Interview with Dr. Ariel Lefkowitz
Ariel Lefkowitz is an internal medicine physician at Sunnybrook Health Sciences Centre. He obtained his medical degree at McGill University before completing internal medicine residency at the University of Toronto, followed by a year as Chief Medical Resident at Mount Sinai Hospital and a fellowship in General Internal Medicine. He completed a Master of Education at OISE at the University of Toronto and a research fellowship at the Wilson Centre. His research interests include ethics, equity, narrative medicine, and the involvement of patients in medical education.
Q: Many of our readers, I’m sure, are already familiar with Dr. Lefkowitz, but nonetheless let’s start off with you telling us a little bit about yourself.
I'm an internal medicine doctor based at Sunnybrook and I teach at the University of Toronto at both the undergrad and postgrad levels. I graduated from medical school at McGill before coming to Toronto for residency and last year I completed a Master of Education at Ontario Institute for Studies in Education (OISE). My background isin philosophy, math, and computer science, which has informed my interest in ethics and equity. And certainly, narrative medicine has also been a great interest of mine.
Q: Speaking of your interest in narrative medicine—it's been almost a year now since your first two weeks on the COVID ward, which you documented and published for the Toronto Life. What motivated you to share your story?
Creative writing has been an interest of mine throughout my life and throughout my medical training. But I'm not the sort of disciplined writer who sits down and writes every day. I write when I'm struck by something important or emotionally transformative happening to me. The first piece I wrote was as a first year medical student upon meeting a patient on the palliative care unit. It was a transformative moment where I was suddenly gripped by the need to write and was encouraged to publish and share my piece by excellent mentors. That experience has since guided my perspective. And so suddenly, on the COVID wards, I realized that every single moment was a moment worth writing down. You know, gripped by all this anxiety and the feeling that what I was involved in was so important for my patients and for the world—everyone was talking about the COVID ward in the news—after this incredibly exhausting two week block, the day after I finished on the COVID ward, I stayed up until 3 AM and wrote it all down. I realized that it was something that people would want to know about. And I'm the sort of person who doesn't mind sharing my vulnerabilities, but certainly I know that there are people who would not feel comfortable doing that. But I felt that it was important, and I decided to submit [the piece] to see if other people felt the same way.
Q: It sounds like you were able to immediately recognize the gravity of the pandemic at a time when the public maybe did not. What gave you that impression?
I could sense from my own discomfort and how different this was from normal life. In medical school and residency, when everything is new, everything is scary. But then eventually to an experienced person, it all feels normal—even things like running a code or doing a surgery feels run of the mill. And so, when I was on the COVID ward and realizing I was very out of my element, I felt afraid for my life and the lives of my colleagues, family, and patients. There was this element of familiarity with the discomfort because I recalled what it was like to be a trainee, but at the same time, there was this element of it that felt almost historical.
Suddenly, I—as a COVID doctor at a time when lots of people hadn't taken that role yet—could feel the eyes of history on me, and I knew that meant something.
Q: How has your personal response to the pandemic and even just managing your day-to-day changed since last year?
I shared in that piece that even by day 14, things started to feel normal. I think that's the blessing and curse of humanity—that we can come to terms with things that previously were unimaginable. Since then, many more colleagues have taken on the role of COVID doctor and we've learned a lot more about the disease, about how it's transmitted and even treated. I just came off my latest two week stint on the COVID ward and these days are nothing like [last year]. So while the world is still in a tough situation, it feels personally and professionally a lot less stressful.
Q: Speaking of the two weeks that you've just spent on the COVID ward, have you been struck again to write any accounts or diaries?
That’s mostly a no. I was struck again to write when my daughter was born. She's 4 months old now. Something I didn't share in the piece in Toronto Life was that two days before going on the COVID ward, we found out we were pregnant with our second child, and that really contributed to my understanding of myself during that time. The first person to find out we were pregnant was my wife, the second person was me, and the third person was the Head of Infection Prevention and Control at Sunnybrook. It made things more stressful, but it also allowed us to count the days off in a way that felt more meaningful as we approached our due date. When our daughter was born it felt like she was giving us a promise and hope for the future. So, I wrote a piece for her baby naming which tried to capture my feelings and hopes for her and for us all at a dark time, when welcoming a new baby shows more clearly than anything else that the future will be brighter.
Q: What do you believe is the value of storytelling, both within and outside medicine?
I think in the clinical context, storytelling is incredibly important. Storytelling is how patients gain an understanding of their situation that can be captured and contextualized in a way that makes it more meaningful. The same is true for physicians and physicians-in-training.
Part of why I value creative writing so much is because when we are suffering from emotional or moral turmoil, thinking of it as a story gives it a beginning, a middle, an end, and a meaning.
It allows us to grow from an experience rather than only suffer through it. I tell my trainees that if they think of taking a patient’s history as gathering a list of facts they’ll have a tough time remembering it. But if we think of history as an exchange of stories, suddenly it becomes really easy to remember, to understand, and to think of the next question to ask. Humans are natural storytellers and story receivers. It's incredibly important and something that I think we need to talk about more explicitly in medical education.
Q: You mentioned earlier you recently completed a Master of Education at OISE. When did your interest in education and pedagogy start and where do you see it going forward?
I have a background in acting and theatre and I find that teaching and acting have a lot in common. You're not just a presenter of facts, you're a presenter of a story. You are bringing your audience into this world that you're creating. The added bonus of teaching is that you are accomplishing a different type of good. You are enlightening a new group of professionals, you're hopefully inspiring them, and you're creating a relationship with them that can be as powerful as the therapeutic relationship between physician and patient. So certainly, from a selfish perspective, [teaching] ticks a lot of boxes for me as something that inspires and fulfills me.
Going forward I'd like to explore the ways in which we can do this sort of transformative education in realms and towards goals that it hasn’t been used prior. For example, I gave a lecture to the second-year class in the fall on the lessons from the Holocaust that physicians and physicians-in-training can learn to gain a greater sense of ethical duty.
Medical education has the capacity to fulfill this greater moral and ethical agenda, and I don’t think that the soul-searching transformative potential of medical education has been explored to the fullest yet.
Q: It sounds like there is a foundation of philosophy and medical ethics to your teaching. Do you see philosophy and ethics being taught in a more explicit and purposeful manner in medical education in the future?
You know, I came into medicine with an undergrad in philosophy and I knew that that was going to make me somewhat of a weirdo. I certainly felt out of sorts at the beginning, not having had a background in anatomy and physiology. I always felt like maybe my background in philosophy would lend something extra to my perspective, and you're right about the role of philosophy and ethics going forward—the truth is, I think that research, education, clinical practice, person-centred care, all of these things should be guided by a deep exploration of the theoretical underpinnings that grounds our practice.
Q: Just as your background in philosophy informs your teaching, do you see the reverse being true for you? Do you see practical experiences as a physician forming and shaping your philosophy on life or teaching?
Oh, 100%. I recall in undergrad I used to have an absolute disdain for anything practical. I did computer science but I only wanted the theoretical—I didn't want to learn how to use a computer, I just wanted to think about computation. And since then, I have learned how clinical practice teaches you what life is like. Practical experience guides theoretical exploration. Narrative medicine fits into that as well, because it captures the reflective lessons of an actual experience and lets that guide you to your next idea or to your next revelation.
Q: And how do you lend legitimacy to narrative-based medicine when the medical and scientific field is obsessed with evidence-based medicine and the more “objective” facts?
From my experience, you cut through the noise with a compelling story. So much was written about COVID in March, I just happened to write something that hit home. For example, it's not as if no one had ever identified that there were not enough black medical students at the University of Toronto, but Dr. Chika Oriuwa used this medium and this power to cut through the noise and reach a greater audience with greater force. In some ways, a compelling story transcends the delegitimization of narrative-based medicine. I'd like to see that change. I want to see narratives stand at the power and stature of other forms of communication.
Q: You mentioned that your interest in teaching, and I imagine storytelling, stems from your background in acting and theatre. Can you tell us more about that?
In high school I did improv at SecondCity and started performing in SecondCity shows. Some of my peers and I at SecondCity were recruited to host this TV show called Workforce for a season. And then in undergrad, I did a bunch of theatre and loved it. I believe that medicine is, in so many ways, also improv. In clinical practice, especially as a trainee, you take on a role that you don't believe is true. You say “Hi, I'm part of the surgery team,” or “I'm a medical student on psychiatry.” And then you pretend to be a surgeon or a psychiatrist—and that's improv. What are OSCEs if not improv? Certainly, I think that background has really helped me in my journey, my training, and how I teach.
Q: Speaking of all your different interests, and past and present pursuits, how do you balance it all?
I think first and foremost is the importance of following your own inspiration. If you had told me that improv and philosophy was going to be a workable combination in medicine—I wouldn’t have thought that it was going to work. But it was what inspired me, so that's the path I followed and I am so glad that I did. The only way to make it work is to be passionate about what you do and to combine the field you've chosen with your own unique factor. You and your interests are your most powerful assets, so never neglect those things that rev your engines.
Second, I would say there is a delicate dance between saying yes and saying no. You want to say yes to those opportunities that arise and are so new and exciting and important that you can’t possibly go on without participating in them. And sometimes that's even at a time where you're too busy. You know, I should never have written that article at 3am in the morning after 14 of the most exhausting days of my life. But I had to do it, because it was an opportunity I couldn't say no to. There are some times where you must say yes to an opportunity.
By the same token, you have to learn how and when to say no. It's very easy to get sucked into the trap of the trainee—the person always willing to go the extra mile. That can really get you into trouble. And being able to say no when it's going to do more harm than good is an important skill and difficult to gain due to self esteem and power differentials. The ability to differentiate between what is going to be that critical opportunity and what is really going to just destroy your time management, the delicate dance between yes and no, is just consummately important.
Q: I'm sure that advice will be very useful to a lot of medical students. We’re curious, what’s next for you?
I think that at the level of the medical school, the interests of the faculty and my own interests are aligned in a lot of exciting ways. My interest in ethics, equity and narrative-based medicine are dovetailing with the direction of the university and, I think, of medical education in general. And so, I do hope to be involved in that most transformative effort. For example, I recently developed the new curriculum on religious discrimination, which I hope may have a big impact.
In life, I will be starting as a clinician teacher and assistant professor at Sunnybrook in July. And I am hoping to shift the culture of medicine away from the stodgy spirit of traditional med ed and inject some energy, levity and inspiration in areas of med ed that were previously considered dry. I think that we can engage our patients, trainees, and colleagues in ways that enhance our delivery of health care, our communication with one another, and our compassion for one another. I want to be part of that change.
