Op-Med is a collection of original articles contributed by Doximity members.
Name: Earl Stewart Jr, MD
Specialty: Internal Medicine
Education: Brown University Affiliated Hospitals, Meharry Medical College
Areas of Expertise: Preventive cardiology, Heart failure, General internal medicine, Public health, Cardiology, Preventive medicine, Smoking cessation, Clinical research, Medical education, Healthcare disparities, Spiritual therapy, Medical writing
Current Position: Internal Medicine Physician
1. Why did you choose internal medicine?
I often joke that internal medicine is the perfect specialty for those with commitment issues, simply because it gives one the option to do so many different things and to take so many disparate career paths. As far back as high school, I always knew I wanted to study the heart, developing this interest early on through my curricular and shadowing experiences, finding a love of cardiovascular medicine, which remains an enduring passion and was nurtured time and again by mentors who are both African-American and outstanding and upstanding cardiologists.
2. What area of internal medicine is changing most rapidly?
I think the answer to this is preventive care, which is the hallmark of effective primary care. For years, during my early training, I observed physician mentors and learned from what they said, taught me, and how they practiced so that they were paid mostly according to what they did. At that time, the medical economy was one predominantly based on fee-for-service. The more you did and the more procedures you performed the more you made.
There has been a much-needed and delightful switch to focusing more on the prevention of disease and making outpatient practices the medical homes for patients, instead of emergency departments. I love prevention, so this is deliciously intriguing to me, because I’d rather prevent 1,000 diseases than cure one. Health care policies on the local, state, and national levels due to efforts of CDC and HHS are nicely starting to reimburse physicians for higher quality of care that focuses substantively on prevention rather than higher quantity.
3. What is the last journal article or piece of research that significantly changed your practice?
Well, this question is interesting because what I likely treat and manage the most is hypertension, and for years we’d been waiting to learn of new guidelines from the JNC on the management, treatment, and prevention of hypertension, especially since the SPRINT data came out. ACC/AHA along with partnering physician groups just released new guidelines on November 17 recommending we consider Stage 1 Hypertension to be 130/80 instead of 140/90, which effectively eradicates the diagnosis of pre-hypertension. This is a good start to giving us all guidance as to how to incorporate SPRINT data effectively into our treatment of patients with hypertension. Doctors have been anxiously awaiting teaching on how to “sprint”; now we have some welcomed but controversial guidelines. Lowering the threshold for hypertension effectively increases the prevalence of adults with hypertension in the United States from 32–33% to 42–46%. That increases the amount of adults on anti-hypertensives and particularly introducing elder patients to more potential complications to achieving strict blood pressure control goals — something we were worried about with SPRINT. So, I certainly think we will have to incorporate lower targets soon, but the jury is still out on when and for which populations of patients. These recent ACC/AHA guidelines have honestly left us with more questions than answers to the best approach.
4. What are your research interests?
I’m steadfastly interested in always learning how to incorporate spirituality and spiritual wellness into everyday medicine and have done research projects on and have given journal club talks on the topic as a resident physician in the past. I pray with my patients, but that doesn’t mean that I force my religious beliefs onto them. They and their family members guide the process, as it is an option for them. This is something I saw practiced during my early shadowing experience in high school and college as well as during my academic career as a medical student at Meharry Medical College.
I believe that I as a physician have the responsibility to provide holistic care to my patients, and this includes helping to meet their spiritual needs or connecting them with someone, in situations where I cannot, who efficaciously can. I believe knowing how to do so effectively remains almost a mysteriously unchartered territory in healthcare and provides continued room for exploration. The nursing literature and palliative care literature have made great strides to help us out with this aspect of holistic care, but we can always do more investigation and exploration. I’m also engaged in teaching other physicians how to do this and learning more about spiritual wellness assessment tools validated for this purpose. I’m also interested in anything pertaining to cardiovascular disease prevention to fostering diversity in the physician workforce to end-of-life care, all of which affords me to learn about, teach, practice, and research.
5. Outside of your daily practice, do you have any personal or professional projects that you’re passionate about?
In another life, I’m a self-taught pianist and a writer of Christian-themed poetry. I’ve published digital CDs and have also written a few books of poetry. I continue to write. Writing is both cathartic and therapeutic for me, especially of poetry. Some of the poetry I’ve written is based on my experiences providing medical care daily. I envision my next book will be one where I write about lessons of patients who were at the end of their lives throughout my training and into the early days of my attending career.
I also love to cook and maintain a personal blog at ESJMD.wordpress.com that showcases my dishes, some of my poetry, and also community service initiatives. These include bringing a chapter of Walk with a Doc to the community in which I practice. I’m very passionate about all of these things.
6. What is a common misconception that other clinicians have about internal medicine?
I think physicians of other specialties think that internists are glorified referrers, and that’s not true. Though we will refer to other specialists for their expertise in certain patient situations, we like to be thought more of as gatekeepers instead of revolving doors.
7. Who are your mentors?
My fathers in medicine are Mac Andrew Bowman, M.D., FACC, and Michael Stewart Holman, M.D., FACC, both cardiologists who have been in joint practice for decades in my hometown and who are also of African-American descent. They took me early under their wings, allowed me to question them, challenged my call to service mankind as a physician, and nurtured that calling for years. They allowed me to pull at their white coat tails and shadow them time and again.
By observing their prowess as master clinicians and seeing them outside of their offices in the community, I also noticed a simply honest truth in being a christian man, a black man, a family man, a fine and well-respected doctor, and a community and public servant. They showed me how to be yourself and doing what you love to do, and what it means to welcome daily stellar humanism into the healing arts. I’ve always wanted to be like both of them, individually and collectively, when I grow up. I still do. I joke often in saying that if you don’t have at least some of what they have you can mimic it, at least.
8. What’s the best advice you’ve ever received?
Dr. Princessa Johnson, an OB/GYN in my hometown and a former member of my home church, told me after learning I was heading to medical school years ago to “always do more than they ask you to do.” She probably doesn’t even really remember telling me that because our encounter at church that afternoon was so very brief, but it always, always stuck with me and has been, in essence, of tremendous benefit to how I practice and approach the study of medicine.
Also, along the interview trail for medical school, Dr. Greer Falls, a full professor and Pathologist at the former Medical College of Georgia, now Augusta University, told me when I asked him about what his recommendation for me would be going forward to “be a sponge,” to get all the knowledge you can while you have the time to be a formal student. That also, especially as an internist, continues to gird my loins in daily practice. The best teachers are innately the best students. The best doctors are also good students of our patients and of medicine.
9. What has been your most gratifying moment of being a clinician?
There have been multiple, and they are there waiting for me and all of us each and every day, whether it be partnering with a patient to get his or her A1c to goal, or finally getting that resistant hypertensive patient to a good blood pressure goal. I suppose the greatest reward I get everyday is simply being able to help someone help themselves be and live better each and every day. That’s really what drives me to get out of bed with anticipation each morning. I thirst for it, and I love it. If I ever lose that passion, then I should prepare to see my last patient on that very day. I feel on some days that I love what I do so much that it’s almost robbery. I heard once, “When you love what you do, you’ll never work a day in your life.” Such is how I feel about practicing medicine every day.
10. How do you unwind after a challenging day?
Music is usually integral to any relaxation technique of mine, whether I’m at the keyboard playing a hymn or personal composition or listening to the vocals of Sarah Vaughn, the work of John Coltrane, or newer artists like Esperanza Spalding massage my vestibulocochlear nerve with her silky, smooth voice. Gospel and vocal jazz are usually where it is at for me. I also find orchestral music quite relaxing and stimulatory to the mind.
As stated previously, I love to write poetry, so I do that often. I enjoy traveling, but I also enjoy quiet evenings at home relaxing and watching a favorite television show or doing some project on my list around the house. Dinner with friends is always nice, too, during the week, which is a common occurrence. I’m also always reading some non-medical book with historical or societal implications that a friend or family member has recommended.
11. How do you motivate patients to do what’s best for their health?
I bring a sense of real-world, familial tough love to the practice of evidence-based medicine, and I keep it real. I don’t sugar coat things, because I find that nearly all of my patients like when their doctors are straightforward and as pragmatic as they are knowledgeable. For instance, I tell patients during obesity counseling that I do not expect for them to run the triathlon or to eat ketchup spread onto cardboard cutouts, but I do ask that they slowly initiate at least 30 minutes daily for at least 5 days a week of moderate-intensity exercise into their lifestyle routine and to start low and go slow.
Also, colorizing their plates and focusing more on a plant-based eating plan is an ideal way to make small changes in their diet that make a tremendous difference. Getting family members excited and encouraged to participate are helpful as well. We also are inviting more patients to come out and walk with us, given we’ve really start a new Walk with a Doc program in the community in which I practice.
12. What is the biggest challenge or obstacle in internal medicine?
Anyone who knows me knows that I loathe insurance companies and dealing with them regarding getting the best and evidence-based therapies for my patients approved and paid for. We are getting into deep doo-doo in medicine when we are having insurance company personnel 2,000 miles across the country telling a doctor who has seen a patient for 10, 15, or 20 years regularly what medical therapy is best for his or her patient. I have little patience for dealing with all of the prior authorizations and am daily trying to find appropriate ways to maneuver that infrastructure for the patient’s benefit. Doctors don’t control medicine. Patients, although our goal is for them to be more empowered, don’t even control it. Insurance companies are becoming more dictatorial by the minute in terms of deciding the why, the what, and the how of medicine, and it really is a sad and pitiful situation. I’m worried because I’m not entirely certain if there is much at all we can do about it.
I just love DocNews. It keeps me up-to-date on interesting articles on topics relevant to the everyday practice of medicine with their selection that we do not see in medical research journals. I’ve often read about everyday factors that play into just being a doctor and the experience entirely, not just gaining more medical knowledge to practice well.