Interviewing an Internist: Dr. Agrwal

Interview with Dr. Agrwal

Can you tell me why you decided to enter the medical field?

• So I started thinking about medicine when I was probably 10 years old. I can’t even remember when I didn’t think about it. And then I got to college, and I still really wanted to do medicine. But then, I started doing research. And I got really excited about doing research, so I was working in an immunology lab. And from there, I thought: “wow this is really something I could get really interested in.” And I went ahead and got my doctorate in Biochemistry, and then as I was doing that..doing my postdoctoral work; I realized I really enjoyed working with the patients, and I wanted to do that kind of work. And I didn’t want to put in grants all the time which you have to do in research. So I went back to get my medical degree. I chose internal medicine because I felt that it was a great melding of my interest in immunology, biochemistry, and patient care.

Can you tell us about your specialty of internal medicine?

• So we call internal medicine, medicine for adults or general medicine. It’s the field where we are the folks who do everything that surgeons do not. So, even though medicine has become subspecialized, if you want to think about it, the two basic fields are surgery and internal medicine that is nonsurgical. And this is where we see patients who have acute medical conditions that are nonsurgical and chronic medical conditions which we have a lot of in today’s world as the population ages. We have all the diabetes, heart disease, and high blood pressure. All of medicine that is not taken care of in a surgical procedure comes under the view of internal medicine and that is for people over the age of 18. Although today, internists will actually see patients up to the age of 16. So that is also part of internal medicine. So I would say anything that is not surgical is what we do. And internists, today, are primary care physicians which means you are the first contact with the patient. You are the one who then figures out whether the patient needs to go to a surgeon or whether the patient needs to go to another specialist or not. In this today’s day and age, this concept of something known as the medical home, the internist is the person at the center of the medical home.

We also understand you are involved with medical education. Can you tell us a bit about how you are involved with that?

• So, medical teaching is anything to do with both undergraduate and graduate medical education. So with undergraduate medical education, that’s with the medical students. And then graduate medical education is with the residents. After four years of medical school, you then do training programs where you train.. you actually apprentice and you learn the art/science of medicine..practicing on patients. And so, with that, you need to have mentors. I have been involved with medical education for as long as I can remember. And really, for me, that goes back to when I was in my graduate work. As a graduate student, you teach undergraduates, so we would run lab classes and be the TA’s. So from that, I’m involved in separate things. So when it comes to graduate medical education that’s residency training, that’s really working with residents when they are doing clinical practices. So, they go see a patient, and they try to see what’s going on with that patient. But, they are still in training, so they come back and talk with you, and they present their ideas on what’s wrong with the patient and what they want to do. Make sure they are doing the right things; make sure that they are not missing something, make sure they are following the latest evidence (evidence based medicine), meaning the latest research. My job is basically to make sure they know about that and practice accordingly. And then, they provide something known as high value care which means they don’t do anything unnecessarily, they don’t do testing unnecessarily, they don't get the wrong treatments unnecessarily; they do the right things at the right time. So that is graduate medical education, and I help them work through that evidence based medicine. In the undergraduate world, there are many different types of education so there are people who teach biochemistry, anatomy, and microbiology and all sorts of stuff. I don’t do that. What I work on is what we call the science of healthcare delivery. How do we deliver healthcare today with today’s resources? How do we provide the optimal care for the patient? How do we make sure that they are able to acquire the care they need? So, I teach the medical students what is known as high value care which means again not wasting money, doing the right things at the right time, what techniques can medical students do.

Has there been a shift in focus in the medical field when it comes to teaching and training since you have been in school?

• Oh tremendous, it’s really quite incredible. For one thing we’ve become a lot more humane. There has been a shift from the “old days” when it was much more about ‘be seen and not heard’ if you’ve ever heard those terms. You were there, you followed your attending‒ what they called us, the mentors. You followed your attending, you answered your attending’s questions, and the attending didn’t help you so much with the hands-on work but were there to guide you. In those days, we worked 36 hour shifts and we didn’t have time off‒ all those sorts of things. I don’t know if you’ve ever heard this saying: you know it’s wrong being on call every other night? The joke is if you’re on call every other night you miss being on call every night, missing out on all the experiences. There was this sense that the more you worked, the more time you spent there, the better it was for you. There was this perception that if you couldn’t hack it or didn’t want to hack it, you were weak, you were lazy. And that shift from that modality to the more current methods started in about 2002. Starting around 2002-2003, people asked ‘Is this the right thing to do? Are we endangering patients’ lives by asking these trainees to work 70 hours?’ That is the single biggest change we’ve seen‒ the understanding that you shouldn’t work that many hours, that it’s not safe for you and it’s not safe for the patient. There were days after call, after being up for 36-40 hours, I would be waiting at a stop light to go home and I fell asleep at a stop light. Only did that a few times! But I did do that. The other thing that we are also working on‒ it’s a paradigm shift‒ is understanding that everybody, residents or medical students, needs to have a balance in their lives‒ wellness. Wellness is really important, but I don’t know where that sweet spot is. For a lot of us, we don’t know that sweet spot and we see the differences. Today’s generation doesn’t know what it used to be like, so they still feel as if their work is too harsh. There’s definitely a sweet spot between experiences… getting experiences. Medicine is an experiential field. If you don’t see it, if you don’t learn with hands-on experience, you do not learn it. You absolutely do not learn medicine from books. You can read every book three times, I can read everything, but I will not remember. I will not recognize that disease, I will not know how to treat it unless I do it myself. There’s something to be said for that sweet spot between having the wellness, the life balance, but yet seeing as much as possible. That’s even more crucial for the surgical field. We know from lots of data that the best surgeons are the ones who do ‘X number’ of procedures per year for that. For example, for carotid surgeries, data shows that if you do not do 300 carotid surgeries per year, your skills degrade. Our surgical people have to carry a case lab on how many procedures they’ve done. They have to have done so many procedures in their field. Same with anesthesiologists; they have to have so many procedures because we know every single one increases their skillset.

How have you seen the gender roles in medicine change throughout your career?

• That’s a fantastic and very intuitive question. Do you know who Elizabeth Blackwell is? Her birthday was February 3rd, so it’s one of the days we celebrate and if you haven’t read the book about her it’s a really fascinating book. She was the first woman who went into medicine, and I don’t know if you know her story of why she went into medicine, it was kind of a calling but it was also so she could prove that she went in. When I went to medical school, y’know what I’ll tell you a story… When I was a first year medical school we had this woman neurosurgeon, and she told us “listen I’m a neurosurgeon but the reason I got here is because I chose not to have a family. I don’t even have a dog. That is why I’m a neurosurgeon.” So the message that she gave us was that in order to succeed in medicine, especially in the surgical fields, you have to give up every other aspect of your life. That was 35 years ago and that is not the case today. Today we recognize that women are equally skilled, women have different pressures, whether it’s the pressure to bear children, or not pressure I should say, biological. Women bear children, men do not, and our child bearing years are between the ages of 20 and 35 and so medicine means that we delay all those so there’s that higher degree of infertility in women physicians. There’s also a higher degree of divorce. I think people are recognizing that and in terms of practice people are understanding that women can succeed, women do succeed, but they need different support systems. In fact, I belong to the American College of Physicians, which is a mesh group for internal medicine, and one of their initiatives for 2022 which I just signed off on was this notion that we need to understand that women have to be able to be given the opportunity to bear children before becoming 37, somehow we need to accommodate that. I helped a lot on that because that is a big part of our personal lives, our wellness, so that is a change. Other aspects… There's still a glass ceiling. Having said that, there has definitely been a movement to bring more women into leadership. There’s still a huge discrepancy between women in leadership versus men, and a lot of that goes back to child rearing, child bearing, but again I think there’s a bigger push to getting women into that. Women have entered fields that I’ve never seen them entering 40 years ago. Today women are urologists, neurosurgeons, and transplant surgeons. Back in the day, women either went into pediatrics, OBGYN, family medicine, internal medicine, or psychiatry. Today that’s not the case. Women are entering all sorts of fields, so definitely a huge shift I would say in the last 40 years and I think more to come.

Where do you see the future of medicine? (specifically healthcare delivery)

• I don’t know if you’ve had classes on the state of medicine in the United States. You probably are aware that medicine in the United States is ranked pretty much generally last when it comes to healthcare outcomes amongst the OECD countries. So the 34 OECD countries, the hike economic countries, which they regularly track 13 of them which includes the United States, Canada, Great Britain, France, Germany, Switzerland, Japan, Australia. When they regularly track these countries in terms of healthcare outcomes, and by outcomes we mean mortality, infant mortality, pregnancy outcomes, heart attacks, heart attack care, etc., the United States almost invariably ranks last when it comes to mortality. And yet when it comes to per capita spending we are by far, by a factor of at least 2, more than any other country. The second most expensive country is Switzerland. American medicine is in a rough spot. We are close to spending… a few years ago it was 18%, almost 20%, of our GDP on Healthcare with these outcomes. This year our GDP percentage spending went up 1% in 2021. One whole 1%. That’s a tremendous amount just because of covid. Covid is going to bring us at least a decade, if not more, of chronic illnesses. People who’ve gotten covid are going to have chronic illnesses. Healthcare in the United States is really precarious. I hope to see that we recognize that healthcare… We need to make it more valuable. In other words, there are things we need to do and things we don’t need to do. We do a lot of unnecessary care in the United States. I hope that some of the education we bring to the newest groups of medical students and residents, I hope they recognize that it’s really up to them to stand up. My generation has not been able to fix it, but I hope your generation and the generation above you can do something about it because if we don’t, it is not sustainable. We cannot possibly spend a third of our GDP on healthcare and yet we’re headed in that direction. I think we can all say healthcare is broken, but the other part of the equation, and I don’t know how to have this happen, is the American public needs to recognize this. We’re aware that healthcare in the United States is very dichotomized. There’s a group of people who have excellent healthcare and actually do very, very well, but then there’s a large group of people who have terrible healthcare, and that’s why our overall healthcare outcomes are so poor, and it’s that disenfranchised group that somehow needs to get its message across that ‘we need to serve healthcare, we need to do better.’ The affordable care act tried to go there but politically it’s been a very difficult situation and politically I don’t know what can be done unless voters get out there. Unless your generation and the generation in their 20s say ‘This is not acceptable. We need better care. We need politicians who understand that and work with good health policy people to figure out what to do.’ It’s not that health policy can’t figure out choices or can’t figure out solutions. The problem is solutions are going to invariably take away some care or some privileges from some and that’s where the difficulty arises. Nobody wants to give up anything.

How has covid impacted teaching in the medical field in terms of online classes versus hands-on learning?

• Gosh I see that every single day. It’s affected teaching. I think you guys have experienced this and it has certainly affected our undergraduate medical education, our medical students, because everything has been by zoom. That has created definitely zoom fatigue, a lack of physical interaction between us, me and the students, so I don’t get to know them personally. I see faces on zoom and it’s very easy on zoom to hide your camera or shut off your video so I don’t see you, I don’t see the body language, so I don’t get to establish that rapport with them and so I feel that loss. Students feel a loss in the fact that they don’t have that comradery as a group as much. In terms of graduate medical education and residencies, several things have happened. Number one there’s been a lot of physical fatigue because of covid. For the two years they’ve been working so hard, the hospitals have been so very busy with covid patients and there’s mental fatigue because some of those patients are just so sick, it’s really hard to see. There was a patient I was taking care of in the hospital 10 days ago, just a young man, who I learned died yesterday from covid. And those are very difficult. It really affects you emotionally and it affects our residents a lot. Our residents have never practiced at a time when there really wasn’t covid, so for them this is the world they know. They don’t know what it was like when we all walked around masks, when we shook hands with each other, when we gave hugs to each other, when you weren’t gowned and gloved, when you still had events, when you had conferences where you got together and ate lunch-- today we don’t do that. That has affected education, so I think there’s less sense that you’re a team because you work by yourself in order to have social distance between everybody. Those are some of the biggest things I see in medical education. I will also tell you, because of safety rules, when we go see a covid patient, most of the time I don’t take the team in with me because I don’t want to subject them to more covid exposure than they’ve already had. So we’re very, very careful about that. I don’t think there’s been anything positive that covid has brought to us. In terms of education, we’re all just waiting for it to go back to normal. I don’t know when that will be. But I think we are, at Mayo anyways, getting information in the next few months. We’re going to try to resume more normal activities and we’re going to treat covid, like the CDC says, as an endemic illness- in other words it’s going to be with us for the foreseeable future.