An Interview with Michael Stein

Author Michael Stein — a primary care physician, researcher, and chair of the Department of Health Law, Policy, and Management at Boston University School of Public Health — recently published two new books, Me vs. Us and Accidental Kindness: A Doctor’s Notes on Empathy

Me vs Us. explains why public health a lower priority than medical care, receiving less funding and resources. He argues that health should be recognized as a communal experience rather than a private one to adequately address our most pressing health crises.

In Accidental Kindness: A Doctor’s Notes on Empathy, Michael Stein examines the relationship between doctor and patient. Using his personal experience and knowledge of medical practice, Stein discusses why empathy is crucial in the doctor/patient relationship and why it may be lacking. I had the opportunity to interview Dr. Stein to gain more insight into the motivation behind these books.

Q: In Me vs. Us, you explore why the US is so invested in medical spending but spends comparatively very little on public health. What is it about your experience, professionally or personally, that motivated you to write this book?

A: I am a primary care physician who took a job in a public health school six years ago. That transition opened for me a new way of thinking about the world. I understood for the first time that paying attention to health or to health care require very different perspectives. Health care, the work I did in my medical office—interviewing, examining, testing, diagnosing, treating—involved taking care of patients one by one (what I call “Me” work). Creating health, on the other hand, involved more broadly thinking about populations (what I call “Us” work).

 Certain statistics that I learned before joining the public health world really bothered me. Why did the people living in the richest counties in the US live nearly twenty years longer, on average, than people living in the poorest counties? The combination of causes—poverty, bad water, bad air, poor food—could only be addressed by public health officials working at scale (if the political will was also there) in those places. It was clear that the life expectancy gap would never be filled by putting more money into health care systems, even if those systems addressed the inequities in care we also know exist in the poorest places.

So writing Me vs. Us was my way of saying: Reader, if you want to improve the health of all, and improve our sinking national life expectancy, then let’s turn the conversation away from doctor visits to public health and understand why we haven’t paid adequate attention to public health over the past fifty years, while pouring money into health care that now constitutes nearly one-fifth of our economy.

Q: Do you foresee global threats such as pandemics and climate change prompting greater public health funding because the American public can no longer pretend that public health initiatives are for “poor people”? Or are there still political forces that make this too optimistic? 

A: Me vs Us offer eight reasons why we underfund public health. That is this book’s pointed and I hope helpful contribution to the policy conversation in the U.S. If we don’t recognize these reasons and why they are potent and have taken hold in the public mind, we will not fund public health more except when we have to, when we are in the midst of a crisis, the next pandemic, and by then it is too late to produce optimal effects, as we now know. Public health initiatives do and will disproportionately aid low income people and they should because that is one way to address inequities in this country. Public health work is primarily government work and one of the functions of government should be to reduce the burden of the country’s leading causes of death, which too often fall on the poor.

Q: How do you address critics that say that the financial incentive in investing in youth and community takes too long to pay off, whereas we face pressing medical issues that need funding now? 

A: I’m not sure what pressing medical issues need funding now that at their core do not have underlying social causes and therefore policy solutions. Obesity seems to me the driver of tremendous disability, premature death, lost employment; it is the pressing medical issue. And the ultimate lessening of obesity in America, affecting 50% of the population, are related to food and economic policies. But for return on investment policies that affect children like the Earned Income Tax Credit, are notably effective, and critical if you believe like I do that poverty is the major driver of poor health in America. But taking on large societal problems will always be slow work. And let’s not forget vaccinations, under attack in the US, but an investment in children that saves lives even in the short run.

Q: In Accidental Kindness, you discuss how the medical environment may be improved by increased empathy and humility between doctors and patients. What led you to exploring the interpersonal aspect of medical care? 

A: Empathy is one of those words that has increasingly entered our vocabulary in the past few decades. Why? I believe because we want it so badly and see it so little. That’s why we talk about it so much more than we used to. I don’t know what it’s like inside you and you don’t know what it’s like inside me, and to be part of a deep significant conversation with another consciousness, another person, we feel human and unalone, and I get to do this work at my medical office and wanted to put down on the page for others to engage. I’ve always thought that any great book allows a reader to leap over that wall of feeling alone. My book relates stories about how I and other doctors I’ve met have been kind and also unkind, and how and why that happens, and how patients react. Remember, I am an internist who still works in a system of reimbursement which explicitly values surgical procedures more than talking to someone about what matters to them most.

Q: What do you think is the first crucial step in fostering the empathy and humility you advocate?

A: Kindness must always built on top of competence, knowledge, skill. This is what patients expect and what we expect from ourselves as doctors. To provide poor care is to be unkind. Kindness means giving talk and time and being open to the patient experience. It requires attention to patients and their suffering, curiosity—we have to keep asking questions—tolerance, as well as self-reflection, understanding the sources of our unkindness, our negative or positive response to certain patients. We can’t provide all patient needs, but a warm and wholehearted presence can bring comfort. Patients need to know their providers are concerned.  Humility is necessary when there’s no obvious or immediate solution.

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