PE R S PE C T IV E Pharmaceutical Marketing Revisited

Disclosure forms provided by the author -­million​-­drug​-­k ickback​-­settlement​-­e ve​-­t rial​
are available at NEJM.org.
From the Harvard T.H. Chan School of Pub-
lic Health, Boston.
This article was published on October 29,
2022, at NEJM.org.
1. Raymond N. Biogen agrees to $900 mil-
lion drug kickback settlement on eve of trial.
Reuters. July 20, 2022 (https://www​.­reuters​
.­com/​­legal/​­government/​­biogen​-­agrees​-­9 00​
industry documents. Ann Intern Med 2006;​
-­2022​-­07​-­20/​­).
2. AHIP. New study: in the midst of
­COVID-19 crisis, 7 out of 10 big pharma
companies spent more on sales and mar-
keting than R&D. October 27, 2021 (https://
www​.­ahip​.­org/​­news/​­articles/​­new​-­study​-­in​-­the​
-­m idst​-­of​-­covid​-­19​-­crisis​-­7​-­out​-­of​-­10​-­big​
-­pharma​-­companies​-­spent​-­more​-­on​-­sales​-­and​
-­marketing​-­t han​-­r​-­d).
3. Steinman MA, Bero LA, Chren M-M,
Landefeld CS. Narrative review: the promo-
tion of gabapentin: an analysis of internal
145:​284-93.
4. United States District Court of Massa-
chusetts. Relator’s trial brief: United States
of America vs. Biogen Idec, Inc. Civil action no.
12-10601-IT. June 28, 2022 (https://fingfx​
.­t homsonreuters​.­com/​­g fx/​­legaldocs/​
­zjvqkzolovx/​­biogen_trialbrief​.­pdf).
5. Schwartz LM, Woloshin S. Medical mar-
keting in the United States, 1997–2016.
JAMA 2019;​321:​80-96.
DOI: 10.1056/NEJMp2210637
Copyright © 2022 Massachusetts Medical Society.
Pharmaceutical Marketing Revisited

The Worst Thing

The Worst Thing

Chris Adrian, M.D.​​

“What’s the worst thing

that’s ever happened to
you?” the mother asked me. It
was a year into the pandemic,
and we were talking over Zoom.
“Would you tell me about why
it feels important to know that?”
I asked — a response that was
drilled into me during training
as a hospital chaplain and pallia-
tive care physician.
“I guess I just want to know if
I can trust you,” she said. She ex-
plained how hard it was to find
anyone who could really under-
stand what she was going
through after the worst possible
thing had happened to her, the
death of her young son. We
veered off into a discussion of
community and grief — I was
part of a multidisciplinary team
helping her prepare for a psyche-
delic retreat for bereaved parents,
held in Jamaica. She didn’t ask
again about my worst experience;
like most parents who ask me
personal questions, she returned
to her own story when I didn’t
tell mine.
Parents ask me personal ques-
tions all the time. Are you married?
Do you have children of your own? Are
you a Christian? What do your tattoos
mean? As I’ve been instructed, I
answer only when the informa-
without making a show of it. You
reveal enough of yourself to reas-
tion really seems to matter to sure them that they’re talking to
them. Usually, I forget the ques- an experienced human being, but
tion and focus on the sentiment not so much that you distract
behind it. But this question stuck them from themselves.
in my head, partly because in my Of course, holding that kind
20 years of practice, no patient or of boundary asks for a full aware-
parent had ever asked it before. ness and understanding of one’s
It seemed strange to have been own experience of emotional
asked such an intimate, invasive, hardship. In my case, it was hard
powerful question. Yet it also to manage without a great deal
seemed strange that it had taken of help. I was trained as a pedia-
so long for one of my patients or trician and oncologist by sensi-
their parents to ask it, since I’m tive, compassionate clinicians who
often present with them in their never asked me to talk about the
own worst thing, and it’s not worst thing that’s ever happened
surprising that they might look to me, or even to acknowledge
up out of their own pain and that my own experience of suf-
wonder about mine. When the en- fering would color my clinical
counter stuck with me as I pre- encounters. I was grateful not to
pared for the retreat, it seemed be asked — my vocation in the
auspicious, a sign that I should hospital depended on putting my-
be prepared to hear the question self in the way of other people’s
again soon. It called to mind pain so I wouldn’t have to think
something a supervisor had told about my own. But that question
me in one of our first education- — What are you bringing into
al sessions: A sound professional the patient’s room with you? —
boundary is not a line in the sand but was central to both chaplaincy
a dynamic field. That is, clinicians and palliative care training.
can best serve patients and cli- Clinical pastoral education,
ents by cultivating a habitus and which trains seminarians, divin-
persona that suggest some per- ity students, and clergy to be-
sonal familiarity with suffering come hospital chaplains, is pred-

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PERS PE C T IV E
icated in part on the notion that
other people can see parts of you
of which you’re not habitually
conscious. In the two training
units I completed while working
as a pediatric oncologist, I was
gently but firmly challenged into
emotional self-awareness. My peers
and supervisors showed me that
my affable, easygoing affect was
only part of a personality that
was also rigid, controlling, and
fearful, and that this hidden-
from-me aspect of my psyche
came alive in the traumatic set-
ting of the hospital because it
had developed out of my child-
hood coping with trauma.
Pediatric palliative care train-
ing refined this discernment,
pushing me specifically to recog-
nize much of the personal emo-
tional material I carried into pa-
tients’ rooms as grief. Palliative
care asked me to consider how I
relate to both other people’s suf-
1634
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Copyright © 2022 Massachusetts Medical Society. All rights reserved.
fering and my own, and it insist-
ed that mastering a mature clini-
cal style required that I reconcile
to my own experience of loss.
Like everyone in the group of
U.S., Canadian, and Jamaican
physicians and therapists who
would be supporting the parents
at the retreat, I had also trained
as a psychedelic guide. In a long
course of study, we each learned
to work with psychedelic mush-
rooms both as practitioners and
clients, discovering for ourselves
how negotiating mental and emo-
tional pain within an altered
state of consciousness can lead
to personal integration and heal-
ing. As novel as this training was
for me, it was also essentially
familiar, because the vector of
instruction recalled those of chap-
laincy and palliative care: train-
ees in all three disciplines must
acknowledge and examine their
own suffering in order to au-
n engl j med 387;18  nejm.org  November 3, 2022
The New England Journal of Medicine
The Worst Thing
thentically and effectively support
others in their spiritual, psycho-
logical, and existential struggles.
As it turned out, no one at the
retreat asked me again about my
worst thing, but the question re-
mained alive for me anyway as
we spent our time in Jamaica
preparing for the group ceremo-
ny that would be the culmination
of the week and the midpoint of
our work together. While I was
among those loving parents who
had lost children to overdose,
suicide, accident, or murder, no
one had to ask about my person-
al history for me to be cast back
into my own family story of vio-
lence, heartache, and traumatic
death. Like all the staff that
week, I made use of every strand
of my training to support the par-
ents as they revisited the worst
pain of their lives.
As the parents opened up to
each other, sharing their stories
and working with us to refine
their goals for the retreat, I hung
on tight to the wisdom of my
mentors and peers, remembering
their patience and compassion as
they’d coached me to acknowledge
my grief over the early loss of my
brother, the fear I carry from
growing up in a physically vio-
lent family, and my anger at be-
ing sexually abused by my parents.
I remembered their hope that self-
awareness would allow my expe-
rience to become a window in-
stead of a mirror, so I might see
my patients and their parents for
who they really are, so that I
might in a clinical situation like
this one really know who I am in
relation to any parent who suf-
fers in love for their child.
I’d like to think I might have
made my teachers glad, because
it seemed to me that during the
days of preparation, my profes-
PE R S PE C T IV E The Worst Thing

sional training allowed me to be,
like my colleagues, supportive in
boundaried and useful ways for
the parents. But then — after the
parents had taken their mush-
rooms and were facing their in-
dividual ordeals, and after the
staff had fallen into a rhythm of
close observation and support,
and after the mother had started
to recognize that some part of
her son was not actually lost to
her — something else happened.
In the highly charged atmosphere
of the group psychedelic journey,
the question came back to me
with special power: What’s the worst
thing that’s ever happened to you?
The static picture of self-
awareness began to move. Instead
of just being cognizant of myself,
my history, and my emotions in
response to these parents and
the worst thing that had ever
happened to them, I began to ac-
tively relate to them through
some of the worst things that had
ever happened to me. In that mo-
ment, I was their clinician and
guide, but I could also feel part
of myself as a child in relation-
ship to them. It mattered desper-
ately to me how much they loved
their children. I wondered if it
might not matter desperately to
them how much I love my parents.
When strangers comment that
being a palliative care pediatri-
cian must be so difficult and ask
me how I do it, I generally say,
“It’s hard but beautiful work” or
“It’s hard work, but I am very
fortunate to get to do it.” Sup-
porting bereaved parents in psy-
chedelic experiences has taught
me to add something that com-
plements and supersedes these
explanations: “These human be-
ings are my patients and clients,
and we are also companions. The
privilege of working with them is
not just mitigating suffering but
becoming, like them, painfully
alive in it.” I’m nearly certain
that I’ll never tell any parent or
patient about the worst thing
that’s ever happened to me. Never-
theless, I can connect with them.
Nevertheless, I get to feel with
them a remedy of sorts for any-
body struggling to make sense of
a world where children suffer
grievous harm no matter how
much their parents love them: To
not be alone in it.
Disclosure forms provided by the author
are available at NEJM.org.
From the Division of Comfort and Palliative
Care, Children’s Hospital Los Angeles, Los
Angeles.
This article was published on October 29,
2022, at NEJM.org.
DOI: 10.1056/NEJMp2210242
Copyright © 2022 Massachusetts Medical Society.
The Worst Thing

Double Take Video: Climate, Pollution, and Children’s Health

This instructional video focuses
on five key ways in which cli-
mate change is creating a long-
lasting negative impact on chil-
dren’s health: extreme heat,
climate-intensified events,
changes in air quality caused
by wildfire smoke and aero-al-
lergens, disruptions in food and
water supply, and changes in
vector ecology.

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The New England Journal of Medicine
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Copyright © 2022 Massachusetts Medical Society. All rights reserved.