Call for Patient-Centric Care

Q&A with Abraham Nussbaum

By Mark Couch

He has been a faculty member at the University of Colorado School of Medicine since 2009. As an associate professor of psychiatry, he developed an award-winning curriculum for interviewing patients, which evolved into The Pocket Guide to the DSM-5 Diagnostic Exam.He believes a diagnostic exam begins with forming a therapeutic alliance in shared pursuit of health. With Robert J. Hilt, he recently published The DSM-5 Pocket Guide to Child and Adolescent Mental Health . He maintains a personal website at http://www.abrahamnussbaum.com/

Earlier this year, his book, The Finest Traditions of My Calling: One Physician’s Search for the Renewal of Medicine, was published to acclaim, including a review in The New York Times, which said: “He writes beautifully, in a lucid prose as notable for its process as its conclusions: The reader can actually watch him think…. Many medical memoirs are one-shot deals, offered to the public purely to unburden the author. From these books, readers and writer all move on with some relief. In Dr. Nussbaum’s case, we will eagerly await the next volume in the set.”

Where did you grow up?

I grew up in Colorado Springs, went to public schools there. I’m the oldest of five kids and I wanted to get out of Colorado when I finished high school. It was the 90s and the culture wars were at their peak in Colorado. I wanted to get away, so I went to a college I’d never heard of and I had visited just one time. I went to Swarthmore. I thought I was going to be an engineer. I took a course on the literature of the grotesque—reading Rabelais was a lot more interesting than engineering, so I switched and I decided to become an English Lit major.

What did you do after college?

My first job was making pasta for $7 an hour with my degree from Swarthmore. My ability to read French literary theory held me in good stead with my coworkers! I did that for about a month and a half and then I switched and took a job Colorado College repairing computers. That was depressing, so I signed up for Americorps. I did Americorps for year in Chicago and I worked with medically indigent homeless people who discharged from the hospital. Again, my ability to do literary theory was not particularly helpful. And so I started looking for something that was helpful and as engaging as literature.

What did you find?

While in Americorps, I went to a used bookstore and I bought two books there. One was a book called The Birth of the Clinic by Michel Foucault. And the other was a book by a theologian named Stanley Hauerwas called Suffering Presence. Foucault was dead, but Stanley was alive and so I wrote him a letter. And I just said, I’ve been reading your book and I’m kind of curious about some stuff about it. He told me to move out to North Carolina and to come work for him. So he hired me for a summer, he found a place for me to stay since I was a broke twenty-something.

While working for Stanley, I told him I’m thinking about becoming a bioethicist because it seems like I could address these difficult, intractable problems I saw in the life of patients in Chicago and use my ability to read books as a literary theory guy. Stanley told me I shouldn’t do that. He said bioethicists tell people what to do, but they don’t do it themselves. He said I should go and be a physician.

So how did you prepare?

I had not taken the pre-med requirements, so I had to do that. I did that at a tiny little liberal arts school called Bryn Mawr, which is a women’s college. They have like 1,400 women and 20 men getting their pre-med requirements done. I did that for a year. It was a pretty miserable year. Not much to do. Mostly just studied all the time and took tests. I think I had a green mohawk during that year – that’s back when I had hair! I had no car, no money—those were the Ramen years. I moved back to North Carolina to work while waiting for my admission ticket to med school. By that point, I was a resident of North Carolina and when the University of North Carolina offered me admission, I stayed.

How was medical school?

I hated the first two years. I was lonely, I was broke, I didn’t know why I was doing what I was doing. The classes seemed very different than any kind of school I’d been in before. The body seemed abstracted into a series of parts, cartoon systems that didn’t really map on to anything that I knew. There was an assumption of clinical privilege that I found kind of astounding.

I probably would have left med school if weren’t for three things. One is that I’m stubborn. I always tell med students that once you’re in med school, you don’t have to be smart, you just have to have a trucker’s ass. You just have to endure. The second thing was that I started volunteering at a free clinic, which really reminded me why I had gone to med school in the first place and that was helpful. And the third thing was there was this girl [now my wife] and I didn’t think there was a chance she would be interested in me if I wasn’t a med student, so I stayed in med school. And it got better.

I decided that I’d become a psychiatrist, but I had already applied to grad school, so I took a year off and got a master’s degree.

What is your master’s in?

Theological studies. It’s like a M.Div. It’s for people who want to be a pastor, which I did not. It’s an MTS, which is the first step for people who want to get a PhD in religious studies or theology, but theology was where people studied the historical care of the indigent ill, which was my interest. So my master’s degree was in the theology of medicine and I was reading a lot of Foucault and a lot about the history of medicine.

What did you do after medical school?

We stayed in Chapel Hill for residency. My wife trained in family medicine. We had our second kid during residency. During residency, I did a lot of schizophrenia research. I’m most interested in persons with mental illness who are experiencing psychotic and manic episodes and extreme varieties of mental illness.

We finished residency in 2009 in the midst of a worldwide recession. My wife’s from New Hampshire, so we looked pretty seriously at jobs in the northeast. The University of Colorado had an ad out for an inpatient psychiatrist. I applied and they never wrote me back.

Then there was an ad that popped up for Denver Health and it had a faculty appointment at the University of Colorado, so I applied. I scheduled it over Christmas because I figured I’d just come home and see my family and do a day of interviews. I didn’t think I would take the job. I came and I met Bob House (director of behavioral health services at Denver Health) and he was terrific. He said: ‘You want to work with the underserved, you should be at Denver Health. You should come here.’ So I took the job.

Why did you write The Finest Traditions of My Calling?

I had kind of gotten burnt out and I made a list of things I wanted to do and I thought one of them might happen and all three of them happened and they all happened at the same time. My wife gave birth to our youngest child in April 2012. In May 2012, I signed a contract to write my first psychiatry textbook and then June 2012, I moved to Chicago for five weeks to start a grant-funded program at the University there.

During the week, I worked at the University of Chicago and participated in their faculty scholars program and read a lot. It was great. At night I worked on a textbook version of a class I was teaching interns at the University of Colorado on how to do the psychiatric interview. That textbook wound up doing well, enabling me to get a literary agent. My literary agent told me, “You write like an academic,” which was fair. So I hired Bridget Rector, a local editor, to help me and I started writing. I tried to build each chapter of the book around three things: one, an experience of the people I’ve met as patients, two is a metaphor for what it means to be a physician, and three is the philosophy-in-medicine questions that have always interested me.

It’s about how the training and practice of physicians is being transformed. Many of the books that address those questions are written as policy books. This book is meant to address the experience, what it’s like to be training and practicing in this environment and how different kinds of ways that we imagine that physicians are and structure their lives affects the way they experience themselves and how they work with patients.

You challenge the emphasis on measurement of outcomes in medicine. Why?

There are all sorts of ways to account for betterment that don’t involve measuring things. It’s actually just a symptom of our contemporary age that we think the only way to seek improvement is to measure something. Historically, there were plenty of ways to think about making things better. There are lots of ways of accounting for human experience and getting better at something beyond measuring it. We have a current mania for outcomes and metrics, but it does not mean that those are the outcomes or the way that patients experience our care or wish to see them measured.

Much of the literature that has led to outcomes measurement in medicine derives from industrial engineering, in which there is a straightforward sense that the product being managed is under the control of the manager. I do not wish my body or the bodies of the people I meet as patients to be under that level of control of a physician or a health care system. The body is not an inanimate object.

Another problem is the outcomes that we measure tend to be designed for the benefits of the insurers and regulators and the systems that do the