Becoming a doctor
NOVA: Your father was a doctor, right?
David Friedman: Yes. My father was a surgeon, but I had never planned on becoming a doctor. I always wanted to do international development work. I studied East Asian studies as an undergraduate at Yale, but right before I finished college, I realized I wanted to be a doctor.
Q: Was your father an influence on you choosing medicine?
David: Sometimes as a kid I would go into the hospital and see him, and I knew it was a really rewarding job. But I don't think the fact that my dad was a doctor is what drove me into medicine.
Q: Were you motivated by the status and money?
David: I remember when I interviewed with a woman at Yale about career planning, and she said to me, "Well, you want to be a doctor because of the status and the money, right?" And that had not really crossed my mind. It was always for me about patient care and trying to make a contribution.
Q: Do you think doctors deserve a special status?
David: I think it's reasonable to have respect for people who provide service to others. Many physicians do charity care and help people for nothing and make huge sacrifices. But on the other hand, doctors are generally well compensated. So I don't know. I think you earn respect or status by how you behave, not just by your profession.
Q: Do you think some doctors, perhaps because of the long training, can be arrogant dealing with patients?
David: Some doctors take it very personally when their patients question them. My take is, everybody has their own style of trying to figure out their disease. I view it as their right to ask me as many questions as they want.
Q: Has your career matched the hopes you had when you went to medical school?
David: I've been incredibly fortunate. The work I do is exactly what I hoped to do when I started medical school. I wanted to care for patients, to have the opportunity to research, and to do development work internationally. And I'm doing all three.
The business of medicine
Q: In your practice at Johns Hopkins, you sometimes waive the fees for patients. Do physicians in private practice have that option?
David: The flexibility to waive fees is the same in academic medicine and private practice. When it's your own business, though, and you say, "I'm not gonna collect $100," it might impact you more. In my position as an employee, I'm not taking $100 out of my pocket and handing it away.
Q: Are you glad you don't have to deal with the business aspects of running a private practice?
David: I'm sure there are joys to running your own business. But for me, it's a real pleasure to not have to deal with billing and collection agencies, all the nitty-gritty. In academic medicine, a lot of the little details are managed on a larger level.
Q: If you had one thing to change about your job, what would it be?
David: The paperwork related to patient care. I spend a fair amount of time documenting that I really looked at tests I ordered or really took care of patients. I understand why it's in place, because there are doctors who might cheat the system. But I would love to see some of that go away.
Q: Have you ever wanted to get involved in changing the health-care system?
David: When I was younger, I thought I really wanted to change how health care is delivered in the United States. Then, after the whole Clinton failure, I lost a lot of my enthusiasm for the political process. I've chosen to spend my efforts differently.
"Delayed gratification is a key to success in medicine."
Q: Do you think pharmaceutical companies influence your practice?
David: All doctors say that pharmaceutical companies don't influence their prescribing behaviors. But I think they probably do. They're present at a lot of meetings. There's a lot of signs and advertising. I have had grants from several companies. I like to think that I don't let that influence me, but it's hard to tell the subtle influences. The fact that these companies are very present at meetings means that they think it works.
Q: What changes have you noticed in the profession over these years?
David: There are more business elements. You hear patients today referred to as "consumers of our services," as if they were going to a store and putting ketchup on the checkout counter. I don't like thinking of them as consumers and us as a service industry. We want to provide good care that's timely, that's easily accessed, but there's also this unique bond between a doctor and patient.
Taking it in stride
Q: It was interesting watching you and the other six people in this group. You didn't complain much about the workload and the deprivations. Why do you think you got through the follies of medical training relatively unscathed?
David: I don't know. Having a little less sleep never got to me that much. And I always liked the work. I like the process of my life, each step of the way.
Q: You seemed fine with delayed gratification.
David: Delayed gratification is a key to success in medicine. There is such a long period of not being independent, of not running the show. But if you can make it, and if you enjoy the process, it can be great. I have so many opportunities at this point.
Q: Has the work culture in hospitals for med students and young doctors changed since your time?
David: I think it's changed a lot. When I was going through medical school, there weren't the same restrictions in hours that we have now. You were expected to stay until every last thing was done. That was part of being a responsible doctor. Now there's a greater understanding that sleep deprivation isn't good for anybody. People are more awake and healthier and probably happier, but maybe we've lost the absolute commitment that I remember.
Q: During your training, what were the hardest things to bear?
David: My greatest frustrations were when people had power over me, especially when I felt it was arbitrarily used. That happens a lot in medicine. You're at the low end of the totem pole when you start.
Q: Did that influence your choice of specialty?
David: It did. I remember on my surgical rotation really not liking my interactions with the person running that rotation. I definitely wasn't going to be a surgeon after that.
Q: It's serendipity. If you'd gone to a different hospital...
David: Absolutely. That's the amazing thing about a lot of career paths. It may look like you went in a straight line, but it just ends up looking straight. I never knew I'd do ophthalmology, and then I had an interaction with an eye program, and I thought, "Wow, that was really great." It's all who you bump into at key moments.
A busy life
Q: What are some of the things you value about being in academic medicine?
David: In a good academic environment, they pick people they think are going to succeed and then they give them a lot of independence. At Hopkins, I've been my own boss on many levels. As long as you can get grants and keep moving ahead, nobody tells you to do otherwise. It's a tremendous benefit.
Q: How many hours a day do you work?
David: I work a lot, at least 11 or 12 hours most days. I get up around five, and I usually put in an hour and a half before I wake my children, because I need to catch up on written work and communications. I work a little bit on the weekends. One rule I have is I don't work when I come home at night. I relax and hang out with my kids.
Q: Have you found ways to find a little oasis in your busy life?
David: The only time my phone is off is when I'm in yoga. I make sure that nothing can disrupt me. It's very relaxing, three days a week. Also, when I'm gardening, it really takes my mind off the day.
Q: Some people would say to get where you are in your career, you have to entirely sacrifice your life outside of work. But you seem to have struck a balance.
David: I've had a supportive family. And I do have a lot of energy, so I'll read and do other things that interest me. It really comes down to enjoying what you're doing. And I've been lucky. I had a great research grant when I first started out.
Q: You also didn't have any debt from medical school.
David: Yes. My father was incredibly generous and supported me through medical school. For many people, it's much harder.
The human element
Q: Has the way you interact with patients changed over the years?
David: Yes. Talking to patients has completely changed for me. Doctors are generally trained to collect data by saying, "Does this hurt? Does that hurt?" We ask a series of questions that often are incredibly limited in what they allow the patient to say.
Studies have looked at what happens if you just ask the patient, "And what else?" With just those three words, you'll learn a ton more about what's really going on.
This sort of lesson has completely changed my dynamic with patients. I used to spend a lot of time giving a medical lecture about glaucoma, and I realized that patients often don't care. Now I spend time trying to understand how the patient lives their life, and whether they're able to use the therapies I give them. That gets us on a level that's much more satisfying.
Q: Where do you think you got your positive outlook?
David: You know, my mother was born in Poland during World War II. She was a hidden child, and she was actually malnourished. In the end, she's one of the happiest people I know. It's incredible that she could survive so much and yet be outgoing and energetic and happy. Maybe I got some piece of that from her.
Q: Were you always happy as a child?
David: My parents got divorced when I was 12. As far as I knew, I was doing fine, but it must have affected me, because other people, and one teacher in particular, recognized that I needed some assistance.
"Part of that search for connectedness is fulfilled in the patient-doctor relationship. There's this true intimacy."
Q: You've risen to a place in your career where you play a lot of different roles.
David: Yeah. I have about five different jobs. I'm a clinician—I take care of patients and I operate on them. I have my research effort at Hopkins. Part of my salary's paid for by a nonprofit called Helen Keller International, and I travel overseas for them and help them with eye-care development projects. Every now and again I've helped the federal government with medical fraud cases. I also teach and give lectures to undergrads and to School of Public Health students as well as to residents. I've been serving on the Institutional Review Board reviewing the safety of research. So I wear a series of hats.
Q: You obviously manage a lot of things. But can being in that highly productive, management mode be a problem in your personal life?
David: Absolutely. One of the problems I ran into early on with my wife was I would act like, "How come you haven't finished the tasks I set aside for you at home?" You can't be like that with somebody you're married to. Productivity isn't what life's about outside of work. You can't manage your friends. You can't manage your spouse.
Q: Has reaching midlife changed your perspective?
David: The thing that really strikes me as I get older is how alone we are at some level. I mean, I have these great relationships with friends, and I have great relationships with my patients and my family. You try to create these intimate relationships, but ultimately I think we are alone at some level. That's the one realization that's been a little hard as I age.
Q: Yet you seem to work hard at having strong relationships with the people around you.
David: We all really want to be connected—it's one of the things all humans strive for, and I think I've managed it, especially with my kids.
Q: I can see how much you love your children.
David: Yeah. I'm lucky, I have two really great kids. It's constantly enjoyable to be with them.
Q: Is the desire to be connected to other people part of why you enjoy being a doctor?
David: Absolutely. Part of that search for connectedness is fulfilled in the patient-doctor relationship. There's this true intimacy. You're alone in a room, talking about life. Probably every week, somebody cries to me about something that happened in his or her family.
One of the appeals of medicine for me was to get to know people over time in this really wonderful relationship. I've never been an authoritarian figure, so I never saw myself as telling them what to do. I saw it as us working together, and I still do.
David Friedman in 2008, around the time he became a full professor of ophthalmology and international health at Johns Hopkins
While academia poses its own pressures, David appreciates the autonomy he has as a medical researcher and clinician at Hopkins.
One of the greatest satisfactions David has in his field is being able to dramatically improve a patient's vision through cataract surgery.
Interview conducted in June 2008 by Michael Barnes, producer of "Doctors' Diaries," and edited by Susan K. Lewis, senior editor of NOVA Online
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