A doctor’s passion for medical storytelling

For a Yale alumna, the patient history and physical takes on a new narrative life in The New York Times.

Lisa Sanders, M.D. ’97, HS ’01, loves a good story and has built her career around her narrative skills, beginning with her early days in television and continuing through her subsequent decade in medicine. The form her tales have taken, however, has changed over the years.

A few years ago, when an editor friend asked Sanders what she thought doctors could write about, her answer was that they write one thing and they write it every day: the history and physical. Her belief in the storytelling power of the H-and-P led to “Diagnosis,” a monthly column in The New York Times Sunday Magazine, about cases that stump doctors and how they are ultimately resolved. In Sanders’ hands, the column’s H-and-P format is an effective way of weaving tales about such cases as an emaciated 9-year-old girl who suffered months of vomiting and diarrhea before being diagnosed with Addison disease, or a young man whose Hodgkin disease was diagnosed after frightening episodes of memory loss. The column’s success inspired the TV series House, about a curmudgeonly physician who is a brilliant diagnostician. “Until House came about, diagnosis [in TV medical dramas] was the one-liner between symptoms and the terrible response to treatment. House takes that moment and looks at it, which is what my column did,” said Sanders.

Sanders started her working life not in medicine but in journalism. After graduating from the College of William and Mary in 1979, she worked as a producer at CBS News, where she earned an Emmy Award. By the early 1990s, she was looking for something else to do with her life. She had covered medicine and it had captured her attention. “I thought, ‘This is something interesting.’ If I can do it, it will be fun,” she said. “And it turns out it has been fun.”

In 1992, after two years at Columbia University’s Post-Baccalaureate Premedical Program, Sanders entered the School of Medicine. At age 36 she was the oldest member of the Class of 1996. She completed her internal medicine residency at Yale and became chief resident in 2000.

Since then, Sanders has combined her talent for storytelling with her passion for medicine. She is an assistant clinical professor of medicine at the School of Medicine and teaches in the Yale Primary Care Residency Program at Waterbury Hospital. Sanders believes that when talking with the same patient, different doctors get both the same story and a different story, depending on how comfortable the patient feels and what questions the doctors ask. Eliciting a history is an important skill, she believes, and one she spends a lot of time helping residents develop. She also uses the physical exam to teach residents how to think about and approach problems. Although she occasionally lectures, Sanders feels that medicine isn’t learned that way. “The trick in medicine is not facts,” she said. “The trick is figuring out how to apply what you know to the case at hand. That actually turns out to be a very difficult skill.”

Sanders listens to each person’s story, never spending fewer than 20 minutes with a patient. She specializes in obesity and has plans to set up an outpatient obesity clinic at Waterbury Hospital. Several years ago, while researching low-carbohydrate diets, Sanders realized that adhering to a way of eating, rather than a specific diet, is the key to losing weight. This led to her 2004 book, The Perfect Fit Diet: How to Lose Weight, Keep It Off, and Still Eat the Foods You Love (St. Martin’s Griffin), which offers guidelines on how to devise a sensible eating plan based on personal food preferences.

Sanders lives in New Haven with her husband, writer Jack Hitt, and their two daughters. She fits teaching, consulting, writing and treating patients into her schedule by getting up at 4 a.m. to write for three hours before beginning the rest of her day. In addition to her column, she is working on her second book, The Tools of the Trade: The Art and Science of Medical Mysteries. Scheduled for publication next spring, the book seeks to put the reader into the doctors’ shoes as they negotiate the uncertainty between symptoms and diagnosis. She loves writing because it requires her to step back from the immediacy of treating patients, but medicine is the driving force behind everything she undertakes. As for what her future holds, the ending to that story hasn’t been written yet. “I used to have five-year plans,” she said, “but nothing I’ve ever done has been on them.”

—Jill Max

A gastroenterologist moves around the country and into a top job at UCSD

An academic journey that began at Yale’s Ezra Stiles College in 1971 has led David A. Brenner, M.D. ’79, HS ’82, from coast to coast and, most recently, to the top leadership role at the medical school of the University of California, San Diego (UCSD).

After an internal medicine residency at Yale-New Haven Hospital—“I escaped after 11 years,” he chuckled—a fascination with basic research brought him to the National Institute of Arthritis, Diabetes, and Digestive and Kidney Diseases. In 1985 he went to UCSD for a gastroenterology fellowship, later joining the faculty. Next he joined the University of North Carolina at Chapel Hill as chief of the Division of Digestive Diseases and Nutrition, and in 2003 he became chair of medicine at Columbia University’s College of Physicians and Surgeons, where his daughter Laura is currently a medical student. (His son, Nathan, is a recent graduate of the University of Georgia.) San Diego, though, has lured him back. In February he became vice chancellor for health sciences and dean of the school of medicine after his predecessor, Edward W. Holmes, M.D., accepted two research positions in Singapore. Brenner is head of the schools of medicine and pharmacy as well as of the hospital and its faculty, and his duties bring him into close contact with students, bench researchers, patients and decision makers for the university as a whole.

Brenner’s interest in research began early. At Yale College he majored in biology. In medical school, he began working with researchers in the Yale Liver Study Unit. “I was always interested in biochemistry and genetic diseases, and I picked this because it looked interesting, not because I thought there was something intrinsically interesting about the regulation of metabolism by the liver,” Brenner said. “Gerald Klatskin, one of the most famous hepatologists ever, was director of the liver study unit, so I just stayed, and got interested in liver disease.” With his mentor, Joseph R. Bloomer, M.D., FW ’72, a student of Klatskin’s and now director of the Liver Center at the University of Alabama at Birmingham, Brenner published several papers in the late 1970s on the group of diseases known as the porphyrias, enzyme disorders that cause skin problems or neurological complications. He and Bloomer remain in touch. Brenner continued to make important contributions to knowledge about protoporphyria; intracellular signaling and regulation of gene transcription in the liver; and the process of hepatic fibrosis. From 2001 to 2006 he served as editor in chief of the field’s most prestigious journal, Gastroenterology.

His current research explores why so many types of liver disease lead to the same ends—cirrhosis or permanent fibrotic change. “The liver’s not that smart; it’s not like the brain. There’s a limited repertoire of responses to insult, it doesn’t matter what the initial insult is; the final common pathway is very similar,” he said. “The only effective drugs now for fibrosis are directed at the treatment for the underlying condition. But the goal is to develop specific therapies that are directed at fibrosis itself, and not the underlying agent. Maybe half the patients with hepatitis C in the real world will fail to respond to the current standard-of-care treatment. They will go on to scarring, fibrosis, decompensation and liver cancer.”

Asked how gastroenterology has changed since he began his training, he says he is concerned about what he considers to be a shrinking of its focus. Screening colonoscopy, a procedure that has saved innumerable lives since becoming routine, now dominates many gastroenterologists’ practice. “It’s incredibly important, relatively straightforward and very profitable. I’m worried it’s gotten too narrow. The whole field is keyed on this one single disease [colon cancer] and one single procedure.” Indeed, recent advances in imaging technology may force gastroenterologists, ready or not, to alter their practice pattern. “This interest in CT virtual colonographs [a less invasive means of screening for colon cancer]—what if it becomes the major way of screening? Then all these millions of patients will not need an endoscopist. … In 10 more years, diagnostic endoscopy might no longer be done. I wish the field would be more general, more entrepreneurial about issues of nutrition, obesity and GI diseases.” European gastroenterologists have been more inquisitive in this sense than their American colleagues. “When a new technology becomes available, they bring it into their practice, whether it’s ultrasound or CT.” In the United States, cardiac ultrasound is done by cardiologists, but abdominal ultrasound is still the province of radiologists. Gastroenterologists, he thinks, should do their own ultrasounds.

Brenner’s new job suits his eclecticism. His career has been replete with accomplishments in research, clinical work and administration, and at UCSD he is still able to round on patients, troubleshoot gels in the lab and maintain leadership roles in several medical and philanthropic organizations.

“I decided that if at all possible I want to continue teaching and seeing patients; I want to continue my research program,” he said. “Sometimes hands-on experience is the best.”

—Jennifer Blair

A public health alumna brings social justice to the campaign for healthy food

Michele Simon, M.P.H. ’90, J.D., is incensed that businesses spend $36 billion annually “on marketing to get people to [consume] the wrong things.” She’s convinced that advertisements for alcohol, tobacco and junk foods promote chronic illnesses. And that’s why the author of Appetite for Profit: How the Food Industry Undermines Our Health and How to Fight Back (Nation Books, 2006) crusades against “diseases caused by marketing.”

As part of her food campaign, Simon established the website www.informedeating.org to build awareness of the politics of food, and to encourage active public responses to the food industry. Simon gives frequent speeches in which she urges, “Look at what the food industry has done to alter our choices, then go after agricultural policy in a social-justice way. For example, poor communities suffer because of the availability of inexpensive alcohol and the lack of healthy food.” Simon is also the research and policy director for the Marin Institute, an alcohol industry watchdog group in California.

Likening her crusade to antismoking campaigns, Simon asked, “How can we change the laws so that eating healthy is not the exception? Agricultural policies are heavily influenced by industry. We’re subsidizing the wrong kinds of foods—we don’t even produce enough fruits and vegetables to meet daily recommended servings.”

Simon’s passion germinated during her years as a biology major at Carnegie Mellon University and her dual interests—bioethics and policy—spurred the New York City native to pursue a public health degree at Yale. When assisting with prenatal counseling at Yale-New Haven Hospital drew her toward genetics, Simon sought permission to take a course in reproductive law at Yale’s law school.

“Jay Katz’s class was fascinating,” she recalled, referring to Jay Katz, M.D., HS ’56, J.D., the Elizabeth K. Dollard Professor Emeritus of Law, Medicine and Psychiatry at the Yale Law School. [See; “A Campaign Makes a Stop at Yale University”] Simon became Katz’s research assistant and was influenced by his pioneering work in bioethics and informed consent. “He certainly had an impact on me in combining health and law.”

At that time Yale offered neither a health policy concentration nor joint degrees in law and public health, but Simon was permitted to design her own program, which included courses in law, medicine and business. “I’m grateful I was able to do something that really suited me, and always felt I got support from the faculty,” she said.

During her first job, at California’s Department of Health Services–Genetic Disease Branch, Simon decided to enhance her health policy credibility and earned her J.D. at University of California Hastings College of the Law in 1995. Then, inspired by her new vegetarian diet and convinced that nutrition curricula at colleges and universities often reflect industry-influenced “science,” Simon taught herself about nutrition and quickly identified key political issues.

“With so much scientific evidence pointing to a plant-based diet being superior, why does the government tell us to eat meat and dairy every day? Why are school lunch programs so heavy on animal products?” she wondered. Using her legal training, Simon targeted nutrition policy, which was traditionally concerned with remedial programs like food stamps. “I was interested in quality, not just access—how to help people be healthier rather than just not hungry.”

She soon discovered a prominent nutritionist, Marion Nestle, Ph.D., the Paulette Goddard Professor of Nutrition at New York University’s Nutrition, Food Studies and Public Health Department and author of Food Politics and What to Eat, who was uncovering how politics influences America’s food choices. “I’m a disciple of hers, a great admirer, following in the trail she blazed, popularizing the notion of politics attached to what we eat,” Simon said.

Working with colleagues at Yale’s Rudd Center for Food Policy and Obesity, Simon analyzed industry influences on state food-related laws; her report, which argued that despite recent legislation to improve school food, more needs to be done, was published in the Food and Drug Law Journal in 2007. In late 2006, she spoke at both Rudd and the School of Public Health. “It was a lot of fun to go back as an alum. Talking about how I combine public health with law was a great opportunity to encourage graduates of the M.P.H. program to pursue policy and law, a growing field. Some major funders are seeing the need for more lawyers to work on nutrition.”

Nestle calls Simon “an unusually clear thinker about food issues, as she proves in Appetite for Profit, a terrific book. I use it to teach students how to interpret what food corporations really mean when they mutter platitudes about wanting to improve health, and to understand why the goals of food companies and public health can never really overlap. She’s so on top of the issues that I’m always learning new things from her.”

Now in its second printing, Simon’s well-reviewed book provides practical tools for “going up against the food industry. It’s a voice for people who have been working on this issue, frustrated by the obstacles.” (She has chapters on “Exposing Government Complicity” and “Battling Big Food in Schools.”) And, challenging a central argument of the food industry—that nutrition is a personal lifestyle choice, not a matter of public policy—she said, “This isn’t just a matter of personal choice—it’s a societal responsibility.”

—Carol Milano


			Originally published in Yale Medicine, Spring 2008. Copyright © 2008 Yale University School of Medicine. All rights reserved.