#226: Medicine Men and Doctors: Common Challenges with Dr. Robert Klitzman

I sit down with Dr. Robert Klitzman—director of the Masters of Bioethics program at Columbia University—to delve into the complex intersections of medicine, ethics, and culture. In this episode, we explore fascinating stories from Papua New Guinea, the cultural roots of disease understanding, the profound vulnerability of patients, and the challenges of doctor-patient communication. Dr. Klitzman’s insights on holistic medicine and the ethical dilemmas in modern healthcare are both thought-provoking and deeply human.

Robert Klitzman's work: 

https://global.oup.com/academic/product/doctor-will-you-pray-for-me-9780197750841

https://amzn.to/42RVgDL

Transcript

Christopher Balkaran (00:00.783)
Welcome to another episode of the Open Minds podcast, folks. I'm your host, Christopher Bulkman. Folks, this is going to be a very interesting one. If you haven't already hit that like button and subscribe. Folks, today we have Dr. Robert Klitzman, the director of the Masters of Bioethics program at Columbia University, a member of the Division of Psychiatry, Law and Ethics. Dr. Klitzman has co-founded and served as co-director at the Center for Bioethics.

And his work spans so many different areas that many of you have heard from me on this podcast before. Ethics, psychology, social issues in medicine and psychiatry. Here in Canada, we have a litany of topics and Dr. Klitzman's work touches on many of them. He's authored 10 books, over 190 academic articles. He's explored topics like HIV disclosure, genetic testing, reproductive

choices and the evolving role of the institutional review boards in medical research. Folks, welcome Dr. Klitzman to the podcast. Doctor, thank you so much for joining me.

Robert Klitzman (01:10.028)
Happy to be here.

Christopher Balkaran (01:12.583)
Professor, I am really interested in your work. I have researched many of your articles, but one thing that really struck out was your research on medicine men in Papua New Guinea and the correlations you saw with modern medical doctors here in the West. So I wanted you to start there and tell everyone about some of the parallels you saw.

Robert Klitzman (01:41.346)
Great. thank you. So I went to New Guinea, Eastern Highlands of Papua New Guinea. New Guinea is an island that lies just north of Australia. It's the third largest island in the world. It lies around the equator. so for many hundred years, when Dutch and Portuguese and other explorers were exploring the area, they kind of stayed away from it. And so it wasn't until World War II when Japan

after bombing Pearl Harbor, wanted to take Australia and New Guinea lay in the way and so became a major war zone. So the Battle of Guadalcanal, for instance, was in New Guinea. And for the first time, planes flew over the interior and it had been thought that the interior was uninhabited and instead they found that there were four million people living there in the Stone Age, this in World War II, and very little was known about them.

I worked for a doctor at the NIH named Carl Gajdarszek, who starting in the late 1940s thought that there would be interesting diseases in remote isolated populations that whether because of the environment or genetic or whatever, and he found all kinds of interesting diseases. And one was this disease in New Guinea. It ended up years later being found to be mad cow disease caused by prion, which also causes mad cow disease.

Magcow disease did not yet exist. It was just this odd disease. And he discovered that it was spread by cannibalism. That when in this tribe, the women had no meat in their diet. So when someone died, their loved ones would consume the person in an act of ritual mourning. One woman said to me, this way I'll always have part of my mother inside of me. And they, what happened, the one person in the tribe got this disease.

Christopher Balkaran (03:26.652)
Wow.

Robert Klitzman (03:33.962)
and they were consumed and everyone who ate them or a lot of people got the disease. And then when they died, they were consumed and the disease soon spread and killed up to two thirds of the women. And I was there right when I finished university, so 1981, and we'd not yet isolated it. this was not, mad cow disease didn't happen until 1986. And what happened is, and there's some noise in the background. I know you can hear that, if that's okay.

Christopher Balkaran (03:43.101)
Wow.

Christopher Balkaran (03:54.813)
Mm.

Robert Klitzman (04:03.246)
Do want me to close the window or something or no? Okay, all right. Sorry about that. Let me actually let me just close the window because it's a little loud.

Christopher Balkaran (04:05.764)
All good.

No worries. Sure, sure. No worries.

Robert Klitzman (04:17.294)
That didn't help much. What's that? No, they're doing some work on the building. they had stopped and suddenly they're starting again. Right. but you can hear okay. Even though there's, okay. right. Okay. What's my turn of thought? anyway, so yeah. So mad cow disease wasn't discovered until 1986.

Christopher Balkaran (04:18.581)
No worries. Is it the radiator? Is that the radiator? like the noise that's... nice.

Christopher Balkaran (04:34.983)
Perfectly.

Christopher Balkaran (04:39.901)
86 mad cow disease,

Robert Klitzman (04:45.87)
So I was sent there to study basically to measure the incubation period because when I went there in 1981, the cannibalism had stopped around 1960, but people were still getting ill. And so the feeling was these people probably were at feasts in 1960, but they needed someone to find out if that was the case. And that's what I did. And I found that people were at a feast and then now 20 and then later more than 20 years later getting infected. But what struck me was when I was there,

I said, how come you continue to practice cannibalism when the disease was going on? And they said, well, cannibalism does not cause a disease. What causes the disease? Sorcery causes the disease. And they believe that a sorcerer would take something that belongs to you. So people protected all their belongings. And then it was said the sorcerer can even use your food scraps and they would wrap it around a stone and bury it and cast a spell on it. And people would dig up stones and say, see this stone.

This is the stone that killed my mother. And I'd say, no, no, Kuru is caused by a little thing like an insect. And they said, well, show it to us. And I said, it's too small to see in your special machine. Well, what does it look like? We don't know. Have you seen it? No, I said, because we hadn't identified it. And they said, that's just magic. It's a stone that killed my mother. Then they said, and besides, we've cured Kuru. You haven't. And so at this point, anyone who thought they had a headache, the medicine man would cure.

Christopher Balkaran (06:02.705)
Wow.

Robert Klitzman (06:12.98)
And I said, who have you cured? And he said, all these people I've cured, 20, 30 people who are near us watching this, me talking to them. I said, who haven't you cured? And he said, well, that one guy there who was the one person I thought had the disease. So I said, what's the treatment? And he said, well, for two weeks, you're not allowed to drink water or eat salt or touch, remember the opposite sex. And I give them some plants and I cast a spell on them. So said, well, how come someone got sick anyway? said,

Christopher Balkaran (06:38.631)
Drink water.

Robert Klitzman (06:41.474)
He wasn't a good treatment. wasn't a good patient. He failed the treatment. And what I found later is when I trained in medicine and worked in a major cancer hospital, for instance, when patients didn't get better in general, we would say, well, the patient failed the treatment. So in other words, we would often blame the patient for not getting better rather than looking at our own treatments. And sometimes our treatments may not be the most effective. But medicine has a, and is a sort of system of thought where

Uh, you know, doctors want to do everything they can. They're trained to do everything they can. We often don't reflect on what we're doing as much as we should. So we don't. So when I worked as a doctor, my first day as a medical intern, for instance, I was given a list of patients and I went and spoke to the first woman and she was a Japanese woman who was complaining that her grapefruit wasn't fresh. She was cutting her grapefruit. We talked and I went back in the hall and my supervisor said, what have you been doing? I said, I spoke to Mrs. So-and-so.

He said, well, she's dead. Don't waste your time with the dead. I said, what do mean she's dead? I just spoke with her. He said, she's dead. Don't waste your time with the dead. I thought, maybe there's a different patient with the same name. No, he meant her, but we had labeled her do not resuscitate. And so in his mind, she was dead. Don't waste your time with the dead. In other words, she's going to die anyway. Spend your time with other patients. And I was horrified. And I felt like I was back in New Guinea. In other words, why do we have these beliefs we do about medicine?

Christopher Balkaran (07:43.442)
Wow.

Christopher Balkaran (07:53.915)
Wow.

Robert Klitzman (08:08.45)
In other words, it's not just, know, in New Guinea, they said, well, no, it's not, you know, it's a stone that killed my mother and here's the stone you can't even show me. And so people have, you know, why do we have the assumptions we do about what's, what's a disease, what's not a disease and at different points, homosexuality 50 years ago, homosexuality was still a disease until exactly 50 years ago this year, the American Psychiatric Association voted that it wasn't, you know, there are many other things that we call diseases that are or aren't, or we switch or

Et cetera, et cetera. So I became interested in not just the science of medicine, but how we understand it, how do we explain it to people, how patients understand or have trouble understanding it, how doctors, what are our biases, et cetera. And to look at the larger surround of what we're doing, of what we think is a cure or treatment, et cetera.

Christopher Balkaran (09:01.03)
Professor, this is really fascinating because as I listened to your talk and read your research on Papua New Guinea, one thing that struck me was in both instances, people were coming to the medicine man in Papua New Guinea or the Western doctor under duress, under stress, all types of, like, you you're going to your doctor because you're worried about some life altering illness or disease you may have. And that stress compounds with

what the doctor or medicine man is telling you. So you're very vulnerable in that state. Can you talk about that vulnerability and how much trust the patient puts in the doctor in that moment and the real impact the doctor or medicine man has to that patient in that specific chapter in their lives?

Robert Klitzman (09:50.508)
Yes, great question. So patients are vulnerable. When we're sick, we're not ourselves, so to speak. We don't have the energy. Sometimes we're not clear thinking because we're tired or adults are thinking or we don't have the energy or whatever. And we're afraid we're going to die. so part of that is patients are desperate. So patients may say, well, do whatever, do something for me or do it. You have to do something for my mother or

your loved one, whatever, you know, because none of us like death is a huge threat historically. In every culture, there's a lot of attention to how do we understand the fact that we are all just mortal? You know, the Greeks and in many other religions in the past, you know, what separates gods from human or simply the gods live forever and we don't, the gods could be.

Christopher Balkaran (10:31.101)
Mm-hmm.

Robert Klitzman (10:42.26)
screwing around and having affairs and doing bad things and hurting other, but they're immortal. So they were God. So, so we don't deal well with death and Western culture, least in America doesn't deal well with it at all. take old people and put them away in old age homes, quote unquote, et cetera. so

Christopher Balkaran (10:47.741)
Right.

Christopher Balkaran (10:58.119)
Yeah.

Robert Klitzman (11:02.936)
Patients get anxious, they get depressed. Some of that is the result of the actual illness. So if you have cancer, of the biologic effects is anxiety, is depression, et cetera. So patients are very vulnerable. patients put their trust at doctors. And it's very important that doctors work to deserve the trust that's put in them. So if you go back even to the Hippocratic Oath, it's very clear that Hippocratic Oath says, for instance, that confidentiality is very important, that what you hear

Christopher Balkaran (11:23.568)
Hmm.

Robert Klitzman (11:32.522)
As a doctor, patients may tell you whatever it is, it's very personal information that you don't repeat it outside, that you respect what patients say, and that's a key element of confidentiality. And so doctors have to have a high degree of ethics. And this goes across cultures. If you look at the Ayurveda in Indian tradition, if you look in China at traditional Chinese medicine, there's always a sense that being a

Christopher Balkaran (11:54.215)
Mm-hmm.

Robert Klitzman (12:00.588)
medicine man, you say, a physician, a doctor, has a more responsibility that comes with it. It's different than just selling potatoes in the marketplace or selling, you know, whatever in the marketplace, you know, selling vegetables. I mean, you have a high standard where people are putting their trust in you. You have to have integrity. You have to be concerned primarily with the patient's well-being. You need to respect people, et cetera, et cetera, you know, avoid harming people. It's often said,

Christopher Balkaran (12:08.359)
Yeah.

Christopher Balkaran (12:12.018)
Mm-hmm.

Robert Klitzman (12:29.006)
wasn't part the original Hippocratic oath, but first do no harm is often said. In words, want to, know, these are, and treatments have harms. Unfortunately, there's a lot of treatments they may help, you know, they have, you know, even when you watch Lisa in America, there are ads on TV for drugs and they'll say, here's the good things. And they'll rattle off all the side effects, including death. So, you know, you hope medicines may help 70 % of people, but 2 % may die from the drug. mean, this is just.

Christopher Balkaran (12:48.443)
Yeah.

Christopher Balkaran (12:57.629)
Right. Right.

Robert Klitzman (12:58.21)
You know, we wish we had better medicines, but this is just the state of medicine today. So, patients are vulnerable, as you say, and therefore it's important that doctors be as ethical as possible. And as you mentioned, I work in bioethics and what we do is try to figure out what that means, both train doctors to be as ethical as possible, but also help figure out, you know, what is the ethical thing to do in particular situations? Cause sometimes it's not immediately clear there's competing ethics.

Christopher Balkaran (13:27.463)
Professor, as you were speaking, and we'll get to doctor training in a bit, one thing I want to ask you, I know this may sound far-fetched, but I understand if you haven't had a good night's sleep, if your blood sugar is low, if you got in an argument with your significant other, your friend, your boss gives you terrible news, you lose your job, and then you go to the doctor's office, you're already in a heightened state of stress, anxiety, even depression, even...

may even include suicidal tendencies. And you're coming to the medicine man or you're coming to the doctor already really upset or at least really enraged. Is there an opportunity for physicians to ask those questions, say, have you had a good night's sleep? But before I kind of go down this path of diagnosing, you're giving a prognosis, maybe we should chat when there's a semblance of emotional stability.

Is there that opportunity? But I recognize that's also overstepping into someone's personal life and what they're going through.

Robert Klitzman (14:32.382)
No, I don't think it's overstepping. think one problem is that doctors in the United States and a number of other countries, I'm not as sure as I would like to be about Canada, often have limited time. So the average doctor visit in United States at this point is something like 11 minutes. And a lot of that is spent with the doctor entering data on the keyboard to enter into electronic medical records. I think that good doctors realize that the

Christopher Balkaran (14:45.884)
Yeah.

Christopher Balkaran (14:55.121)
Yeah.

Robert Klitzman (15:01.998)
patients, we call it psychosocial situation, is an important part of the patient's health. So doctors should say, you doing? Tell me what's going on and listen. And they may not go through every question. How is your love life? How's your sex life? How's your relationship with your parents, your spouse, your kids? But what's going on? Any problems?

Christopher Balkaran (15:10.684)
Mm-hmm.

Christopher Balkaran (15:17.563)
You're right.

Robert Klitzman (15:30.922)
One hope that the doctor could pick up on looking at the patient and sensing, okay, the patient looks distra, like you look kind of distressed today and what's going on or, I'm not sleeping, well, why aren't you sleeping? Well, I had a fight with, or, well, I've been drinking a lot, or I've been working, or well, why, what's going on? I mean, so you hope the doctor understands, you know, the holistic picture of the patient to understand what's going on. Because some patients come in and they look, you know, you could,

Christopher Balkaran (15:35.229)
Hmm.

Christopher Balkaran (15:41.156)
Mm-hmm.

Christopher Balkaran (15:47.793)
Mm-hmm.

Robert Klitzman (15:58.796)
You could tell when some people are under a lot of stress and they're strained and especially if the doctor has known the patient for a few years, they can tell something's not right today. so doctors should be asked, they should be aware of that and asking and you know, good doctors are and do that.

Christopher Balkaran (16:01.415)
Yeah.

Christopher Balkaran (16:13.373)
Hmm.

Christopher Balkaran (16:17.263)
That's a great point, Professor. In fact, last year I received some terrible news and I just happened to fall on the same day as my annual checkup and I was so stressed. I went to my doctor and as he was taking my blood pressure, I was asking him, said, do I seem stressed? He says, you're fine. Everything's fine. Your blood pressure is normal. Everything's fine. I don't know. Maybe it's all in your head. And it's so interesting that there are sometimes we do create a reality in our head that doesn't necessarily manifest physically, but we are so convinced mentally, emotionally.

Robert Klitzman (16:26.572)
No.

Christopher Balkaran (16:46.365)
of our reality that we do need that doctor to kind of step in to say, listen, you're okay. It's okay. You're fine. Keep breathing. Everything's okay.

Robert Klitzman (16:55.414)
Yeah, and so doctors, part of doctors offer a lot of reassurance and our emotional state. think Mark Twain once said something like, I'm going to misquote this. I've been through some awful, terrible, terrible experiences, some of which actually happened. Yeah.

Christopher Balkaran (17:10.813)
that's a great quote. I'm going to find that quote. That's great. I wanted to pivot to there's this real issue which you've explored as well, which is that patients having that choice. Some have argued that there is some form of coercion that medical practitioners undertake. And I wrestle with this professor because

Is it coercion or is it providing options given a patient's condition? Similar to the medicine man, know, writing off that patient who's not adhering to his prescription, is it because that person's resisting the coercive nature of what that medicine man is prescribing, or is it in fact someone completely doing away with medical science or a practitioner's diagnosis? What are your thoughts on that kind of options that a patient could consider versus coercion?

by medical practitioners.

Robert Klitzman (18:07.872)
Right. So, so we believe in the United States and Canada, the West in patient autonomy, respect for persons. there's four basic ethical, bioethical principles. One is autonomy, respect for the person, respecting for them, then make decisions about their own body. One is beneficence, doing good, trying to help people. Third is avoiding harm. And fourth is justice, which is trying not to make the gaps between the haves and the have nots.

worse, not unfairly burdening or benefiting any particular group, not saying we're going to do research on poor people of color that's going to wealthy white people. We want to make things as even as possible. So we respect people making choice about themselves. That said, the one proviso is that they're able to make an informed choice. So I've had patients with terrible schizophrenia, say, and who say, I want to leave the hospital right now. say, you if you go home, you just had a heart attack.

you know, whatever the problem is, you may collapse on the street, know, you're on these machines that are keeping you, you need to be another week. No, no, I want to go home. So we value. then if you ask that I've had patients who say, you know, I'm going to go home. I want to go home because, you know, Jesus Christ is going to come down from heaven and do a miracle and he's going to give me a new heart or, you know, people say things that are just crazy. So you need to say, or someone may say, someone else may say, look, I'm 101 years old and I've had a good life and

You know, I'll take the risk. may drop dead if I leave, but you know, I've had a good life. So you need to sort of see, well, do they, and we asked them several questions. What is their understanding of what happens if they follow the treatment? What is their understanding of what happens if they don't follow the treatment? You know, why do they want to do what they want to do? And, you know, they understand they have a choice and what will happen either way. So they'll articulate, if they say, well, if I leave the hospital, Jesus Christ is going to send me to heaven and a miracle is going to happen or the UF, you know, the

Christopher Balkaran (19:39.003)
Hmm.

Christopher Balkaran (20:00.445)
.

Robert Klitzman (20:03.214)
that the aliens from outer space are going to come down and save me. And you doctors are really putting poison, putting, I know you're really putting microchips into my body through the IV tube. mean, if something's crazy, say, in the United States, you need to get a judge involved and say, look, the patient's, quote, not in their right mind, et cetera. The other area where

Christopher Balkaran (20:07.579)
Mm-hmm.

Christopher Balkaran (20:15.261)
Mm-hmm.

Christopher Balkaran (20:27.933)
Mm-hmm.

Robert Klitzman (20:31.582)
where we don't always do what a patient wants is with public health. So for instance, if someone says, have syphilis and I'm going to go spread it to everyone I meet, I'm going to pick up whatever, whomever on this, you we say, no, you need to sort of, it's a retreatable disease. need to report it. Who have you slept with, et cetera. Similarly, for instance, stopping at red lights and stopping at a stop sign.

Christopher Balkaran (20:35.453)
Hmm.

Christopher Balkaran (20:51.813)
Mm-hmm.

Robert Klitzman (20:58.862)
You may not want to stop. could say, well, it's my right to go through every stop sign and red light that I want, no matter who's coming at me. And we say, no, in the name of public safety, sometimes you can't, you know, you have to stop at the stop sign or wearing a seatbelt. People's, don't, I don't want to wear a seat, but well, we know that if you don't wear a seatbelt, the risk of accidents goes up. People end up in the hospital for years and costs tons of money that everyone else has to pay for.

And in the United States, the Supreme Court justice at one point says, your freedom of speech ends at the point at which you yell fire in a crowded theater when there's no fire. So there's certain limits and we use this very sparingly. So, but this comes down, has come down with vaccine mandates for children, for instance, that, know, we have many states in the United States have mandated all kids need to be vaccinated for measles and mumps because we know that they don't.

Christopher Balkaran (21:37.298)
Right.

Robert Klitzman (21:55.414)
measles and mumps breaks out, instance. So we avoid, so as long as someone can make the decision themselves and it doesn't affect other people, it's just them. If you wanna make this about your health, if you wanna leave the hospital and die in the street and you understand that, you can do it. If it's, you know, I want to, you know, tuberculosis, I have tuberculosis, I wanna go cough in everyone's face and give them tuberculosis. We say.

Christopher Balkaran (22:20.477)
Hmm.

Robert Klitzman (22:22.946)
Whoa, you you can't do that. You're harming other people. So I think that's where, you know, we avoid coercion at all costs, but if you're harming other people in a very clear way, we say, you know, we can't, it's like someone saying, well, it's my right to go and shoot people. Well, no, it's not your right to go and shoot people. You're, we're going to lock you up. You may say, it's my right to go shoot people, but, infectious diseases, if you've been, you know, infectious disease, you know, you don't have a right to go give it to anyone you want.

Christopher Balkaran (22:38.813)
Yeah. Yeah. Yeah.

Christopher Balkaran (22:50.959)
Right. Professor, I wanted to ask you more on the training physicians undertake for communicating much of what you've just discussed. In fact, in a previous life, used to tutor medical students for writing their acceptance papers or their essays and interviews for some of the big schools, including Columbia in the United States. And one thing many of these students were telling me was like, listen, if someone's diagnosed with

a terminal illness, I just tell them it's a terminal illness. So I would help coach them on like, there's a way you can kind of talk to the family. Can you talk to me about some of that training? Because I recognize a lot of this people just, they need to internalize first.

Robert Klitzman (23:25.006)
Yeah, right, yes, yes,

Robert Klitzman (23:31.234)
Yeah. Yeah. Yeah. Yeah. Great question. So unfortunately, we don't train physicians in communication as well as we should. And this is a huge problem. And why is that? Because there's a lot of science that medical students need to learn. And the science is increasing every year. We're making new discoveries. So there's a lot that medical schools are trying to pump into.

medical students' And a lot of medical students who have gotten into med school by being good at science and facts are not always as good naturally at communication, and it gets short shrift. There's increasing attention to it, but there's a long way to go. So for instance, I wrote a book a few years ago called When Doctors Become Patients, and I interviewed 75 physicians who became patients. And they talked about, when I asked them, what do you now

Christopher Balkaran (24:22.567)
Yes.

Robert Klitzman (24:29.016)
do or know differently, having been a patient yourself with a serious illness that you did not know previously. How do you treat your patients differently now that you've been a patient? A few of them said, I'm much more aware of communication problems. So one surgeon I interviewed said, I've been a surgeon for 40 years, he told me. And the night before my surgery, my surgeon said to me, and I was the patient, there's a 5 % chance you may die tomorrow in the operating room.

And he said, that night I couldn't sleep. And only later that I realized that my surgeon could have said to me instead, there's a 95 % chance things should go OK tomorrow. And he said to me, this person I was in, I've been a surgeon for 40 years, and I never realized that those two bits of information that are statistically the same have such different emotional meaning for patients. Another.

Christopher Balkaran (25:21.413)
Right.

Robert Klitzman (25:24.174)
doctor in that book said, you know, he underwent surgery and after the, you the, you know, came out of the operating room, you know, was in the recovery room. And then the doc, the surgeon came and said, well, I never need to see you again. This doctor's like taken a bed. So rude. mean, he meant, you know, I'm done with your treatment. I don't need to see you again, but it came across as like, screw you. And for the doctor says, you know, every year after that, I send him a postcard on the anniversary of my.

Christopher Balkaran (25:48.349)
Mm-hmm.

Robert Klitzman (25:53.832)
discharge. So I think doctors don't realize that, you know, they're saying things that are going to be heard in much different ways. And they and part of that is from not being a patient themselves. And another doctor I interviewed said, when I asked him what a change he said, well, you know,

You when I went to see the doctor, you know, he would keep me waiting 40 minutes. I was driven up the wall. So I said, well, have you ever kept patients waiting? He said, I don't know. I never thought about it. But talking to him later, said, you know, but I now realize what I need to do is every patient who comes in, I'm going to say, I'm sorry to have kept you waiting. Even if I didn't know that they were waiting and because invariably they are. And just don't think that the person's sitting there 40 minutes and they're anxious and depressed. At least the United States.

To sit in the doctor's waiting for 40 minutes is nothing. That's routine. You expect to sit there for a while, but you know, doctors don't, you know, the word patient is to suffer in Latin and it's both to be patient is to wait and to be a patient is someone with a medical problem.

Christopher Balkaran (26:53.062)
Right.

Christopher Balkaran (27:06.461)
That's so interesting, professor, because often, you when I'm taking public transit and there's a delay, I always think to myself, you know what could calm everyone's anxiety if there was just a 30 second announcement saying, there's an issue on the track, the switch is frozen because it was minus 30 last night in Toronto and we're working on it, we've got heaters out there, that would just ease everyone's anxiety versus nothing, right? So very interesting.

Robert Klitzman (27:31.616)
That's right. The lack of communication is also a problem.

Christopher Balkaran (27:36.925)
Right. Professor, in your book, you also mentioned that doctors, a significant number, attempt to manage their own care, self-prescribe, self-treat themselves. And I feel like that's not just doctors. I feel like many of us do this. You know, we go on Google, we go on YouTube, and we just kind of do this. What are some of the limitations of self-treatment that can help people overcome that hump of like,

I don't want to go in and hear what the doctor has to say. I know what's best for me. I'm just going to do X, Y, and Z instead.

Robert Klitzman (28:09.422)
Yeah. So I think that, um, as you say, some people are, don't go to this doctor because they're afraid. Uh, and that's not a good reason. Um, uh, you know, you want to get treatment if you, know, if you break a leg, you don't want to say, I'll kick care of it myself. It needs to be mixed or whatever you need to cast on it sometimes. Uh, so, uh, people, think, um, there's a lot of information you can get on Google.

Christopher Balkaran (28:18.226)
Yeah.

Christopher Balkaran (28:30.215)
Yeah.

Robert Klitzman (28:37.93)
One problem is there's a lot of information on Google that's wrong or that's biased. So, years ago, a major magazine asked me to pick the best mental health website. So, I at all the different mental health websites and I found there were several groups. were mental health websites that were from not-for-profits interested in helping people with mental health and they were outdated and they didn't have a lot of fancy things. And there were those that were

funded by a drug company that was trying to get you on an antidepressant. And they had support groups and click here and chat with us instantaneously and call right away. And the operator's now on duty and they had more services, but it was all to sort of get you to take the drug. So I felt that there wasn't one best. said, well, either can I give two like one that has sort of support groups online and one that says unbiased information. No, you got to pick one.

Christopher Balkaran (29:11.397)
Mm-hmm.

Christopher Balkaran (29:17.82)
Yeah.

Christopher Balkaran (29:21.797)
Mm-hmm.

Christopher Balkaran (29:27.357)
you

Christopher Balkaran (29:31.003)
you

Right.

Robert Klitzman (29:35.384)
You know, there's a lot of bias information, either it's from a, you know, a drug company or it's outdated because it's from a not-for-profit. So I think you need to look around and there's also conspiracy theories and there's just stuff like disinformation and you know, whatever. So, you know, there are people who hate any Western medicine, you know, you don't need Western medicines. Well, first of all, everyone has a choice. You choose what you want, but

Christopher Balkaran (29:47.666)
Yeah.

Christopher Balkaran (30:01.178)
Yeah.

Robert Klitzman (30:03.554)
You know, for many, conditions, know, Western medicine is very helpful for some things also, you know, often in addition, some people do herbal medicine or something. I'm not saying they have a zero purpose, but, but you know what I'm saying. In other words, so I think, so one problem in doctoring yourself is that you're not objective. no, this, I can ignore this. It's nothing, you know,

Christopher Balkaran (30:24.85)
Mm-hmm.

Christopher Balkaran (30:28.423)
Mm-hmm.

Robert Klitzman (30:29.25)
So a lot of doctors, it's probably nothing. I'm not going to worry about it, et cetera. And it's often said that, you know, the lawyer who represents himself has a fool for client. was like lawyers should not represent themselves either because we're bi, we're all biased. So we may deny certain things, we get over anxious, my God. So there's something called medical student disease, which is when medical students, you know,

Christopher Balkaran (30:42.48)
Hmm.

Robert Klitzman (30:55.598)
young people go to medical school and they read about lymphoma and this and then, know, oh my God, I do have some bumps here and oh, I am forgetting. I must have Alzheimer's. You know, I must have, you know, a brain tumor because I, you know, I'm, you know, and they're not thinking, well, you know, you're not sleeping. You're going out and drinking at night. You're kind of, you're getting crammed full of information. You're under stress. That's why you're not remembering. I forgot to call my mother last night. I must have a brain tumor. So people, it's easy to get anxious and to let your anxieties sort of

Christopher Balkaran (31:02.727)
Wow.

Robert Klitzman (31:25.09)
go wild. But it's important to stand back as you as we talked about earlier, as you mentioned, you know, the doctor said, no, you you had this bad news the day you saw the doctor, but you're, everything's fine. So, you know, our emotions are not over or not rational. So so we get carried away in all kinds of ways. And, know, you need a doctors are trained to have, quote, attached concern to be

Christopher Balkaran (31:43.143)
Yeah, yeah.

Robert Klitzman (31:54.776)
concerned, but also a little bit detached. You don't want to treat every patient as if it's your mother, you know, like, my God, she's dying, but you don't want to be so detached that like, it's just another patient who cares. But we're trained to sort of be objective, be concerned, but objective. And I think that our emotions go wild and diseases make people anxious and depressed.

Christopher Balkaran (31:59.655)
Yeah.

Christopher Balkaran (32:20.637)
Professor, that's really interesting that you mentioned that because I'd be remiss if we didn't talk about patient autonomy and you've written extensively about this. I wanted to throw something out there because this is something that I've wrestled with as well when I read books by Thomas Sass, who's very open, very much a libertarian when it comes to...

to medical science and saying, thank you doctor for the prescription, goes home, doesn't take the prescription, that's the patient's right and autonomy. But yet I know in your article, return of secondary genomic findings versus patient autonomy, you discuss that tension between respecting the patient's right as well as the medical duty to inform. And so I feel like this is the ethical debate. How much patient autonomy does a doctor respect?

while also, as you mentioned, be objective yet still concerned. Can you talk a little bit about that and this tightrope I find that medical practitioners walk?

Robert Klitzman (33:26.38)
Yeah. So the ideal situation is where people make their own decisions and that they're informed decisions. So ideally we have the notion of informed consent, which is that you hear the info. Yes. I understand the information. I understand that if I walk out the door, I'll drop dead. I'm going to be crude about it or that the surgery has a, you know,

Christopher Balkaran (33:35.698)
Yes.

Robert Klitzman (33:51.338)
or this drug has a 70 % chance of helping me, but has a 10 % chance of side effects or death or whatever it is. So you want, you don't want someone to say, I refuse to take the medicine because it's going to kill me. Nor do you want someone to say, I want this medicine because I want to take this medicine because it's going to cure me. I'll never have another problem in my life. And the reality is that we deal with probabilities, right? So that, you know, it's, you know, there's a 70 % of patients or whatever, there's only help.

which means that you may not be helped. And, you know, there's a small chance there may be, you know, bad side effects. And so here's the information. We want to make sure the patient, you know, ideally understands that and then makes a choice. They say yes or no. And the reason is you don't want either of those two extremes. You don't want someone who says, you know, I thought you said this was going to cure me and I still have some symptoms. Yes, they've gone down. I mean, I have an elderly friend who is 90 years old. He has had back problem and he had

surgery and he's upset because he's the pain's gone down but he still has some pain and he thought you know I thought this was going to cure me of the pain and I'm sure the doctors intended to cure the pain but the pain went down 60 percent but unfortunately there's still pain I mean that's an unfortunate situation but so it's important that people understand you know what the reality is now that being said we don't deal well with probabilities

Christopher Balkaran (34:55.709)
Mm-hmm.

Christopher Balkaran (34:59.335)
Hmm.

Christopher Balkaran (35:17.116)
Hmm.

Robert Klitzman (35:17.198)
Think about, don't even know, the weather forecast is often where there's a 30 % chance of rain or a 40 % chance of rain. mean, you'd think that within 24 hours, they'd be able to figure out whether it's going to be in Toronto or New York, right? And whatever the weather now is in Saskatchewan or something is what you're going to get in Toronto in two days or whatever. But we can't even do that right.

Christopher Balkaran (35:34.556)
Eh.

Yeah.

Robert Klitzman (35:42.286)
There was a football, a baseball coach, Yogi Bear, who said, you know, predictions are very hard to make, especially about the future. right. So, you know, we don't always, this is the reality. And we'd great to say, oh yes, we have all the answers. We don't have all the answers. We make our best guests, know, people in pain, we want to help them. You know, there are a you know, a few amazing drugs, but a lot of drugs are, you know, where even surgeries, things go wrong, even anesthesia. I mean,

Christopher Balkaran (35:50.269)
Yeah. Yeah.

Robert Klitzman (36:11.15)
a small percent of people, anesthesia, know, harms in big ways can kill them. So, you know, we do our best to sort of minimize the risk, maximize the benefit and form patients. I think, but that's hard to do and it's hard to communicate that. So a lot of people don't understand statistics well. So there are genetic testing companies.

23 and me and also now you can even test embryos and they'll say well the risk your risk the risk of schizophrenia is double. Well that means it sounds terrible but there means a risk goes from 1 % to 2%. So only 1 % of the population has schizophrenia so if you've doubled the risk it means you have a 2 % chance there's still a 98 % chance you're not going to get schizophrenia.

Christopher Balkaran (36:41.373)
Yeah.

Christopher Balkaran (36:52.541)
Hmm.

Christopher Balkaran (37:01.948)
Right?

Robert Klitzman (37:02.286)
But some people here have double the rate. Oh, I don't want that as a child or I don't want to use that embryo or let's abort the fetus or whatever they'll say. So it's important that people understand there's, you know, there's relative risk and absolute risk. So the relative risk may be it's twice, but the absolute risk is still just 2%. So

Christopher Balkaran (37:07.143)
Mm-hmm.

Yeah.

Christopher Balkaran (37:22.141)
That is so interesting, Professor. I remember Atul Gawande, I think, in Complications writes about this exact issue, and that, like you say, it's not an exact, like, there's an issue in communicating. And then you wonder sometimes, Professor, how many bad medical decisions are done or moved forward based on an

interpretation of the misinterpretation of the data. Like that's very scary actually when you think about it.

Robert Klitzman (37:56.12)
I'm just gonna close the blind here for once.

Christopher Balkaran (37:57.445)
Sure, yeah.

Robert Klitzman (38:06.742)
I think it's okay to do that, right? You could splice in or out, whatever. So, yes, so you hope that the, the doctor communicates the information well in a way that's correct. You hope the patient understands it. One problem is that there are companies trying to sell their product who may not communicate that well. So there are,

Christopher Balkaran (38:06.791)
Just when it's getting good, Professor.

Christopher Balkaran (38:14.649)
Yeah, of course.

Christopher Balkaran (38:34.439)
Right.

Robert Klitzman (38:36.12)
genetic testing companies that don't say, they say, buy our tests for $200. We're going to tell you all this information and it's, you know, we'll tell you it's double these disease, you double the risk. Well, it's again, they don't say, well, it's really 1 % to 2%, for instance. So, and they're people going to buy the tests. It sounds like it's really valuable information and it's not, you know, there's a genetic test that's being sold that predicts whether a patient will commit suicide based on their genes.

Christopher Balkaran (39:01.661)
Wow.

Robert Klitzman (39:03.648)
It's not a good test. mean, there's no genetic test that's clinically useful. That's going to be, you know, can really predict suicide because it's based on all kinds of things. mean, you know, not everyone who's depressed commits suicide and you get the idea, right? You know, they happen to own a gun or they, you know, you can imagine that, you know, whatever the other factors that are involved in some things we just can't predict. It's as I said, we can't even predict the weather 24 hours from now.

Christopher Balkaran (39:21.757)
100%.

Christopher Balkaran (39:31.207)
Yeah.

Robert Klitzman (39:32.598)
you know, to predict what's going to happen. If I were to say, what's the weather going to be 20 years from today? You know, what temperature is going to be, you know, you can make it gas, you know, but it's not, there's lots of, you know, improbables, you know, can, you know, whatever. So, so you hope that, you know, that we train doctors to have integrity, to be ethical. You know, I wish I could say that every doctor is a hundred percent ethical every, with every patient all the time.

Christopher Balkaran (39:39.77)
Yeah.

Christopher Balkaran (39:45.404)
Yep.

Robert Klitzman (40:02.07)
you there's human nature you know there's some unfortunate there as in any profession there are some people who were going to do things they shouldn't be doing we try to avoid that and we try to teach people what they should

Christopher Balkaran (40:14.279)
Professor, that's so interesting and actually really interesting segue because as I read Atul Gawande's work and your work as well, there's something as well. Dr. Gawande says, people who are super stressed often before surgeries, doctors prescribe anti-anxiety medication because they, again, they focus on that 5%, the 1 % that could go wrong, not the 99%. And then that anti-anxiety medication may actually

mix not so well with the actual medication needed post-surgery. And so there's all types of complications as a result of that, that are, you know, if there were more relaxation techniques and meditation. One thing that's interesting is in patients who meditate regularly, I'm sure you're very much aware, they're very much at peace. There's much lower levels of anxiety, less likely to prescribe anti-anxiety medication, things like that.

Robert Klitzman (41:09.442)
Yeah.

Christopher Balkaran (41:12.965)
And those are the techniques that perhaps doctors wish they could communicate with patients about. Don't worry. There's a lot outside of your control. Yes, but there are things you can control like your response to these news. And it dovetails well into your work, Professor, on how patients define suffering. Because if you give me a negative diagnosis, I might on a scale of one to 10 immediately jump to 10.

and then define my suffering at that 10, but through, you know, meditation and others, that can come down quite dramatically to the point where my suffering is just, it's a two or a three, yes, it sucks, but it's not part of my existence.

Robert Klitzman (41:53.612)
Yes, right. Right. Yeah. So we know that mindfulness meditation is very important. I just wrote a book that came out a few months ago called Doctor Will You Pray For Me? Medicine Chaplains and Healing the Whole Person, which is about how doctors and patients when facing terrible diseases, try to find some source of purpose and hope and meaning.

Christopher Balkaran (42:22.161)
Yes.

Robert Klitzman (42:22.542)
and connection their life and and their know their existential issues spiritual issues religious issues people vary some people are spiritual but not religious some people are atheist agnostic evangelical whatever it is but hospital chaplains have found ways of working with patients to find for each person you know how can we give you a sense of purpose and meaning and hope and a lot of that is getting rid of negative thoughts so

Uh, you know, one chap, when I interviewed for the book, uh, said, uh, he was speaking to a elderly man who was, you know, basically still alive, but had this terrible disease and was saying, you know, what's the point of my life? Why am I even still here? You know, shouldn't I just drop, kill myself? You know, my, you know, I've been a terrible father. I've been a son of a bitch and, you know, what's the purpose of my life? Uh, I didn't want to kill himself. I'm like, why am I even here still? And the,

Chaplain picked up the piece of bread on the patient's tray and said, see this piece of bread, let's talk about bread. Isn't bread amazing? You know, it tastes good, it comes from the earth, it's nutritious. know, Jesus called bread the stuff of life, whatever. You know, maybe the point of life is not to have done all these great things, which he said, I haven't done great things with my life, but just to appreciate the moment. Just to live in the moment, appreciate the time you have here, call your kids, you know, try to...

ask forgiveness or apologize, you know, just make the most of what you have now. So there's a lot of, you know, mindfulness techniques focusing on the present, living in the now that can help people. Doctors have not been trained to do this. Chaplains, I found, are hospital chaplains who do great jobs. And I think I wrote the book to give people examples of how they can help themselves in this. And I think part of the reason is that

Historically, medicine in the West has tried since the 19th century has made itself very scientific. So a few years ago, I went to Greece and I went to the site of the largest intact ancient Greek theater in the world, which is Epidorus, that famously, if you drop a pin on the stage, 10,000 people could hear it. It's just perfect acoustics. And it's from, you know, 500 BC. And what I didn't, and it's famous, it's a UNESCO World Heritage Site. What I didn't realize it was part of a hospital.

Christopher Balkaran (44:33.799)
Hmm.

Christopher Balkaran (44:38.416)
Wow.

Robert Klitzman (44:47.83)
And there was a theater, a hospital, and a temple. And I thought, what a wonderful idea. If you're going to have a hospital, you should also have a theater and a temple. And I think that in the late 19th century, in medicine, Western medicine discovered viruses and bacteria and the germ theory of disease. It wasn't all superstition or other things, but it was we can find the cure and find the cause in a treatment. Western medicine said, we're going to be scientific. And all this other stuff is quackery.

Christopher Balkaran (44:55.783)
Yeah.

Christopher Balkaran (45:16.829)
Hmm.

Robert Klitzman (45:17.694)
mindfulness or Chinese medicine or all that stuff's quackery, we're going to ignore it. And I think that's what I found when I wrote the book, when doctors become patients is that's not how patients experience their illness. That what, with nothing these doctors said to me when I said, how have you changed the doctor having been a patient? A few of them said versions like the following, said, you know, patients used to say to me, doc, would you pray for me? And I'd go, yeah, yeah, whatever. And I pooped through it and then I became a patient.

And didn't know if I'd survive. you suddenly realize that these existential spiritual issues are important, but I have no training to deal with them. And so, you know, I think medicine said we're going to be very scientific and we're going to ignore the experience of being a patient. And part of that is mindfulness, but with not everything's going to be a biological answer. It's partly, it's going to be, you want to combine, you want to biopsychosocial approach. You want to pay attention to the person's body.

Christopher Balkaran (45:45.437)
you

Christopher Balkaran (45:52.526)
Mm-hmm.

Robert Klitzman (46:12.494)
course, but also their mind or spirit, et cetera, however you define that, their higher power, whatever it is. And so I think that needs, we need to come back to that as a model of how do we integrate mindfulness, meditation, concern with the person as a whole person, with their humanity, not just there are a bunch of organs that are biological in nature.

Christopher Balkaran (46:33.809)
Mm-hmm.

Christopher Balkaran (46:37.457)
Professor, I know we have limited time, and that's a great response because here in Canada, we have something called medical assistance in dying, and we introduced that here in Canada in 2017. Now, what's interesting about our MADE program is that there's two tracks. One where we have a terminal illness and death is foreseeable, and the second track is where you have a mental or chronic illness and death is not foreseeable.

You just need two physicians to sign off. Well, what's interesting about Canada is this is not unlike other jurisdictions, other jurisdictions have made, but since our introduction, we've seen a 16 to 17 percent year over year increase where now it's in the latest report from the federal government of Canada, 65,000 made provisions.

Now that dwarfs any other jurisdiction. If it were deaths, it would be one of the five leading causes of deaths in Canada. And so to your point, what's interesting, and this is really fascinating. Now, the people think that, you got a terminal illness and you chose made. What they find in the report is 95 % of those who select made is not because of the terminal illness diagnosis.

Robert Klitzman (47:32.065)
Yeah, yeah, yeah. Yeah, that's good. Yeah, yeah.

Christopher Balkaran (47:56.985)
It's feelings of isolation, feeling like they'd be a burden on their family, feeling like they would be a loss of bodily functions. And to your point, I just think, imagine if there were, you know, holistic health services for the individual, would they still select made? And I don't know if that would be the case because they'd be like, this is my reality, but there's health workers. I have strong social supports. My family may not be around, but I have other community connections.

Robert Klitzman (48:10.322)
Yeah, yeah, yeah. Right.

Robert Klitzman (48:22.363)
Yep. Yep.

Christopher Balkaran (48:26.365)
and may no longer be the choice for me. So anyway, it's very interesting to your research.

Robert Klitzman (48:30.86)
Yeah, no, I agree with you. think that, that my understanding is that made make sense for a small group people who, as you say, have a terminal illness where two doctors say this person's not going to survive at the end of three months or six months or whatever. The person over several points says that, and they have options of comfort care of hospice, a palliative care. they're not desperate. have treatment available, et cetera, et cetera. I mean, I think it's.

I think it raises many concerns if it's just for mental health problems, because some of those may be treatable either with antidepressants or as you say, it may be someone who's lonely. again, they may be depressed and if they're in therapy, they may realize that they still can contribute. And there are things that they have to teach younger people or be there for their grandkids or whatever or volunteer to help make the world a better place in whatever cause that they care about.

I think there are many problems with that.

Christopher Balkaran (49:32.605)
Professor, I know we are limited on time. I want to say thank you. We've covered such a wide range of topics on this, and I think you've left the listeners with something that I hope most will explore your work, but also ask those questions internally and talk about these things, because I feel like with a more informed citizenry, I want to thank you for your research. I feel like we're going to get to a place where we can combine Western science-based medicine with

holistic spirituality, religiosity, because that does play a role in patient care. And again, I just want to thank you for raising these ethical questions. Sometimes people find that these are uncomfortable, but I find not talking about it is the greatest injustice for our society as a whole. So thank you so much for your work. folks, I will leave links to the professor's work in the description below. Check it

Robert Klitzman (50:22.124)
You're welcome and thank you.

Christopher Balkaran (50:29.787)
Dr. Klitzman out and I will leave links to his YouTube talks as well because I think they're very powerful. Thanks again, doctor, and thank you for your time.

Robert Klitzman (50:36.12)
Thank you very much. Take care. Bye-bye.