The Doctor–Patient Relationship as Seen by a Senior Physician

This episode dives into the real-life evolution of the doctor–patient relationship through the eyes of a senior physician. Dr. Alex Lickerman shares how decades in medicine have shaped his approach to balancing authority and empathy while moving toward more relaxed, genuine conversations. He also explains why building trust with patients matters more now than ever, especially in the face of widespread patient misinformation. He reflects on moments where taking the lead, sometimes what might feel paternalistic, can help families make difficult, life-and-death decisions with clarity and compassion. The talk touches on the unique skills needed to care for patients at the end of life. Along the way, you will hear honest takes on the quirks and frustrations that come with the job.

What is The Clinical Excellence Podcast?

The Clinical Excellent Podcast, sponsored by the Bucksbaum Institute for Clinical Excellence is a biweekly podcast hosted by Drs. Adam Cifu and Matthew Sorrentino. The podcast has three formats: discussions between doctors and patients, discussions with authors of research pertinent to improving clinical care and the doctor-patient relationship and discussions with physicians about challenges in the doctor-patient relationship or in the life of a physician.

[00:00:00] Dr. Cifu: On today's episode of The Clinical Excellence Podcast, I'm joined by Dr. Alex Lickerman, talking about the evolving doctor-patient relationship.

[00:00:13] Dr. Lickerman: But what does push my buttons, the type of patient who pushes my buttons now is the type of patient who has been swallowing the barrage of misinformation that's now available online and is almost unrecoverable in terms of helping them to think through issues they may be facing, and has these just almost delusional beliefs.

[00:00:41] Dr. Cifu: Welcome to The Clinical Excellence Podcast, sponsored by the Bucksbaum-Siegler Institute for Clinical Excellence. On this podcast, we speak to patients and doctors about all aspects of clinical excellence in medicine. I'm Adam Cifu, and today I'm joined by Dr. Alex Lickerman. Dr. Lickerman is actually a return guest.

He's a direct primary care physician and founder and chief medical officer of ImagineMD. Alex is previously a colleague of mine at the University of Chicago, where he did pretty much everything. He was a general internist, an early hospitalist, and he even led the student health practice for a while.

Alex is a nationally recognized speaker on the topic of resilience. His book, The Undefeated Mind: On the Science of Constructing an Indestructible Self, details evidence-based steps one can take to increase resilience. His second book, The Ten Worlds: The New Psychology of Happiness, details an entirely new psychological paradigm that explains how it's possible to achieve a kind of happiness that can't be destroyed.

I've always thought of Alex as sort of a kindred spirit in his interest and dedication to excellence in medical care. So Alex, thanks so much for joining me today. I really appreciate you taking the time.

[00:01:56] Dr. Lickerman: Thanks for having me. Glad to be here.

[00:01:58] Dr. Cifu: So this season, I'm kind of going all in on the doctor-patient relationship, and I wanted to talk to people who've, you know, spent some time... I won't age you too much.

[00:02:09] Dr. Lickerman: Thank you.

[00:02:11] Dr. Cifu: So the first question is just if you think about your sort of relationship with patients over the years, how has it evolved? And I'm interested in both, you know, your relationship with new patients who you're seeing for the first time, with patients who you've seen for a long time. What's changed? What's stayed the same?

[00:02:31] Dr. Lickerman: So I think two main ways. And I think about what patients really want from their doctors. I think they want basically two things. I think they want leadership from their doctors, you know, confidence and authority, and direction to a degree. And I also think they want a doctor who knows how to listen and empathize, and sometimes balancing those things is a little tricky.

I think I've gotten better at both. I think, purely just, you know, being a doctor for decades now, you develop a certain confidence and a certain understanding of your own abilities and limitations, and you know who you are, and you know who you are professionally. And I feel much more confident at sort of the latter parts of my career than I did in the earlier parts of my career, being a leader to my patients, feeling confident in what I'm telling them. Same time now, having practiced as long as I have, I've had many opportunities to become a patient myself. And I think that along with those experiences, plus the confidence to lead and not have to, um, not have to feel like I have to prove anything to patients, I find the type of dialogue I have with patients now is much more like kind of the one we're having now. I don't feel like a physician who is professionally sort of distanced a little bit. You know, talking to someone like a real person, like as if we were at a social event and just exchanging, you know, conversation as equals in a way.

I mean, we're not equals in terms of medical knowledge and ability. They're coming to me for my expertise but there's something about holding that space for people and that conversation in a way that is relaxed, informal, and personable. I think as time has gone on, mostly as I become more comfortable with myself and my abilities. That has improved.

And between new patients and return patients, I mean, the one difference there is that many of my return patients I've taken care of literally for decades, and so have seen them through a lot of things. And have really enjoyed, over that time, having built trust. And I think, never more than before in our current era, is having a patient trust their physician been more important.

[00:04:39] Dr. Cifu: Yeah. There are so many things you said that I think are important that I wanted to kind of highlight. I think the first thing which rings so true to me is this sort of balance of, you know, I don't want to use the word paternalism, you used authority, which I thought was really important, which I think is kind of on a spectrum, you know, with paternalism on one side and like patient autonomy on the other side.

And although it seems so simple, I too have almost taken a career to figure out that, you know, patients really want direction and sort of want authority but they want it in some way where it is truly shared decision-making. It doesn't just feel like that, but it's kind of two people in a room who share an interest in the outcome of things.

They're bringing different things to the combination. Do you think that's something, you know, we've both spent our time in medical education, and admitting that like, I'm a whole lot better now at this than I was ten years ago. Like, can we get people to that faster?

[00:05:50] Dr. Lickerman: That's a great question. I guess the optimist in me says yes.

And I guess I'm asking myself, how could I have gotten there faster? I wonder if I had a mentor who drew attention to the idea and sort of made it more explicit. It kind of was a gradually dawning awareness and just an evolution of my style with patients, and I sort of reflected on it and thought about it.

On the other hand, and maybe you've had this experience, I remember when I was a resident working in the ICU, there was no more setting where... And I actually had an attending once say to me this very thing, like what they want is leadership. Especially, when you know, you have somebody who's circling the drain as we have seen in ICUs, and yet, you know, you say to yourself, well, I can reverse the renal failure and I can reverse the heart failure and I can treat that and that, but you add them all up together, this person's mortality is really high, and what do we do?

And what I learned was, and actually from this mentor who taught this to me, to be very explicit about saying things like, you know, in an empathetic way, you know, "The disease is going to win here. Us deciding to withdraw care, this is not on you, the family, right?" Because the last thing in the world families want is to think that they're the ones who made the decision that killed their loved one.

And you take that responsibility on yourself, and you lead them and say, this is the right choice, right? There, I feel comfortable being really paternalistic. Other circumstances that are not as clear cut, I think, you know, that slider you depicted, you want to be a little bit on the other side. And I think to answer your original question, to take trainees and give those examples, and maybe even model, and even give them a script about how to think about it might accelerate your ability to sort of navigate that tension better and faster.

[00:07:29] Dr. Cifu: I like that. I think there probably are some things. You know what I notice most often in our urgent care when I'm sort of watching trainees with patients, and I realize that part of it is just having the clinical confidence and competence to be certain about some things. And that just takes time.

Some of it is the direct empathy that we talked a little bit about before we started. You know, you never do a better job taking care of back pain after you've been struck by your own back pain. But you're probably right that we could do a better job at mentoring people into it by really calling attention to the process and what we're doing.

[00:08:11] Dr. Lickerman: I guess. Maybe.

[00:08:13] Dr. Cifu: So I think one of the great things, and I think we've actually talked about this in the past, probably off-mic, about medicine is that like, it so keeps you humble. You never really master it. Every time you're like, you know, "I'm rocking it here," something terrible happens, right? Are there things like about the doctor-patient relationship itself that particularly challenges you? Or I don't know, types of patients that you're like, "Ah, this is something I'm going to have to really struggle with and really play a role here to make this work."

[00:08:46] Dr. Lickerman: Yeah, there are, and this is a relatively recent phenomenon.

I think every doctor has a certain type of patient that they recognize activates their buttons and they don't really do well with. You know, one of our former colleagues once talked to me about sort of patients who struggle with addiction problems. That was a real button pusher for him.

That's never been one of mine but what does push my buttons, the type of patient who pushes my buttons now is the type of patient who has been swallowing the barrage of misinformation that's now available online and is almost unrecoverable in terms of helping them to think through issues they may be facing, and has these just almost delusional beliefs, you know. And I'm talking to really extreme cases, but there's milder cases of this too. And so I find myself, and I imagine you do too, spending an inordinate amount of my time trying to disabuse people of notions that from a medical perspective, are ridiculous. And you're trying not to sort of, you know, just break down and slap them, say, "Stop it!"

Like, you know, like "Why are you listening to those guys on YouTube who..." And so I find... This is my button, when patients are confronted with a reasoned, easily understandable, evidence-based rationale for a treatment. You know, there are some times in medicine when things are really black and white, mostly not, but every once in a while, they're kind of black and white and they simply refuse to make the choice that they want to make.

They're making a choice against their own self-interest, which I see again and again and again. That just drives me crazy. This is just my own particular, like I just... You know, people who insist on being what feels to me like irrational. And I think part of it is that there's been a dramatic decrease in trust between the population and the traditional medical system for so many reasons we could talk about, and a rise in nonsense medicine, nonsense ideas that are being generally accepted, and even in academics, somewhat accepted. I mean, we could point to programs at both of, you know, the academic medical centers in Chicago that you and I look at and say, "Really? They're teaching that?" So that's what pushes my buttons.

[00:10:50] Dr. Cifu: Do you feel like... You know, you've clearly thought about this? I could outline my patient, you know, my type of patient that gets me, which is interestingly, not surprisingly is different from yours and different from our other colleague who you alluded to. I'm often struck by the fact that my insight, I'm not sure it helps me that much, you know, you recognize that, "Ah, wow, this is one of those patients who's really going to work me."

Do you feel like you do a better job because of that? Does it just help your wellness that you walk out of the room and say, "Ah, I knew, I knew I wasn't going to succeed here?"

[00:11:25] Dr. Lickerman: You know, if I'm being honest. If it helps, it only helps a little. What ends up happening is I go home and I rant to my wife about it, and I just have to like sort of vent because every once in a while I have someone who starts that way and who then sort of maybe because of the relationship or I'm just particularly persuasive that day, they actually start... They open their mind a little bit to the perspective I'm trying to give them, the evidence-based perspective, but mostly they don't. And no, I just find it really unpleasant and I'll tell you what I do, what I struggle to do because the risk for me is if I feel like I'm not connecting with them that way, I find myself not willing to, or less willing to go the extra mile and really care for them the way I should, that's where I have to be really careful. And make sure that I'm not, you know, compromising my attention to them and sort of writing them off like, "Oh, they're a crackpot anyway, so I'm just not going to care." And just, "Oh, fine. Take that I don't know..." I can make up some... "Take those Chinese herbs for your CLL."

[00:12:24] Dr. Cifu: I've tried to get myself thinking recently, you know, it's very common with say, an intern who presents me a patient with, you know, 25 different problems and is overwhelmed. And I'm like, "Listen, you know, if you do everything today, you got three years to work through all this stuff."

And I try to apply that more and more to myself in the doctor-patient relationship where it's like, you know, I don't have to leave this first visit with a perfect relationship. Right? Take three years to get right.

[00:12:53] Dr. Lickerman: Right. That's a great insight. That's a really great insight.

[00:12:57] Dr. Cifu: Now I'm just worried that the clock's going to run out on my grave.

[00:13:01] Dr. Lickerman: Well, that might. So I'm curious, what's the patient prototype that pushes your buttons?

[00:13:06] Dr. Cifu: I actually wrote a piece about this once, and for me it's a combination like I'm pretty good with anxious people. I am pretty good with people who express their anxiety in the desire for kind of overtesting. And I'm actually pretty good with people who are just like out and out litigious. But the combination of the three! You know, and I've cared for a few of those people for years, and despite what I just said, it seems to never get easier for me.

[00:13:41] Dr. Lickerman: Yeah, no. You know, you remind me, of course, so I break anxious people down into sort of two categories.

There are anxious people who know they're anxious and recognize they're being driven by that feeling and being driven to want to make ridiculous choices and kind of laugh at it. And those who have no insight into how anxious they are or how it's driving decisions. The latter makes me crazy. The former I can deal with very easily.

[00:14:03] Dr. Cifu: Right. And the former is so interesting because it's that thing that my father was a psychoanalyst and you know. I always thought, oh, you know, he gets people to understand themselves and then they're fixed, but there are a lot of people who understand themselves perfectly well, and it just doesn't help.

[00:14:18] Dr. Lickerman: In fact, I would say most... I think understanding yourself, like how did I get to be this way, is almost useless.

[00:14:25] Dr. Cifu: It did get me through medical school, though, paid my tuition.

[00:14:29] Dr. Lickerman: That's good. Excellent.

[00:14:31] Dr. Cifu: The last question is a little bit more of maybe like a reflection question.

You know, at this point in your career, what is it in your role in the doctor-patient relationship, you sort of feel like you appreciate the most? That you're like, "Wow, you know, I've developed this skill and not only do I think it helps my patients, but I'm, you know, sort of proud of it." Putting aside that that's a deadly sin.

[00:14:56] Dr. Lickerman: Okay. No, no. I'm going to let my pride leak through a little bit and answer you honestly. I think I am uniquely good at helping people understand and manage their own psychology. You know, the challenge we have as physicians, one of the big challenges is we can tell you what to do, but how do we get a patient to do it?

And how do we identify what their particular roadblocks are and understand that. And I think, you know, after I'll age myself, three decades of practicing medicine, and I know you have the same experience, you know, you can grasp a person pretty quickly. We have a unique ability to sort of read people 'cause we've been doing it all our professional lives.

And so I feel pretty proud of the way I've been able to understand people, and get through to them through that understanding and make them feel heard. I think I'm really good at that. And then the other thing as I was reflecting on this was that some of my most, um, how would I say this? The interactions with patients I've been most proud of and felt I had the greatest impact are in patients in whom I can do almost nothing medically for at all, is patients who are dying.

And I think that even doctors in general are really shitty at being with dying patients, confronting honestly, and helping people really prepare for that. And for me, it was very anxiety-provoking as an early career physician to address that and even, you know, talk to someone about them having a terminal diagnosis, but that's something I really learned how to do well. And I feel really proud of the patients whom I have helped die well. And I think that is a real skillset that can be learned. And it just takes the courage to be really direct and honest. And I think I'm good at that.

[00:16:32] Dr. Cifu: Right. I think that's a skillset too, that I've noticed. You know, there are some things that you learn in medicine that you get good at that, you know, works in the office and it doesn't work anywhere else. But you know, that comfort I've developed with people at the end of their life, and being able to sort of sit in a room, address that elephant in the room and be fine with it, has, I think, I hope, I don't know, you know, made me someone who friends and relatives at the end of life sort of appreciate having around because, you know, I'm fine with it. We're all hit with it eventually.

[00:17:14] Dr. Lickerman: Yeah. We're all going to hit it eventually. And I think that especially if you're... I mean, I got to imagine most people are scared. And you know, we're certainly not God by any means, but we're an authority figure, and even if we can't do anything to prevent a death, we can be there and sort of explain things and order things and try to, you know, listen to them. I mean, the entire thing, just having that trusted physician in the room, guiding you through it.

The feedback I've gotten, you know, is that it's just invaluable. And I can easily imagine, I mean, just being a patient, you know, myself, you know, when I have been and having a doctor saying, "This is how it's going to go," and, you know, it's just there's something when you have that person who you trust and they're there for you in that way, in those difficult moments, to me that's the whole reason to be a doctor. I mean, that's... I think that's why we do it.

[00:18:03] Dr. Cifu: Well, if by some shock you outlive me, I'll call on you to visit me at the end. Okay.

[00:18:09] Dr. Lickerman: Adam, I will sit with you and I will... I'm not that much older than you, I think. I think maybe a year.

[00:18:14] Dr. Cifu: It's going to be a competition. We'll see.

[00:18:16] Dr. Lickerman: It's gonna be a competition. We'll see.

[00:18:19] Dr. Cifu: Alex, thank you so much.

It's always a pleasure talking. I feel like we've lived a lot of the same experiences, and so I always learn a ton from hearing the way you look at sort of similar experiences with patients and in life. So thank you very much.

[00:18:32] Dr. Lickerman: Oh, it's my pleasure. Really enjoyed it.

[00:18:34] Dr. Cifu: Thank you for joining us for this episode of The Clinical Excellence Podcast. We're sponsored by the Bucksbaum-Siegler Institute for Clinical Excellence at the University of Chicago. Please feel free to reach out to us with your thoughts and ideas via the Institute webpage, bucksbauminstitute.uchicago.edu.

The music for The Clinical Excellence Podcast is courtesy of Dr. Maylyn Martinez.