 I'm delighted to welcome you today on behalf of the MacLean Center for Clinical Medical Ethics, Chess, the Center for Health and the Social Sciences, and the Bucksbaum Institute. Dr. Meltzer and I helped organize this lecture series called The Present and Future of the Doctor-patient Relationship. It's my pleasure to introduce a dear friend and our speaker today, Dr. Adam C. Sifu. Dr. Sifu is professor of medicine and associate dean for medical school academics here at the university, a great general internist. Dr. Sifu divides his time among clinical practice, medical student education, and scholarly work. He sees patients in the primary care practice here at the university and on the inpatient general medicine service. He also directs a superb fourth year medical student course called Critical Appraisal of the Landmark Medical Literature and another course entitled Medical Evidence. He's the co-author of a textbook on clinical reasoning for medical students entitled Symptoms to Diagnosis. Is that the one we had a picture of for a moment? Symptoms to Diagnosis. The author of another book on medical decision making called Ending Medical Reversal, Improving Outcomes and Saving Lives. Dr. Sifu has been long recognized for his dedication to medical student education and has won honors including the department of medicine's award for clinical teaching and award for preclinical teaching and distinguished educator mentor award. He's a senior faculty member in the Bucksbaum Institute and a master in the academy of distinguished medical educators here at the university. This is staggering but I'm going to say this, Dr. Sifu has been selected as a favorite faculty member by the graduating class of Pritzker for 17 times. I repeat, 17 times. Today Dr. Sifu's talk is entitled the doctor-patient relationship, the view from a mature practice. Join me in giving a warm welcome to Adam Sifu. Thanks so much and thanks for coming and joining us. You know what? I'm going to see if I can get this to work because I'd rather wander if possible. I'll stay back here and I'll shout a little bit. So thanks. I appreciate the invitation. I'm actually kind of honored by the invitation and really happy to do this. So as I talked about, I'm going to talk from a, quote, mature practice. Which my practice is a little more mature than some of you guys and less mature than others of you so hopefully get in the middle of that sometime. I always hate it when people start lectures with sort of a caveat and try to lower the bar for themselves but I am going to do that. My usual topics are very different from this as Mark talked about. I spend a lot of time talking about evidence-based medicine, talking about medical reversal, giving talks on clinical reasoning and especially how we assess our medical students. And so this is a bit of a stretch for me. I also think of myself still as a very cynical New Yorker so it's always a bit of a stretch giving sort of a relational talk for me. But all that said, it is a pleasure to do this. So the question is why kind of give what's really an experiential talk in a setting like this? I think both thinking of the McLean Center and thinking of the Bucksbaum Center, we often think about much more, I think, deeper topics than just reflecting on our practice. But I think there's a reason to do this, right? We all recognize that as you think about the tripartite mission of academic medical centers, clinical care is kind of the neglected stepchild. I'm not really sure why. It's why we're all here. It may be just because it's the hardest to measure, right? It's very easy to measure people's H-index. It's very easy to look at the grants people are bringing in. It's very hard to assess the impact we have clinically but I'll talk about that a little bit at the end of the talk. But I think there's reason to focus on this and there's reason to practice and concentrate on practicing medicine at an academic center. One, you know, we practice here because the quality of colleagues is amazing. It's wonderful to practice with the people we practice with. And also, it's a place that we can be incredibly proud of the care that we deliver, right? Because we work with amazing people, colleagues in all sort of the healthcare professions. And so it's great and so we should think about that. And I also sometimes think we need a little bit of a pep talk when we think about clinical medicine because so much of what we hear about is not our clinical activities. So in a way, that's what I'm here to give. I'm going to divide this up into three sections of what are sort of the pleasures of practicing medicine and especially the pleasures of practicing medicine kind of where I am in my career. Talk a little bit about what I see personally as my inadequacies and I talk about that not to make this into like a therapy session for myself but because I think I hope that where I feel like I fall short is probably where we all feel like we fall short and just give us some time to reflect on that. And then think a little bit about sort of self-reflection and how we know if we're all doing a good job. I'm going to take breaks in the middle of each of these to open it up for comments and I really think, you know, often at meetings we get annoyed when people get up during the question and answer period and instead of asking a question they give a little lecture. I'm actually inviting that because this is certainly not a talk of expertise, it's more of a talk of experience. So whatever people have to add on, I am here to listen basically and I think it'll help make this better and longer than it would have been otherwise. A note on references, I throw up a bunch of references in this. I've sort of had fun writing about some of these reflections as I've gone along. It may be why Dr. Siegeler asked me to speak. So I'm going to reference some of those. I've also referenced some other people who I think have written terrific things about some of these topics. So let's start with sort of who I am and why I feel like I can stand up here and talk to you guys. I've been a general internist since I finished residency in 96. I still have a very active practice here, somewhere 800, 900 patients with my own patients three half days a week and then spend some time precepting in the resident clinic during urgent care and some time on inpatient general medicine. My inpatient general medicine time feels more and more like sort of a CME experience for me these days where I'm learning from the residents more than teaching, but that's an aside. So before getting to the mature practice, I thought we'd talk a little bit about the earlier years, which are incredibly difficult years and I don't think we pay enough attention to this. I think anybody who's there or anybody who can reflect on those, recognize that the first few years are incredibly hard. You don't know enough during those three years. You may go into practice feeling like, boy, I am equipped for this, but as soon as you start and you recognize it's a whole lot harder than you thought it would be, it's amazing that the decisions you make with certainty when you're in training or for our surgical colleagues, the procedures that you did without a second thought, all of a sudden when you're the one who's responsible in the end, you recognize that, boy, this is harder than I expected. Every patient you see at that point is a new patient, right? It's not like you're seeing people who you've seen for 10, 15, 20 years. And those people often have their doubts about you when they walk in and see your youth and can sense your maybe uncertainty in your position. I sometimes feel like shaving my head was the best thing I've ever done to make people trust me more. Also, a lot of those patients are seeing you not because they've chosen you as a doctor, but because things haven't worked out with previous physician or often physicians. And picking up those patients who are just chronically dissatisfied with everybody they've seen before is not exactly a recipe for success. Certainly a lot of talk, a lot of literature these days about burnout. I actually sort of stay away from reading a lot of that intentionally. But I do wonder if, at least a part of that burnout is us not recognizing the difficulty in how hard it is in these first few years. So let's get to kind of the mature practice, what it's like once you've been doing this for a while, and talk about some of what's great about that just so we can sort of appreciate it. So the first thing is practice has gotten a whole lot easier. Those things that I think you feel inequipped for the first couple of years get super easy. I think of the things that I can talk about without a problem these days. And I threw up a few of those, and I think about counseling patients and screening tests, evaluating certain very common things that come into the general medical practice I can do without even thinking about it. I feel like I sort of pop in a cassette tape and it just like runs with my speech on that. I guess I'm dating myself. I was talking about a mature practice when I think about putting in cassette tapes. But as an aside, and then also diagnostically, our illness scripts and our instant scripts, those abilities sort of our type one thinking to make diagnoses are so developed that it's really automatic where you can sit down with a person, look at them, see who they are, get a sense of their complaint and pretty much immediately make the diagnosis. It always makes me feel good when I'm with a student who spends 10, 20, 30 minutes with a patient and is lost. And I come in and it seems like magic to them that I can sort of say, here's 30 seconds, the person has this. And it's all because of the experience which has gone in the past. Admissions decisions, for me in clinic, the things which had the potential to slow me down in the past, man, those decisions are often instantaneous, right? You see the patient from the doorway, you're like, this person is not someone I'm gonna be sending home. And the entire length of the visit is sort of counseling the patient and getting them to accept what's ahead for them and preparing them for what's ahead for them. A few other things which I've grown into and I've come to love is that the patients who seemed impossible the first few times you see them, right? Those persons who either because of distrust of the medical system or anxiety or anxiety about their health. Who you felt like you'd never be able to connect with. After a while, you really get to connect with those people to the point that they trust you over everybody else and it can be a problem. You get those calls from the emergency room, you get those calls from urgent care saying, man, how do you take care of this person? They won't trust anything I say, they wanted to make sure that I called you before I wrote the prescription for penicillin for their strep throat. But you get to really appreciate that and respect that. Also people who seemed intimidating at the beginning of your care and I think it's okay to admit that there are some patients who we find intimidating, very quickly falls into the background. As you've seen lots and lots of people, you recognize that everybody is the same, everybody's sort of seeing their doctor for the same reason and it's impossible to feel intimidating by those patients. Another thing that I love is that early in your career, so much of your time is spent kind of establishing a therapeutic alliance in the room. I think that once you've gone on for a while and the majority of your patients are people you've seen for a very long time, you don't really have to do that anymore. You both know each other, the patient trusts you, you actually trust the patient to tell you what they're concerned about, what they're interested at and the visits very quickly get into, okay, let's talk about the issues at hand, let's not spend a lot of time in sort of developing a relationship. That gets to the bottom point that because of that, you can sort of read who actually do you need to take every concern super seriously and in which patients can you react and say, boy, everything this patient is telling me may be reason to kind of completely freak out, but I know this person and I know how that's how they communicate and maybe I don't need to take every super concerning symptom seriously. I have one guy as I was going over these slides who I always love to talk about who I've seen about every six months for the last 15 years and he has literally come in with three complaints over those years. The first one was chest pain that led to bypass surgery two days later. The second was abdominal pain which led to diagnosis of this fortunately large but benign gastric tumor and the third one was mastocytosis related to a CLL and this is one of those guys like if he calls about anything, I'm like I got to see this person, he's steric or rock with lots of issues and then sort of broadening out a little bit from the patients we see to think about sort of families and communities. I always like to say that as you go on, a lot of your patients become your friends and a lot of friends become your patients and that also makes caring for people much easier in a lot of ways and certainly very pleasant. I'm fortunate sort of having been here for a long time and with what our population is like to care for lots of families of three generations of people which for a general internist is really a treat. I actually saw a woman a few weeks ago, a young woman who I first started seeing her mother and then started seeing her grandmother and then when she got old enough I began seeing her and she came in with the concern that she was pregnant and when I asked her why, she said well I've missed a period, I've been nauseous for the last two weeks and I took a pregnancy test at home which was positive. I was like oh well are you really here for me to make this diagnosis? But it was sort of, it was wonderful to share with her in that experience knowing the rest of her family and then there's the issue which can be hard but also can be really rewarding is when you think about in our community whether it be at the medical center, at the university in Hyde Park or just in Chicago about how much overlap there is between the people we see, the people we care for, the people we work with and I've certainly been at multiple parent-teacher conferences, departmental meetings, even a colonoscopy where many of the people in your room are your doctors, are your patients who you are kind of sharing the entire experience of life and not only caregiving for. I'll take, you know, and aside as I was thinking about this one of the issues with that are taking care of each other, right? I actually had an experience, you know, alluded to on the last slide a few years ago to date myself well of having a colonoscopy and having three of the four people in the room being my patients and I sort of looked at the fourth guy and I was like who's this person? But so as you go on, you know, you certainly end up taking care of a lot more colleagues than you have in the past. Early on, I certainly, you know, dreaded those visits. I found those very intimidating and as I think back on some of those visits, I thought boy, I was not very good at this. But now as time goes on, I realized that these are some of my most rewarding relationships. You know, although I think all of us have progressed into very collaborative relationships with our patients, that's at a whole another level where it's a fellow physician you're seeing. And I really think although you try to be mindful in all of your visits and think about, you know, how this feels from both sides, it really gets to a whole another level seeing physicians. I always throw out a couple of things that some people in the room who I've seen in clinical practice have probably heard me say. I think it's I've found it's very helpful to sort of tell people right off the bat, seeing other doctors that you know, I'm talking like I talked to everybody else and that's going to sound condescending on occasion. But I do it for a reason. Often just recognizing that we as physicians often do a lot of our own diagnosing and a whole lot of worrying about our own health and really encouraging, you know, my doctor patients to turn that over to you to me to say I, you know, I think it's probably healthier for me to worry about you than for you to worry about yourself. I'm a generalist and although I couldn't practice without all of my subspecialty colleagues, I really think my role is important and really try to work to get people to sort of filter their concerns and their problems through me, which is sometimes hard when a lot of physicians have such easy access to, you know, every specialist out there who they can call on as they walk by them in the hall. And then the bottom one is, is of course, you know, let me order your medication so I can be on top of, you know, sort of what, what you're doing. But let's get back to the pleasures before opening things up. Besides the kind of relational aspect of it, there's just the medicine, right? And what's amazing is that, you know, you recognize that medicine is hard, that it's impossible to master, but until you start doing it for a while and you realize that you're never going to master it, you don't truly, truly get that, I don't think. I think it's paraphrasing Osler who said something like, there's a finite number of diseases, but an infinite number of way they present. And that's certainly true when you also factor in people and, and the way that those people react to their diseases and present those to the doctor. You also get the feeling, and I've certainly gotten the feeling for this as I worked on my kind of clinical reasoning work, that most of the test characteristics, you know, the sensitivity, specificities, the likelihood ratios of our clinical tests, our diagnostic procedures, our historical questions are terrible. And it takes so much more than just knowing, you know, do I think I felt a liver and what does that mean? Which reassures me a little bit. I don't think I'm going to be replaced by some sort of artificial intelligence computer at any time in the future, because I feel like changing what we do into a less human interaction will be almost impossible. And then certainly I always get the feeling that whenever I feel like I'm leaving clinic, I'm saying, okay, I've mastered this, you know, I have done so well in the last couple of weeks, both in diagnosis and treatment or in, or in how I interact with people, I get totally burned, you know, and I'm like, okay, you know, I'm not, I'm not there yet. This is some of you know, I spend probably much too much time on medical Twitter than I should. And so something that I started a couple of years ago is, is a hashtag diseases just learned, which are all those things new illnesses, not new illnesses, old illnesses that are new to me that I've sort of just figured out in practice over the last couple of years. And it's either through patients who come in with, with weird symptoms and I spend time working it up and reading up to date and reading Harrison's and like, this is what it is. Or more often than not that I can't figure it out, that I refer them to my colleagues who say, Oh, this is such and such. And then I learn about the disease through there. As I pulled this off, off of the document that I keep these on, I realized that it really reinforces my feeling about how overwhelming medicine is because these are all diagnoses that you know, eventually I made or were made in my patients that I looked up references to read about and post on Twitter. And as I went through the list, I was like, Oh man, there are things on here that I've already completely forgotten what they are. So you never quite, you never quite master this. The other things that I've learned, and this is from an article I wrote a couple of years ago about starting about sort of advising people starting medical school is the things that were told a lot, but you you later realized are really true. First, most of what we were taught is wrong. A lot of those things that are handed down, turn out not to be true. And that's true either for how we relate to patients or how we actually treat patients. One really striking thing is that often what you feel like is important for the patient is very different than what the patient feels is important coming from you. One of the the interactions that I wrote about in this article was a patient of mine who I took care of for my entire residency, who is a man who came in, who I was worried that he was HIV positive. And I thought it was critically important to you know, get that test and make that diagnosis. And he was not hearing about it. And I felt like I was absolutely failing this guy as we went through really a full three years of visits of me saying, yeah, we should do an HIV test. And I'm like, you know, not gonna happen. But it all sort of paid off in the end because this was a man who had absolutely no comfort with the health care system. And it was sort of those visits over three years, which made him comfortable enough that when he actually needed it, he was able to access not me, but actually everybody else. And I would have never guessed that as I was sitting there in these visits saying, man, I'm wasting my time. I'm wasting, I'm wasting his time. The other issue is certainly that I've learned that this is much harder than I thought it was going to be starting out. I think that like the, the, the, the bare, the, the boundaries of our, of what we have to do for patients are so wide that I never really know where that ends. We, we all here, I think, are very much schooled in, in health care disparities and social determinants of health. And you recognize so often when you're with your patients that, you know, writing a prescription for a statin is, is attending to such a small part of what's getting this person sick. But you know, how much can you do? You know, you should be getting involved, maybe, if you want to really want to make them better with, you know, their personal finances, the dysfunction of their family and their living situation. But we can't really do that and do their job. Got to figure out like how available am I going to be to my patients? Is it going to be during clinic hours? Is it going to be work hours? Is it going to be all the time? And I feel like whenever you draw those limits, you probably feel like you're falling a little bit short. And even if you know that that's necessary and how could you live without drawing those limits, you know, it sometimes does make you feel like you're failing or at least not living up to your expectations. So before moving on to inadequacies, I just want to sort of open things up. Any, I don't know, thoughts about that, reflections about that? I think people want to throw out or, or, or object to. I guess my question for you is, over the years I've struggled with saying, even though there is a doctoration or a regular patient, I don't know. Yeah, yeah. How did you get comfortable saying that, seeing somebody else? That's such a great question. It's probably something I should have put up there, right? Because don't you feel like with, with the time, you feel like at the beginning like, I should be the expert, I know everything, right? And then as you figure out that like, God, you know, none of us know everything. And, and when you claim that you're sort of being a fraud, I think it's just time. And I think it's interesting, the other thing which I think about when you, when you say that, is the also, the flip side is probably all the things we can't do anything about, right? And, and I, I try constantly to figure out a way to say like, you know, it's part of the human condition or, you know, that's, that's a concern of yours and that's a trouble of yours. But in a way, it's not something that like we in medicine can almost be responsible for. That's a great, that's, that's a slide to add, I guess, right? Thanks. Great. Let me, let me move on. I'm going to talk about some of the failings and I hope and pray that you guys will say, yeah, me too. Because if you all feel like, what? That's not a problem for me. I'll just get up and leave after this section. So one that I think about a lot is that I certainly don't treat all my patients the same way. And this is despite the fact that I am unbelievably conscious of this issue. And obviously think about it and have slides about it. I'm going to put off until we get to assessment of clinicians, the issue of sort of race concordant and discordant relationships. But leaving that aside, I just think of kind of two sets of patients who I take care of. And I think about the patients who are, you know, my fellow UFC faculty, physicians or not, who lives in Hyde Park, those kids at lab school, who can access, you know, me in every imaginable way, not ways that I expect patients to access me, like, you know, grabbing me at Medici or something, compared to the person who is, say, you know, a steel worker in Whiting who comes in for their visits, and has very different access to me. And actually just the way we communicate, the way we think about health, the way we think about staying healthy is so different. Yeah. Thank you. It's one of those horrible things that Spellcheck doesn't catch and just shows me. The next thing is that, you know, I think we all recognize that our performance varies hugely from day to day. This is maybe a quite a stretch of a metaphor and about as froufy as an article as I've ever written. But I sort of think of these days as my my leaf days, my tree days, and my forest days. And the leaf days are kind of those terrible days. The days that you don't have quite as much staying power as you should. When when you see people, you're sort of firing through things and you're just trying to attend to the easy numbers. The A1C's, the blood pressures, the cholesterol levels, whatever, and trying to base care just on that. They're the days that I feel like I'm susceptible to counter-transference, right, that a patient will bring all sorts of baggage out in me. And that person who maybe sounds like a relative who used to drive me crazy, gets me on edge, having nothing to do at all with the patient themselves. And I know when these days are coming, because I'll look at my schedule and I'll be like, Oh, my God, this is going to be a rough afternoon, you know, before I ever get started. Tree days are the days that are a little bit better. And that I think are actually the majority of my days. I hope that's true. Where you recognize that treating the numbers is not that important, right? That these are surrogates. Nobody ever felt better if I lower their A1C from 8 to 7. And that actually the things that we do have as medical doctors have actually quite little effects, you know, something that has a number needed to treat of 20 to 50 is like gospel, right? And so a lot of the things we do have no effects on the people. I'm much better on these days at sort of prioritizing and personalizing health care treatment plans. I do a whole lot less testing on these days because I can really reflect on like, boy, how am I going to react to these tests? How much do I need to do based on this? And I'm able to sort of sit back and like clinically observe people. And instead of just getting annoyed with with some patients, I'm able to say, huh, you know, what's bothering me here? What's the emotion underlying this that maybe naming it and talking to the patient can make us do a lot better together? Also sort of using my own reaction diagnostically, right? I think a lot of us know how like, this is how someone who's depressed makes me feel. This is how someone who's anxious makes me feel. And using that is almost a diagnostic test. And then also figuring out how, you know, we can use our patient doctor relationship as a therapeutic tool. I'm always struck by how in, you know, 21st century medicine, to a great extent we've like, we've almost given up on on the placebo effect in how we treat people. But it's so, it's so important. I like, it's probably 10, 15 years ago, I was on the point playing soccer with my kids. And I fell flat on my back, you know, I just sort of lied there as they looked down on me. And the next day I'm precepting the residents and I start getting this, this, this weird like left anterior chest pain. And I convinced myself that I have a pectoralis minor strain, which is like, I'd never heard of, but it seemed to fit my symptoms. Okay. And then a couple of weeks later, I'm sitting in the back of the car with my wife and mother-in-law driving. And I sort of pull myself up to, you know, stick my head in between to make some important point. And I get this beautiful like C7 neuropathic pain going down my arm. I was like, Oh, it's not my pectoralis minor strain. It's you know, a C7 disc. And I remember coming back and I saw a physician and a physical therapist on the same day. And I came out of the doctor's office with a, you know, classic sort of five, 10 minute interaction with a gabapentin prescription feeling worse than I felt going into it. And after seeing the physical therapist for sort of 45 minutes, you know, with somebody else's hands on me, I don't think anything that was done in that visit made me actually better. But I certainly felt a whole lot better leaving that visit. And I think we, you know, as doctors have to think about that a lot more and how we can use that more. And then the farst days, obviously, you know, it was coming are like the best days, which, which I feel like only happened on days where I've nothing else going on in my life where I've slept really well, where I've had a cup of coffee, and I'm like, I am raring to go today. And these are those incredible days where you like you, you know, you see somebody, you know, there's like an some 80 year old man who I've seen for years, and his wife is with him for the first time. And it like opens up this whole greater understanding of the guy and I'm able to sort of process this. It's the days where you, you look at your patients and you realize that, wow, you know, so much of the health care problems that people have, you know, is just sort of the hand they were dealt and how they're able to deal with these things. And none of these are like profound observations, but they're observations which I completely overlook on, on, on many or most of the days of taking care of people. This was to get back to Twitter. This was one day that I was having a horrendous day and behind throughout the whole clinic. And I, I came up with like a UChicago college prompt for an essay and, and tweeted when a doctor routinely keeps his patients waiting, he or his employer is valuing his income over their time comment. And it was wonderful that people obviously went sort of nuts about this. These were just a couple of the responses on Twitter that I loved. First one in my experience as a health care provider and as a patient, this is not true. This tweet reads like clickbait. I was just thrilled that I'd written clickbait. I think it's unfair to blame the doctor. I often run late as seeing complex patients cannot be accomplished feasibly in the time our practice allows. I don't get a choice in visit lanes. I kind of hated this because it was so much like, you know, this is my responsibility. I'm stuck with this. And I think so often we do that. And you know, if we feel like we're not able to take care of patients how we should, we should figure out a way to do something about that. I often run late but since patients know that I'll spend the time required to address their problems, they tell me they don't mind. I'd like to hear from that people's that person's patience, I think this next one actually loved. Thankfully society would never tolerate the complete seeding of non procedural imaging work to non physicians, probably our radiologists and surgical colleagues would disagree with that. So I guess in a sense the lateness that exists in the clinical world as a result of society demanding the time of a limited resource doctors. A lot of people got on me because I used male pronouns in the prompt and this woman responded when a doctor routinely keeps her patients waiting as probably because she is peeing, which definitely made me laugh sitting at my computer that day. This is to make the pitch that there's some high level conversation on Twitter and not just people throwing political invective at each other. So I don't know thoughts about inadequacies failing. Somebody bail me out. Somebody say yes, I agree with that. So thank you. Right, right. Yeah. Right. Right. Once you get to know them, yes. Yeah. Yeah. Right. Right. Yeah. Yeah. Yeah. Yeah. I love that. That's actually one of those things like you think you discover on your own, right? But I certainly found out that that that like, you know, naming an emotion somebody's having or naming a feeling is such a positive tool. It usually works. And when it doesn't work and the person sort of yells at you and says like, I am not an anxious person. You know, you've it's actually helped you as well, sort of further make that diagnosis. Your first point is cool, because we talk so much about like, you know, progression free survival versus overall mortality, but overall survival. And it's cool to hear it like go right down to the actual patient care. Yes. Yeah. Right. I think we we pick up on that right over time and seeing people do it, but it probably is not something which is which is clearly taught. And I agree with you. I feel like, you know, maybe other than my family, I touch my patients more than anybody else, right? And you certainly see, you know, so many people and it's not everybody early in career because a lot of people pick up on it right away. You know, it's the sort of stethoscope like this on a person, you know, versus being closer. I've always had a ridiculously short stethoscope tubes. I think it was a mistake on my ordering to begin with. But now I'm like attached to it because it really gets you gets you in there. It's a great point. Yeah. Yeah. Yeah. Yeah. It's such a good point. I mean, I I make the comment about all, you know, we shouldn't just accept the time we're given, you know. But there are days I was talking about one just a couple of weeks ago where, you know, something happened with my schedule, someone canceled, somebody came at like 410 and had nothing really wrong with them. And it was this wonderful, very, very elderly lady I've seen for a long time. And we really finished the visit in about 10 minutes. And I was just like, you know, so, you know, tell me about your life. Do you have any pictures? And it turns out this woman has like, you know, pictures of her when she first moved to Chicago in 1940. And I was able to ask her about like, you know, how things change. And she talked to me about sleeping in the parks on on hot nights. And it was like, it was wonderful. And I don't know if it's going to change outcomes. But it certainly, you know, made her better to figure out a little bit like what what our role is. Okay, I'm going to move on to our last section, which is, I think meant to be a little bit thought provoking. And this this has expanded from something that I did a very brief version for one of the Bucksbound series a couple of years ago. And thinking about how good you actually are as a doctor at what you do, and if there's any way to actually know that, okay. And I really feel like, like, you know, how good am I at this. And there's, there's not a great way to assess us. These are a bunch of ways that we are assessed and also go through and talk about some of the problems with all of these. So patient assessment is, is I think what we agree with most, right? Patient satisfaction is important. We know it actually correlates with clinical outcomes, patient retention, medical malpractice, in an inverse way, medical malpractice claims. It does reflect, you know, timely, efficient patient centered delivery of care. It's what we do, right? We try to keep our patients satisfied because we're trying to make people happy and healthy. But it's not perfect. The way we measured this is incredibly flawed. And patients themselves are actually horribly biased assessors of their doctors. So first talking about surveys and this is getting to anybody who's ever looked at, you know, the press gaining data or any of the other survey tools, they're horrible, right? The return rates for these range anywhere from four to 30%. Anybody who's ever done survey research, you know, if you submitted a study with that sort of response rates, the, the reviewers would laugh at you. They'd be like, I'm not paying attention to this. Patients who return their surveys are certainly not a random sample. You know, I, when I come here, I delete pretty much every survey that comes in, except occasionally I'm like, huh, I'm going to answer this survey. And that's, I'm doing that generally for a reason. We in an academic medical center also, that data is often flawed. It's reflecting on our advisees rather than us. Maybe that's not such a bad thing. Data compares new physicians and physicians with mature practices. And boy, a new physician with new patients, many of whom didn't really want to see that doctor to begin with are going to get very different reviews than someone who's been with the same doctor has chosen to be with the doctor for years and years and years. Symptom based issues, sometimes dysfunction tend to weigh on the evaluations of doctors. And this is the good stuff, you know, you can also look up what people have said about you on Yelp or TripAdvisor, which is, can be frightening. Patient satisfaction also does not equal patient quality. We probably all have been in the experience where people love their doctors and you're like, Oh my God, what is that person doing with you? There have been some, I quote just three studies this, this could have gone on for pages and pages. Just interesting things. Higher patient satisfaction, one study associated with less ER use but greater inpatient use, higher overall healthcare costs, prescription drug expenditures and increased mortality in the study. Lower satisfaction patients who didn't receive desired their nonindicated medications. That was mostly people asking for pain medications and antibiotics, which were not necessary. And then a study really, really nice of looking at anesthesiologists getting much higher ratings for when they gave general anesthesia rather than regional for the same procedures where regional was thought to be safer. And then there's almost certainly bias. If you didn't see this, this is both a really telling but a really horrifying piece of the New England Journal from last year that was written by a Dr. Poole who oversees patient experience at Mayo in Phoenix. And this is just a paragraph. When seeing black patients, the three black clinicians of what she has won, had an overall top box score of 93.8%. When seeing white patients, we had a top box score of 78.1%. For questions on which survey respondents didn't give us five out of five nearly all ratings for black patients were four out of five, whereas the distribution of responses was more uniform among white patients. Since we're all graduates, meaning the three black physicians of predominantly white medical training programs and now practice medicine in Scottsdale and Glendale, Arizona, our own clinical, sorry, cultural incompetence probably isn't the root of our less than desirable patient experience scores among white patients. Moreover, white patients don't appear to have worse health outcomes when they are treated by non-white clinicians. And so it just adds like, you know, what are we doing using this scores when, when, you know, we're not sort of appraising our reviewers in any way. Outcome measures certainly a very hot topic these days, right? These are usually sort of quantitative surrogate or sometimes clinical outcomes, which we measure among our patients in medicine, maybe A1C, blood pressure, opioid prescription rates, screening tests. You know, you can pull many of these things up on epic these days and see it in red, yellow or green. In surgery, post-op length of stay, post- up infection rates, mortality. These are important, but they're certainly limited in a lot of ways. I often wonder how well they are controlled for the patient population in the ear of care teams, how much is a physician, one physician responsible for this? And they have definitely been proven in the literature to have unintended consequences, where, where physicians are sort of chasing measures at the expense of the actual patient's health, often relying on out-of-date evidence-based guidelines where you're trying to achieve something which actually doesn't really have a beneficial effect and avoidance of certain cases. So it's most true looking at cardiothoracic surgery outcomes in a New York state database, which showed very clearly that physicians were avoiding difficult cases to keep their numbers up. Self-evaluation, important, but I always wonder, you know, how good are we at that? How honest would we be? It's hard to have a good sense of how good we are. It's mostly related to the really tenuous outcome between what we do, sorry, tenuous relationship between what we do and what the outcomes are. This may be because what we're doing doesn't actually have that much effect on outcome or in the setting of say the emergency room or even inpatient hospital where you don't really know what the outcomes of your patients are. You do something they vanish and you're not sure if they've done well or not. I do some hobby ceramics and I feel like that's the opposite of this, like when I know I've messed up, you know, throwing a pot, I know immediately. I don't know that immediately when I do something with a patient. There's sort of some cool research on this showing that when we don't know a patient's outcome, we systematically assume that our patients' outcomes are good, even if we don't know that. We sort of say, I haven't heard back from them. They must be doing well. Our patient feedback comes overwhelmingly from patients who've chosen to remain our patients, right? The people in our practice are people who think we're doing a good job. The people not in our practice, sure, some left us because of their insurance change, but others of them left us because they didn't like us. The power differential between a doctor and a patient really keeps most patients telling us from what they really think of us, not everybody. Some are very happy to tell us what they think of us. I think, and this is maybe just me coming up with it, you know, our relatively high compensation makes us feel valued. Many things that we do, people get better without us and we take credit for, you know, just the body's healing process. And then we spend a lot of our days with people who know a whole lot and are very good at what they do, but, you know, have had the medical training that we have. And so we sort of feel good about ourselves, like, boy, we know tons because a lot of the people around us know less than us. Peer review might be a good way of figuring out how well we do, but it's incomplete. You know, I can tell you these things about my peers, you know, some good, some not so good, but I can't really give you any kind of 360 assessment of any of them. I've almost never been in the rooms with people who I work really, really, really closely with both clinically and, you know, academically. Evaluation by trainees, you know, we don't use it all. We let trainees evaluate our teaching skills, but really not our clinical skills. It would be very challenging. It would be hard to get, you know, a resident to honestly say, what kind of a doctor she thought I was. And there's a whole issue of halo effect that, you know, it might be that, you know, that I brought donuts to the team every morning. And so I get good reviews for that, even if my clinical care was suspect. Stare-donized patients, I've always thought interesting and probably not used enough. I've had some experiences, you know, on both sides of the bed, where, you know, doctors who I've had in, and I won't go into these in any sort of deal, but doctors who have had really, really terrific experiences with, that there's one thing said in a visit which sort of sticks out to me and is like, oh, God, you know, that person shouldn't have said that. I wish I could give feedback on that. Or when I say something to a patient, and I realize that, boy, there's so much being lost in our communication. For me, it's common when I say, you know, it's time for you to have your mammogram. And the response is, oh, do I have to? And I'm like, oh, God, I have failed this person by actually saying, oh, no, you know, this is your health. This is why you might want to do this. This is what the risk is of not doing it, but it's your decision, you know, I'm not forcing you to do any of this stuff. And maybe with, with, you know, disguised standardized patients seeing us on occasion, giving really well-informed written feedback, we'd learn something and we'd get better. Obviously, a big problem with any sort of physician assessment is, you know, there's no gold standard, right? We don't know what being a good doctor actually means. And so it's hard to say what's good, what's bad if we don't really have an endpoint. This is a quote from a million years ago from the New England Journal that I just, I just love. To say that, to say that physicians are good or bad would be to imply that there are well-accepted standards of performance and random audits to judge them by, but there are none. They're nearly total freedom to determine the context of their professional activities and their own standards within this context, especially in the private office where much of medicine is practiced, precludes any rational conviction about the effects of their efforts, which is, which is both true and maybe horrifying. And so it just gets back to deliberate practice. It gets back on trying to be honest with yourself, you know, trying to think about how you're doing, try to improve as you go forward without really knowing how well you're doing. So that's all I have. So any comments, thoughts on? Yeah. Out of the great story. Yes. So clearly to that. There's some time, you know, the medicine can be perfect, but it's those communication skills are done well, like all for you know. I used to do it on as a third-year question yesterday and I used to say, that's what I want, is I want to be able to go in and tell a patient what they want to do, and I want the patient to turn to the third-year medical student and say, is that okay? You know, I'll feel terrible, but that's like the goal to learn early. I think it's really awesome. I mean, your book, your discussion about communication skills and that, I think it's still well-thought-out and we'll put that out of the grip. Yeah. Yeah. I don't really either. And as you talk, I think about, boy, you know, that should be a monthly conference, right, where it's some sort of weird, you know, deliberative M&M, you know, where we talk about our own. I think the one thing that I do do, I have a list, a very private list of, you know, mistakes that I have made, right? And some of them are serious. Some of them are not. Some of them are actually, you know, diagnostic or therapeutic mistakes. Some of them are what I feel like, you know, a surgical mistake where I just blew it in the room with a patient. But I have, and I actually, you know, look at it here, and when I make one of those twice, which actually happened recently, a case from actually, when I was a senior resident, and I just had a patient that's so, so similar to it, you know, it's kind of killed me. I was like, wow, here's something I'm doing to try to get better, and this didn't need to help. So maybe that's the opposite of answering your questions. Yeah. Yeah, that's good. Now it should probably be in the same notebook, right, where you have your failures, but also your successes. You can decide if you have your feelings you need to judge what side of it is. And thanks for pointing out that I'm more mature. Yeah, I agree. Right. Right. So on the other hand, don't you feel, so I agree. And I think Daniel Opry's piece was amazing, and I actually think that I don't know what it is about prior authorization, but those seem designed to be the most irritating thing on the planet, right? So like, all that I agree with. The problem a little bit is that, you know, to some extent, there's like so much excess and so much ridiculousness in what's done, that I'm just like, I understand why people are pushing back on you. And we've all reviewed, I'll take it, we're perfect, you know. We've all reviewed the outside hospital records of someone who gets referred into our clinic, and someone who went in with like the most classic benign positional vertigo and had, you know, CT and MRI, karate dopplers, and an echo. So, you know, I should have to approve every test that people look at it, right? So, um, so I... Sure. So, I... I mean, I think over time, I've had the curiosity to reverse and ask myself that I am much better but not perfect at saying I am actually going to wait until I really know what's going to work before I really say, do this. I do a lot more sort of counseling of like, this is what we know, this is what we don't know. This is the case that what you decide, you as a patient decide, is most of the time. Um, I think although I am maybe an early adopter, I'm a tech side of things, I'm probably more of a late adopter on the medicine side of things. And it's something I've thought about a lot when I talk about like, do I treat all my patients the same? And I think some of the most informed, most, you know, enfranchised patients sometimes get lesser care because they're the ones who are pushing me to do things earlier faster, which aren't always better. Um, and I see that as sort of positive disparity in how I treat better people. Sometimes it's for the better, sometimes it's for the worse. Um, but I do think it's it's sort of recognizing that we shouldn't feel like everything we do is that important, that a lot of the things we do are, um, don't have a lot of impact. And so I'm happier to wait a little bit longer with the previous therapy we say that we're going to do. I love having a kind of adventure when I was a resident, Thomas Belbanka who had done a lot of work with like open charting and things like that. He would actually ask people if you really first saw them, sort of, what do you expect from me as your doctor? And they would actually tell them what he expected them as a patient. So that was pretty, you know, out of him. Um, and he would also seek out people who'd left him, um, to say what happened, and would routinely ask people who were seemingly who had seen another doctor which is something I have taken on doing. You know, so, you used to see my colleagues after selling so, you know, why are you switching? Um, because I can use such rich information about, you know, what's going to work in this relationship with you or not. But maybe you know, to add to Julie's kind of idea about a reflection, um, conference where you think about what's done well and what's done right. But since we're in a practice that we do bump patients around sometimes, um, to really think about, you know, what's going right for this person with the wrong person. Yeah. Yeah. My father was a psychiatrist. I don't know. No, I think it's with time and consciousness, you know, um, and I think that's sort of with everything that I feel like. I had for years, I've had a CD of failures, right, of all the things that like I've done which haven't worked out, but I kept very close to my chest for years and years years. But when you get to a place you're like whatever, you know, it's fine, it's fine to admit all the things that I'm not good at. Um, it would be interesting, the great question, it would be interesting to think about like how you get people to do that faster, because I think it is it's good probably not on the patients, but it's certainly good for the physicians and how they live with it. You know, and how they practice. I worry maybe it's a little bit about like teaching empathy, but to some extent you know, you have to have some personal angst and suffering to really become unhappy. Which not everybody has had when they were 24. Um, but I'll think about that. Finish up. Thanks.