What’s Happening Inside Your Doctor’s Head and Heart (w…

Adam Cifu: Thank you so much, Russ. It’s great to be here.

Adam Cifu: Right. I’m afraid I don’t know. It was interesting. I wrote this essay thinking about a pledge that I assume is part of what doctors take or is part of our career, which is that we treat all of our patients equally. And, I assumed it was in the Hippocratic Oath.

And, so, I ended up taking this deep dive into the Hippocratic Oath–the original–which has become quite politically incorrect, and all the new versions of the Hippocratic Oath. And that pledge doesn’t appear anywhere in the Hippocratic Oath. And so, I finally found this Declaration of Geneva, which has been adopted by, I think, about half the medical students at medical schools as their pledge that their graduates take.

And, that declaration does, in fact, include that you will take care of your patients irrespective of wealth, creed, color, sexual orientation, anything else. And, so, I was like, ‘Okay, I found it. I’m doing an essay about this.’

Adam Cifu: Well, I found it interesting because I really do think–it’s an assumption, right? And it’s something that I think doctors pride themselves in: that we have to take care of patients who we like; we have to take care of patients we don’t like. We have to take care of patients who might talk politics in the room and we might find out that we agree with them or desperately disagree with them.

But, I think we all take pride in the fact that it doesn’t matter; and it’s, in fact, one of the wonderful things about the career is that we come to work and we talk to and we work closely with people who we might not have anything else to do with in our entire life. So, not only does it feel good to do, it actually makes, I don’t know, sort of my life more enriching, I think.

Adam Cifu: Right. I think it was when he got onto the table, he said to the team of doctors, ‘I hope you’re all Republicans.’ And, the surgeon, who was in fact Democrat, said, ‘President Reagan, we are all Republicans today.’ Which I thought was a wonderful response. I hope the story is true.

Adam Cifu: Absolutely. And, I also think it speaks to the importance of the role of the patient in the doctor-patient relationship is that the patient has a lot of power to manage how those visits go. And, I think Ronald Reagan, as the great communicator, was really using it at that point. Like, ‘Here’s a way to put everybody at ease, take a little bit out of the stress of the situation, get people on my side.’ It’s kind of brilliant, actually.

Adam Cifu: Let me pull out the Declaration of Geneva, which I happen to carry in my breast pocket at every time.

Adam Cifu: Yeah. Well, I would say it’s certainly not many of my patients. It is a very, very small minority. I think–you know, people bring into the doctor’s office the way that they manage people in the rest of their lives. Most of my patients I think feel, I don’t know, entitled to good care, expect good care, expect an equal collegial relationship with me. And, that’s very easy for me. I think that’s very easy for the patients. Most of us fall in, naturally, to that.

There are also people who come to the doctor’s office feeling like they’re going to be, I don’t know, disrespected, disenfranchised, the way they are in the rest of their life. And, they sort of manage the doctor often in ways that they manage everything else.

Very often, interestingly with the doctors, that’s to be overly appreciative and overly thankful; and it comes off being very nice until you analyze where this is coming from. And, it’s kind of sad that, ‘Oh, my God, this is what this person needs to do to just get what they deserve.’

There are people who, I call them the sort of masters of the universe–the people who are used to bullying people and getting everything they expect in every part of their life–come into the doctor’s office in exactly the same way.

And then, there are people who I think just don’t recognize that there’s a benefit to a rich or at least equal or pleasant relationship with the physician, and almost look at the doctor as they would somebody else who is providing services to them in other parts of life. There’s a quote that I don’t know who it’s from: You can judge people by the way they treat bank tellers, wait staff, things like that. And, there are those people who treat those service workers terribly and they then treat their doctors terribly. And, it’s always interesting to me. So, I’m like, ‘Hmm, I’m going to do my best to take care of you like I would everybody else, but this doesn’t help you a whole lot.’

Adam Cifu: Right. This is a challenge, and I find this difficult. And, I think on my best days in the office when I’m mindful, I recognize this and work at it. At other times, I think I probably fall short on this. But, there are people–very often people who have similar backgrounds, similar life–who you immediately connect with and it’s very easy; and not only is there the doctor-patient relationship, but there’s something else added to it. I don’t know if this improves the care they get, but I can only imagine that it makes them more comfortable with you. This seems like a peer immediately.

And then, there are people who are from very different backgrounds, maybe backgrounds who are not–even the people from different backgrounds who I’m used to caring for, that although they’re expecting me to be a caring physician and I’m going to be that, and I expect them to be a patient I can work with and I’m going to do that, there’s still a little bit of a separation between us, right?

And, it may make them hold back, not tell me things they should. I might not understand things about their life. It may just take a little bit more work for me to understand where they’re coming from, what their social norms are, what their behaviors around medications are. And, maybe this is an argument for our continued effort to really diversify our field. But, I think most importantly, it’s just something to recognize as we care for the diversity of patients that we all do.

Adam Cifu: Sure. I think those are all great points. So, I do; and, I think that it’s something that we do our best to train our young physicians/trainees in, that ability to be empathic, to meet people where they are, to put them at ease in, as you say, which is just, by definition, an uncomfortable experience.

It’s one of the few places that you go around in the world that you go to by choice–if you’re going to the doctor’s office and not the emergency room–where you’re going to be powerless, you’re not–in the end, you’re not really in control of your illness and your body. Certainly, we can all live good lives, but in the end, something’s going to get us no matter what we do. And, it’s so important to be able to support the patient during that time. Make them feel comfortable, make them be able to open up to you, feel like they have you in their corner for support.

While you were talking about it, it made me think of something that I think I struggle with most is that, although I feel like I have control of how the patient feels about the relationship in the room–I can make them feel more comfortable, I can make them feel supported–when they leave the room, what the patient brings to the relationship, in which I don’t have that much control of, does actually affect how they interact with me. Right?

The people who are maybe closer to me as peers, those people, there’s so much less of a barrier to access me. And there are so many ways to access your doctor these days, right?–whether it’s a phone call, an email, a text, the electronic medical record communication devices. Most of those people have absolutely no qualms about saying, ‘I got a question. I’m going to call my doctor about this.’

While the people who are a little bit more further afield and maybe still hold their doctors with, I don’t know, some level of respect, those people are often so hesitant to reach out, even in the ways that are completely appropriate and expected; and they’ll say, ‘Ah, I’ll wait until the next appointment.’ And often suffer for that.

Certainly, I got to take some responsibility. There’s something I haven’t done to make them feel empowered to be able to break through that. And, maybe this is one of those times that you have to think more about equity than equality, right? Those people need more help to get that adequate care that they’re supposed to have. But, boy, this is a challenge.

And, when it’s a day with 12 patients and you’re exhausted by the end of your clinic and are just sort of dying to get home, it’s just sometimes an effort that’s hard to expend.

Adam Cifu: Right. Russ, there’s so much in what you just said. I think I could talk about this forever.

A few things stand out. First, the difference between reverence and respect deserves an essay in itself. I think probably a little bit of reverence is good just because that’s what the placebo effect is. Right? We use that as power, and that helps.

Though I think if you revere your doctor too much, you should probably find another doctor because you’re not going to question things.

I think respect is very different from that. Right? And, you do hope that you–I sort of hope that my patients mostly respect me, but don’t revere me, but also feel empowered enough to question me.

Your other point, which I really do love, is, sort of, the patient’s need for power in the relationship.

And, I have to say–having not listened to every episode of EconTalk, but a lot of them–your ability to–I often tell my students, when you learn to drive, my driving educator told me to aim high in steering, which always sounded like a ridiculous thing, but it was: Don’t just look very close up. Look way into the future. What am I worried about here?

And it’s so important in medical decision-making to say, ‘So, I’m choosing to take this medication. I’m choosing to have this test. What are the long-term outcomes of this? What am I going to do with the results of this test? Is it the right test? Is it worth doing it all? Do I actually want to know the results of this?’ And, that’s critical.

And then, the last thing, you’ve talked so much about artificial intelligence [AI].

And, we are quickly getting to the point where probably if a patient is able to present their symptoms, maybe even their signs–sort of physical examination signs–in a really reliable way, that maybe a computer can do as well or better than a doctor at, at least, outlining a differential diagnosis. Right? ‘Here are the three most likely things to think about and here’s the one thing that we need to really worry about.’

But, I think the vast majority of people would not be satisfied with that, because they’re not going to have maybe a little bit of that reverence for the computer that they might for a human being who they are attached to and feel like will carry a little bit more power in the discussion.

Adam Cifu: I think about that a lot. Again, to talk a little bit about the arc of a career and what you gain as you get further in a career and what you lose, one of the things when I see a patient, say, in our urgent care center where I’m working with our trainees, very often we are delivering the same information. We’ve made the same diagnosis, right? But I am able to say it with such absolute confidence not only in what the diagnosis is, but in what the next steps are and how that person is going to do–I can kind of see into the future a little bit: This is what your outcome is going to be over the next three to six months.

And it’s interesting, patients–I hate saying patients because it’s really people, I’ve been in this situation–really latch onto that, because again it’s a time of uncertainty. It’s a time of powerlessness; it’s probably a time of anxiety. And, to be able to have someone who say, ‘This is what’s going on, this is what we’re going to do, and this is what’s going to happen,’ is so important.

Even if the other person standing in the room told you the exact same diagnosis, but they sort of pitch the plan and the outcome maybe a little bit more honestly, because how well do we actually know what the future holds? And, I think probably part of what your mom was responding to was ‘It’s this,’ and then you’re proven right, and ‘This person is going to be someone I’m going to trust in the future.’

Adam Cifu: Right, exactly.

Adam Cifu: I’ve thought too much about this. I generally introduce–I will say to the patient, ‘Mr. Roberts, Dr. Roberts, what would you like to be called?’ And then, I will respond in that same way.

I will not tell people what to call me. I’m perfectly happy with them calling me Dr. Cifu, Adam, whatever they like. If they say, ‘Mr. Cifu,’ I usually say, ‘You can call me anything. Call me Adam. Call me Dr. Cifu. Just don’t call me Mr. Cifu. I worked very hard for that degree. It seems weird for me.’

And so, most of the time when patients come in and say, ‘Adam, how are you?’ they’re people who I’ve already known and I’m very comfortable with. The people who address me as that right off the bat, it does seem like a little bit of a power play to me.

Adam Cifu: Yeah. And, I’m sort of fine with it, but it gives me some information about the person I’m dealing with and it makes me understand a little bit more about who they are, what they expect from the relationship, how I think they’re going to treat me. And, so, in a way, maybe as the person doing that, it’s fine. It’s a way of signaling and it probably cuts out a lot of the time of trying to work to understand who this person is.

Adam Cifu: You would be welcome to call me any of those things. It’s funny, I’ve never sort of recognized that parallel with clergy. And, I would be wildly uncomfortable, certainly–when I meet someone, which is often for me in the office, I have to call that patient Rabbi, Father, whatever. It’s very interesting.

It probably goes to socialization as well. It’s how I was brought up, how I was taught to respect these people. And, it’s the reason that–the only reason I can call my doctors by their first name is that most of them are peers or former trainees. And, that’s how I think of them.

Adam Cifu: Not at all. Not at all. Certainly, my mentors along the way, even if they have yelled at me and made them call me by their first name, I still think of them as Professor Wittner or whatever.

Adam Cifu: I do. Interestingly, from me, given my role and now advancing age, I think so much when I’m in that position about how I’m going to make sure that I’m actually being seen as a patient rather than as a doctor, and make sure that I’m, in a way, being treated like everybody else, spoken to like everybody else.

And, I probably overplay the patient role because I have seen so many–let’s call them VIPs [Very Important Persons]–treated poorly because people are so careful about how they’re going to ask questions and what kind of tests they’re going to recommend.

And, I want to stress so intensely that, like, ‘God, you got to take care of me like you would take care of anybody else.’ Maybe an opposite reaction than people would expect. But I embrace the paper gown, I guess.

Adam Cifu: Yeah. And, a lot of these things, when I say it, I feel a little embarrassed because maybe they’re obvious. I think the one that comes to mind most quickly from that essay is that it’s the patient who is taking the medications. And, we so often forget as doctors that we think we understand the most important reason that people should be having a surgery, taking a medication, accepting a diagnostic test, because we’re sort of obsessed with, ‘Okay, I’m doing this to get the person better and this is the obvious thing to do.’

But, it’s the person who has to live with the information that they’re getting. It’s the person who actually has to take that pill every day, maybe deal with the side effects of that medication every day. And, boy, I have just come to appreciate the fact that an educated–I wouldn’t say educated–a well-informed adult, boy, should have all the leeway in the world to accept care, to not accept care, to make what seems from the doctor’s perspective an absolutely terrible decision.

And, it seems so obvious, but it’s so difficult after you’ve been through medical training to adjust to that, to adapt to that.

Adam Cifu: This was actually when I was an intern. I was working at the Dana-Farber Cancer Center. We had multiple people at, really the end of their lives on very complicated novel cancer therapies. And, this woman came in, even if she did perfectly last six months of her life–besides her cancer, she also had pretty severe cardiac disease.

And, I wrote her for a low-salt, low-cholesterol, cardiac diet. And the patient actually had the nurse page me to the bedside so she could berate me. And, she began her talk to me saying, ‘I’m told that you wrote me for this diet. You can only possibly be an optimist or an idiot.’ And, I was like, ‘Oh?’

And, obviously, I’m telling this story, this must have been 1993 or 1994: 30 years later and it’s stuck with me so well, and I can still picture her and she’s sort of a mentor to some extent. She taught me a lesson there, which is well remembered.

Adam Cifu: Right. Absolutely. I changed her diet immediately. I have to. I think I might’ve brought her a cookie at some time during that admission as well.

Adam Cifu: Yeah. So, when we do a diagnostic test, we are looking to say, ‘Do you have coronary disease? Do you have a urinary tract infection?’ But, what’s interesting is that very often those diagnostic tests, one, change people’s lives. We’re very fond of saying that they take people and turn them into patients. Sometimes that’s necessary.

Sometimes, especially in the case of screening tests, that’s not necessary. Maybe you’re turning people into a patient in a way that’s not going to benefit them at all.

The other thing is that doing a diagnostic test, especially with 21st-century medicine, generally unleashes an entire string of decisions and possibilities and interventions. And, you just have to be so careful at the very beginning of that string: Do you want to go down this path?

And, I think most of us think that, ‘Oh, what’s wrong with a little bit of information? Knowledge is power.’ But sometimes in retrospect, you, me as the doctor, my patient feels like, ‘Ah, maybe if we’d never known this, instead of living for two years, 18 months of those two years knowing that I had cancer, would I have been better off living for two years but only knowing I had cancer for the last six months of it?’

And, I’m not sure–well, I should say I know I don’t have the right answer most of the time, but very often I just like to pause before placing that order. Have the conversation with the patient and say, ‘Look, these are next steps. These are possible outcomes. Do you want to really start this?’

Adam Cifu: Right. It can kill us.

Adam Cifu: I think it is worth asking the question because, as you say, sometimes a diagnosis can be life or death. And, it’s worth asking the question: How necessary is it that I need to make a decision now? How long would you feel comfortable waiting? As soon as you started talking about it, although I very much identify, as a medical conservative, with: Boy, a lot of the things we take care of just get better on their own and probably waiting is the best medicine.

There are so many people who I’ve taken care of over the years who postpone decisions for so long; and I can hear myself at so many visits saying, ‘You have made the decision not to embark on this workup. You’ve made that decision by postponing the decision.’ And, for me as someone with limited time with patients, I mostly have to tell them, ‘I’m considering this decision made. Because you’ve postponed making a decision for six months, I assume you’re never going to do anything about this. Please bring this up to me again if you change your mind.’ Because at some point as a doctor, I’m like, ‘I can’t wait any longer for this person.’

Adam Cifu: Well, I think your point is–also, and it’s probably something I’m now coming out of this recording, both with a new essay topic but also with a new tool to use with patients–is that I think that delaying a test until you have more information is an intelligent thing to do. And, that ‘more-information’ may be that I’m doing more research, I’m waiting for some study to be completed, or I’m waiting to see how my symptoms progress over the next three months.

If you are delaying a test for more information which will not be coming, then you’ve made a decision not to have that test and that probably just needs to be articulated.

Adam Cifu: So, ambiguous illnesses are something which has gone by a lot of names over the years–symptoms of unknown origin is another one which I love–are patients who are clearly suffering from something but that we in medicine haven’t been able to reduce it to our sort of 21st-century pathophysiologic rubrics.

And so, not only do we not understand them well, we generally do not have good treatments for them.

And, I think probably what we’re talking about most now is long COVID: that even the people who study this the most don’t understand it that well and even have trouble defining it.

And, seeing patients who have these ambiguous illnesses can be very frustrating, both for doctor and patient.

And, what I tried to articulate in this essay was that I have seen these visits go well or these relationships around an illness go well, and that’s usually when a doctor can be honest and say, ‘We don’t understand this, but I am committed to working with you on this. I am happy to entertain suggestions for you. I’m happy for you to seek care that I feel like is safe and not something which will steal your money outside of traditional medicine.’ And, where a patient is willing to almost buy into that uncertainty, accept that uncertainty, work with the physician to try to get better.

Often those relationships go very poorly, either because the doctor just gives up–is so frustrated that, ‘I can’t take care of this the way I can take care of hypertension or diabetes or breast cancer,’ and feels like they have nothing to offer the patient. And, even if they don’t say, ‘I have nothing to offer you,’ the patient understands very quickly that this doctor has given up on me.

Sometimes–although we hate to say this–sometimes it’s the patient’s fault, because the doctor has sort of done what’s right and says, ‘We don’t understand this. No further evaluation is going to lead us to a diagnosis. I am not going to be able to prescribe a silver bullet for you. But I will work with you.’ And, that’s honest. That person is committed to helping the symptoms. But the patient at that point in time is kind of unwilling to accept that and will continue to change doctors, will constantly shop for that diagnosis which will be the answer, even if all evidence says that that won’t exist.

And, those people often put themselves at great risk. Because there’s nothing we’re better at medicine than spending lots and lots of money doing lots and lots of tests; and many of those are invasive, many of those are dangerous, and some of those turn up information that leads to treatments of other problems which aren’t important.

Adam Cifu: Yeah. There are a lot of downstream risks to our successes in the 21st century. Certainly true.

Adam Cifu: So, my memory binder is truly a binder–I have it behind me in my office here–which has the face sheet, the snapshot as we call it, for every patient who I’ve ever taken care of who has died. Not people I’ve known for three days in the hospital, but people who I’ve cared for in my outpatient practice who have passed away.

I certainly did not plan to keep this. I began keeping it because my very first patient who died when I was an attending physician, I was pretty broken up. It was a very difficult–and for a very young woman. And, as I sort of pulled her face sheet out of my file, it was, like, ‘What am I supposed to do with this?’ And, the idea of just throwing it in the garbage was literally painful. So, I stuck it in a drawer. And, that became a habit for me of what I would do with those.

And then, when my office got moved a few years into my practice and I opened up this drawer, and I was like, ‘What do I do with these?’ And, so, I just put holes in them and put them in a binder and I’ve continued that. And it’s turned into this sort of amazing thing for me, because it reminds me of people who I was close to, even if it was for a brief amount of time, often very intense periods–certainly in their life, but often in mine.

The diseases that are represented in there have evolved over time. My patient panel has evolved so much over time: where at the beginning, these were patients who I knew very briefly and there’s usually just a sheet. As time has gone on, very often families send me remembrances, or I take things from their funerals, which I attach on there. Now, given where I work and what my patient panel looks like, I have three-page obituaries which go along with those, which I staple on.

And, I can’t say–it would be very morbid for me to say, ‘Oh, I look at this every week.’ But, there are occasional times when someone passes and I put their sheet in there that I take towards, kind of thumbing through it.

And, interestingly, the memories are usually good rather than painful because what’s lost is sort of the disease state; and what remains is kind of an image of just these people, these patients of mine, which is kind of wonderful to be reminded of them.