pre-med plus med all together. We had big classes, it was a public school, and as it usually happens, the level of the teaching was quite variable. There were extraordinary teachers and then you had some that were not that great, but I had an amazing experience because I learned that there were some people out there who really were teachers who loved to teach and loved what they did, and I took advantage of a lot of these wonderful teachers, and they had a lifelong impression on me.

Tacey A. Rosolowsi, PhD:

How so?

Eduardo Bruera, MD:

Well, I many times, find myself doing some things of the physical exam that I saw some of these people do, and it’s like I’m carrying it now.

Tacey A. Rosolowsi, PhD:

Can you give me an example? I’m sorry to interrupt.

Eduardo Bruera, MD:

Yes. There was a great internist that was at the beginning of my postgraduate training, Dr. Agrest, Alberto Agrest, who was an extraordinary internist, a brilliant internist in every possible way and he loved doing rounds, seeing patients and taking us around. He did his reflexes, putting the finger and hitting the finger with a hammer, and I still practice that way. He had a special way of also doing the liver exam, that is different from the way it’s recommended nowadays, but I kept doing it like that because in a sense, first of all, I thought it’s brilliant, and second, I think it’s a way of remaining attached to that body of knowledge. So I find that there are some symbolic things, that if you do them, it’s like a ritualistic way of putting you back in a sense of responsibility about what you do, why are you here and the things that you do. So I carry some ritualistic things, like this stethoscope that was given to me by the nurses in Canada, when I left, and that’s a stethoscope that I used to steal from them whenever I went to the floor and they had no—and I did not bring my own stethoscope. Then, when I decided to leave, the nurses from that ward came to my office and brought me as a present, this thing that still says, “Station 30.”

Tacey A. Rosolowsi, PhD:

Oh yeah, there it is, Station 30.

Eduardo Bruera, MD:

There were only two stations in our cancer center and I’m still carrying that with me all the time, and I also have my dad’s picture, giving a talk, in front of my desk, because I think that helps me keep focused on how should I make decisions and how should I behave when I’m writing a paper, when I’m making decisions at the clinical level. I try to bring my medical school and my personal experiences to my daily world, and I think that helps keep me focused on what is right and what should be done.

Tacey A. Rosolowsi, PhD:

Does that have a kind of spiritual dimension for you?

Eduardo Bruera, MD:

To me it is, to me it does. It does have an impact on saying, I am here because I am the product of the investment and work of a lot of people and I should not be letting them down. Some of them are around, some of them are not around anymore, but they all invested a lot in me being here, doing a right thing, and so I need to remind myself that all these people invested in me and I should not let them down.

Tacey A. Rosolowsi, PhD:

It does have an amazing keep you, kind of every moment of your day, connected with your past and your network of people.

Eduardo Bruera, MD:

Yes, yes, yes, and it helps me whenever I have some difficult decisions or thoughts. I always anchor myself on the people that had impact on my life and I say well, if they were in my shoes what would they do in this case. Or if I’m in a fork of decisions, for me or for my career or for a patient, what would they do in this case. That helps me.

Tacey A. Rosolowsi, PhD:

A very important dimension of life for sure.

Eduardo Bruera, MD:

I guess so, yes.

Tacey A. Rosolowsi, PhD:

How did your sense of medicine as a practice and an intellectual body of knowledge, how did that evolve over the course of your medical school? What did you discover about your own abilities?

Eduardo Bruera, MD:

I started really fascinated by disease, as many people do, by the process in which things break down in the body, by the process in which arteries don’t work well and nerves don’t work well, cells are invaded by tumors and viruses. I had that focus for several years and then, when I got into clinical practice, I found that in doing the technical things to diagnose and manage those kind of, we might call it biomechanical abnormalities, were still of interest, but I became progressively fascinated and concerned about the person bringing those problems. I found that what really concerned me was that we had this very limited understanding of how to deal with a person that brought us the tumor or the heart disease or the lung disease, and that that very strong focus on being impeccable in diagnosing and treating the problem was insufficient unless we’re able to address the person. We had no training, no knowledge about how to do that. So, I progressively started getting more and more enthusiastic about helping the person. That’s why slowly, within cancer, I noticed that it was the patient with cancer, rather than the type of cancer, that was concerning me, and how to help the person. So, when I was finishing my oncology training, my boss, I went to talk to my boss and I said, “I want to work in this area, palliative care, supportive care,” and so on. Basically I want to do some of that work that is related to people that are suffering and not having a good time. He said, “Well, that doesn’t happen here, we don’t have anything like this. You can do one of the specialty tumor areas, you can do lung or you can do GI or you can do something like that but really, we don’t have that here.”

Tacey A. Rosolowsi, PhD:

Now where were you at this point?

Eduardo Bruera, MD:

I was in Buenos Aires, in the capital city, doing my cancer training, my oncology training.

Tacey A. Rosolowsi, PhD:

Okay. So, immediately on graduating from medical school, you decided to go to the Universidad de Salvador in Buenos Aires, to be a specialist in medical oncology.

Eduardo Bruera, MD:

That’s correct.

Tacey A. Rosolowsi, PhD:

Okay. And you got that, finished that program in 1984, so why did you choose cancer to go, you know after medical school?

Eduardo Bruera, MD:

To me it was the big barrier, it was the big taboo area, the big challenge, and I wanted something, a big challenge, it was a biological challenge. We were starting to understand how cancer behaves, and so I thought this was an extraordinary opportunity from the perspective of the pathology and the biology and so on, but I never really went into oncology thinking about the patients.

Tacey A. Rosolowsi, PhD:

Right.

Eduardo Bruera, MD:

I went thinking about the cancers. It was only after I started doing my clinical training, that I got the vision of the cancer patient, the person bringing the tumor.

Tacey A. Rosolowsi, PhD:

What were some of the things that began to strike you about the cancer experience for patients?

Eduardo Bruera, MD:

I remember that we were telling patients that having pain was “normal,” because they had metastatic disease in their bones, that was said, when they said I have a lot of pain. Yes, well if you have an awful, awful lot of pain, you can get an IM shot, and that is quite painful in itself, over painkiller.

Tacey A. Rosolowsi, PhD:

IM meaning?

Eduardo Bruera, MD:

Intramuscular. They got a shot into the—like when you get the shots of some of the vaccines, that can be quite painful, the shot itself. They were saying, well that’s normal, because you have a disease. Then well, the patients were—I remember a young woman who was telling me yes, doctor, it must be normal but I’m really hurting a lot. I had no words to respond to that. And then I sensed that people were having a lot of personal suffering from their disease. I remember a young mom who could not lift her child. She basically was telling me that she felt so guilty because her child was putting their little arms towards her, but she was so exhausted that she could not lift the child, and then the child would cry. I was seeing all that and I was saying all that is looked at as noise; the real problem is the cancer, we’re trying to treat the cancer, but the personal experience around it, we did not have a language to incorporate it into the medical record, to measure it, to treat it and so on. So I progressively drifted towards my concern about the person. I was doing very well indeed, training, but my boss was puzzled. My boss said, “Why are you going into these soft areas, why don’t you start with the hard sciences, why don’t you stay with the mainstream medicine? Why are you going to fringe areas?” I remember that conversation because that was a way of him telling me unless you are prepared to reason and go into mainstream, there are no jobs for you in our team. He was candid of saying that he really wanted me to stay there, but he wanted me to stay there to do mainstream cancer treatment. I basically felt that I wanted to focus on understanding how to help the patient. So then I had to send fifty-two letters, in the pre-Internet time, to different places in the world, to see if any of the big cancer centers in the United States or Europe or Canada, were having any interest in this area.

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