[00:00:00] Dr. Cifu: On today's episode of The Clinical Excellence Podcast, we have Dr. Mindy Schwartz talking about the underappreciated parts of the medical history.
[00:00:12] Dr. Schwartz: Once you're taking care of a 70-year-old, you better know that you're going to take care of them and whoever loves them, right? For me, a family history of a 70-year-old is, "Tell me what you did but, you know, who are your kids, who are your grandkids, who is your caregiver? Who loves you?"
[00:00:36] Dr. Cifu: We're back with another episode of The Clinical Excellence Podcast, sponsored by the Bucksbaum Institute. On this podcast, we speak to patients and doctors about all aspects of excellence in clinical medicine. I'm Adam Cifu, and today I'm joined by Dr. Mindy Schwartz. Dr. Schwartz is a professor of medicine and gifted general internist here at the University of Chicago.
Mindy has an expertise in nutrition, her undergraduate degree from Cornell was actually in nutrition and biochemistry, and an expert in the history of medicine. She has taught courses in both these disciplines for years at the Pritzker School of Medicine. Mindy is a master in the Academy of Distinguished Medical Educators and a senior faculty scholar in the Bucksbaum Institute for Clinical Excellence.
I've worked with Mindy for over 25 years and know her to be a caring doctor, a dedicated educator and mentor, and a really good friend. Mindy, thanks for taking the time to be with me today.
[00:01:30] Dr. Schwartz: Thank you, Adam, for inviting me to be part of this.
[00:01:34] Dr. Cifu: So, I wanted to ask you. We all learn how to take a medical history, right? For you and me, we learned that years ago. And the important parts are certainly, you know, the chief concern, the history of present illness, the past medical history, what medications the person's taking, allergies, and I always think of sort of the forgotten stepchildren in the medical history is the social history and the family history.
So let's start with the social history. Besides, like the usual you know, finding out do you drink, do you smoke, and do you have parrots at home, what do you see as the social history and why do you consider it important?
[00:02:11] Dr. Schwartz: You know, it's interesting because I think that as physicians and as part of this podcast, we are so into our jobs, there's such an important, deep part of us we trained so long that I feel like we're discourteous to people by not even being a little bit curious about who they are or what they do, right? One of the great things about being a primary care doc, and I am a primary care doc, is that you know when you see the person the first time you're building a foundation of a relationship.
And you know, luckily we, here at the academic university, have extra time for new patients, but I always really try to understand who the person is before I deal with whatever medical issues they have.
[00:02:58] Dr. Cifu: And tell me what you do... I have my own obviously, tricks and style here, is that always something that happens at the first visit for you? Is that something that you accumulate as time goes on? Do you document that stuff? Like, how is it for you?
[00:03:14] Dr. Schwartz: Oh yeah, absolutely, the first visit, and this is what I do 'cause you made me look at my records and get some self-insight is every patient that I see, the first thing I ask is are their parents still alive? And if they're alive, you know, just get a sense of if they're together, where they live, you know, because a lot of people that we'll be seeing will be taking care of elderly parents, you know, if your parents died or whatever your parents died of is going to imprint you and it can really impact you.
And then I kind of want to do a more general thing where I say, "So what do you do?" Or if they're retired, "What did you do?" And I think that's actually equally important. I think we view people who are retired, it's like check, done, you know, but you never know, people may be... People will surprise you, I guess.
The other thing is you said something funny. You meant to be witty, but I think it's actually pretty clever. You said if they drink or smoke or keep parrots. Now, first of all, I want to know every patient of mine who has a parrot just because that's not something you do every day all the time. And, you know, that leads you into the whole issue of like occupational illness, right? You know, and we're not even going to talk about the pets. So I always ask, "Who do you live with?" And they'll say, "You know, I live with my kids." And then you try to probe the family situation, you know, because people have complicated families. Um, but I kind of also ask people and I did this really during COVID, it was very therapeutic, I asked people, I said, "What are you doing to kind of, you know, get over the boredom or now you're on house arrest or..." And it was really interesting, you know, people were doing puzzles and people were, you know, playing music and anyway, regardless but I also want to know something about the person as a person to kind of make me interested.
[00:05:08] Dr. Cifu: Yeah. I love the... You know obviously, you know, if someone's in the hospital sick and we're curious about certain diseases, right? That's when we get into, you know, "Do you have cats? Are you a coal miner?" You know, "Do you clean up the tracks in the CTA?" Things like that. But it's often interesting to ask people about little things at home like that, because when things are unusual, you know, beyond, I don't know, a couple of cats, a dog, that really does tell you about something, right? Because that's an important part of who people are. One of my mentors always said that if someone said that they don't drink, his question was always, why not?
[00:05:53] Dr. Schwartz: I like that.
[00:05:54] Dr. Cifu: Which is a strange question, but it was amazing how much he turned up about family history of alcoholism, personal history of alcoholism because you know, the vast majority of our society says, "Oh yeah, you know, I have a beer every now and then," right? But if people say, "I don't," it probably tells you something about them.
[00:06:14] Dr. Schwartz: Well, but see, that's a very clever insight because it's also a clever way to ask because you could be neutral or by saying, why not, you normalize it in a way, and then you get the emphatic things. I like that.
[00:06:29] Dr. Cifu: That's a terrific point.
I had an interesting one recently that I joked a little bit about which gets to how you ask the questions, that often when I ask about children, instead of asking specifically, you know, count them out for me, things like that, I say, you know, "Are they still local?" And a patient who I saw a couple of weeks ago said, "Well, two are, but one has moved to the North side." And that gave me... Okay, the person has three children and gave me such a view of how this person sort of views the world, you know.
[00:07:07] Dr. Schwartz: Well, that's the thing for me, Adam, I'll tell you. So I think the genesis of this conversation was you overheard me play one of my games I play with residents in clinic and I do this thing I call Ahmed and I say, "Okay guys, we're playing Ahmed today," and they like shrug their shoulders, but I said, "What I want you to do is every single patient that you see, find out what they do or find out, you know, what they are." I said, "We're here at the University of Chicago. You have no idea who you can meet, okay? In urgent care, let me tell you. So I'll tell you a story about urgent care." And so, you know, at the beginning they'll say, "Oh, he works for the CTA, bus driver," or something but by the end of the clinic, somebody will always come back to me and say, "Hey, you're not going to believe this, but I, you know, met either somebody interesting or somebody famous," or somebody that just kind of woke them up.
[00:07:59] Dr. Cifu: Right, right.
[00:08:00] Dr. Schwartz: And it's really fun because I always do the social history. I always find out about people who they are.
[00:08:05] Dr. Cifu: Yeah. So tell me, and this will get to actually what I heard you say which really stimulated this, we both take care of adults and I know that you know, for you and me, given how long we've been here, that many of our patients are you know, let's say over 70. And so from a medical perspective, talking about disease, inheritance, the family history is worthless, right? There's nothing you're going to learn and just be like, "Oh, this is going to affect somebody after 70." So what do you learn from the family history when you find out, you know, how people's relatives died or mothers, fathers, things like that?
[00:08:45] Dr. Schwartz: Oh, Adam, I could kiss you. This is so great. You're looking at family history from the wrong lens.
[00:08:50] Dr. Cifu: Yeah.
[00:08:50] Dr. Schwartz: Okay? Once you're taking care of a 70-year-old, you better know that you're going to take care of them and whoever loves them, right?
[00:09:00] Dr. Cifu: Right.
[00:09:00] Dr. Schwartz: So that in some way... And you know this intuitively, it's like, for me, a family history of a 70-year-old is, "Tell me what you did, but, you know, who are your kids? Who are your grandkids? Who is your caregiver? Who loves you?"
[00:09:13] Dr. Cifu: Right.
[00:09:13] Dr. Schwartz: "Whose pictures do you have up?" I'll tell you something.
[00:09:16] Dr. Cifu: Whose pictures do you not have up?
[00:09:20] Dr. Schwartz: Yeah, or "Who aren't here"? You know? It's funny because the other thing that we never do, but it's so easy, we should really make a play for this, is to go do home visits, okay? And part of it is we live in the neighborhood. Many of our patients come from Hyde Park where we live. And like, there have been times that like one of my patients got a dog bite and she didn't think it looked that bad, and it would have been just a hassle for her to come here, get somebody to park. I just drove by on the way home, but when you do that, and when you go into somebody's house, it's eye-opening, you know? It's like meeting the parents, you know?
[00:09:57] Dr. Cifu: I think that was one of the new benefits of COVID too because you know, during the brief time in whatever, March, April 2020, that we were doing a lot of video visits, you were in people's homes and, you know, the most important thing about any home visit is not seeing the patient, right? It's seeing everything around them. And boy, just seeing how, you know, what people's homes were like, how people were sort of set up. You know, one woman who I've seen for years in her mid-90s, you know, she was propped up in bed like a queen, you know, when I got in there. And it told me so much about, you know, how she's cared for. It was wonderful.
[00:10:36] Dr. Schwartz: Oh, absolutely.
[00:10:38] Dr. Cifu: What about.... You talked a lot, which I think is so critical about, you know, who are the people around you because very often, especially at the end of life, right? The cast of characters you deal with broadens. Do you find things talking about people's family history, sort of about how people relate to medicine given their experiences?
[00:11:04] Dr. Schwartz: That's interesting. No, I'm not sure that's a big focus for me.
[00:11:07] Dr. Cifu: Yeah.
[00:11:07] Dr. Schwartz: Um, but you know, now, like when I do a social history, because I've been here for 35 years, so you know, I used to take care of people like 30, 40, and 50-year-olds, and my whole practice is now a geriatric practice. So, when I see people, and they routinely come with somebody...
[00:11:24] Dr. Cifu: Yeah.
[00:11:25] Dr. Schwartz: ...I write that name and that relationship, so every time I see them, it's a prompt. And people, you know, people are happy to do that. That's just a little pearl.
[00:11:34] Dr. Cifu: Yeah.
[00:11:34] Dr. Schwartz: Write down the person's caregivers or the person who comes with them every time.
[00:11:38] Dr. Cifu: I love that. I asked my question because I've thought about this I think, honestly, more from an academic standpoint than actually a clinical care standpoint, um, that people are affected by the interactions with the medical community that other people in their family have, right? That if, "Geez, my brother died after this horrible hospitalization," that's probably going to affect how they deal with you. And it sort of passes through my mind occasionally, but I've never been able to really figure out, I don't know, is that important? Do I use that? And maybe because it's critically important to the individual, but it's very far removed from when me and the patient get there 10 years down the line.
[00:12:26] Dr. Schwartz: Okay, but that's why, you know, it's funny, um, one of the things I like to do when we do the inpatient services, I really like to do family meetings. You know why?
[00:12:34] Dr. Cifu: Yeah, yeah.
[00:12:35] Dr. Schwartz: Because I've got a certain approach, and you go in there, and what you do is you do fact-finding because whenever there's a family, you know, this happens like the first day of GENS, you're thrown into a... This is okay, it relates to social history, you're thrown into a brand-new situation, you know, the family's all split up, you know, some of the people just want mom to die, the other people want her to be on dialysis, not a vent, and you just met her.
[00:13:00] Dr. Cifu: Yeah.
[00:13:00] Dr. Schwartz: So the way I approach that is like I say, you know, "What's your understanding? Who lived with her? Who was the go-to person? You know, have you ever had any experiences like this? Do you know anybody who was on this? What do you feel?" And more often than not, it's just that you need a therapeutic, you know, relationship because then you do masterclass. Then you say, "You know what? If this was my mother, and I loved her as much... If you love her as much as I loved her... I'm a doctor and this is what I do, whatever you want to do, I'll do," but it just is a perfect combination of finding out what they want to do, laying it down and then walking away. It's like, you know, if you're a good actress so you can overcome their stuff but the good thing about that is you ask people and you find out because you'd be surprised that, you know, "Well, my brother, you know, started dialysis and died two days later." So that's the thing it feels like, that conversation.
[00:13:58] Dr. Cifu: Right, that seems like a great way of getting at that, sort of recognize that people are coming into it with not only various levels of knowledge but various levels of experience and to just ask directly about it, right? Because you're going to find it out.
[00:14:13] Dr. Schwartz: Well, the experience but here's the other thing, not just experience, but one of the things I really like when you have family dynamics is you got to figure out, you got to like look at the family, like who's the alpha male, you know? Who's the daughter that takes care of everything and is underappreciated? Who's the prodigal son who's like out in California, like making music?
[00:14:33] Dr. Cifu: Yeah. Yeah. I published something called My Worst Family Meeting in the past, which was when, you know, the alpha male just beat me to death in the meeting, and I thought I was doing a good job, but I realized who the most important person in the room was, and it was not me, and it was probably not even the patient, actually.
So, what you just said actually gets me a little bit to the third question that I had written down here. I've loved working with you over the years because I think, you know, we relate to each other because we're both very proud of kind of the dedicated and personalized care that we deliver and very proud of being, you know, generalists and primary care doctors. However, I've always thought that we do it with sort of very different personalities, and the areas that we kind of stretch ourselves, you know, that we, I don't know, do more than is called for is different. And I wonder then, you know, for the patients who've seen you forever and the patients who've seen me forever, do you think our patients would be happy with, you know, the other one of us or, you know, have our practices evolved because they're the people who, you know, need what Mindy Schwartz will do for them versus the people who need what Adam Cifu will do for them?
[00:15:54] Dr. Schwartz: That's an interesting way to think about it, but another way to think about it is that these are relationships, you know what I mean? And um, sometimes the different approach in a relationship is actually refreshing.
[00:16:06] Dr. Cifu: Hmm.
[00:16:07] Dr. Schwartz: You know, um, so I think about this a lot because plenty of our colleagues have retired and now there are new doctors that take over.
See, the interesting thing about you and I, just like I was thinking about people like John Yoon and Dan Sulmasy who are, or even Farr Curlin, you know, as part of their social history, they would probe their religious traditions because they're interested and they resonate. So, I think as doctors, even though we're primary care general... We're all technically primary care general internists, the way we practice has kind of a certain spin and a kind of flavor and partially by what we're interested in and partially by our experience.
[00:16:49] Dr. Cifu: That's a good way to put it. And your point about it being a relationship, what came to mind when you said that is that the relationship does affect both people. I think often as a doctor, we sort of think, "Oh, you know, I'm seeing a patient. The patient has one approach to this. That's the way it is," but I do think that if the rest of the relationship is good, that actually patients' expectations sort of change over time, right? And you do notice that when you, you know, take over a patient from a colleague who's, you know, left or moved and you're like, "Oh my god, this person has such different expectations given what their previous doctor was like," but very often those expectations change easily if you say, "Look, this is the way I kind of function."
[00:17:36] Dr. Schwartz: Yeah. And, I don't know, you know, um, we change over time.
[00:17:40] Dr. Cifu: Yeah. Yeah.
[00:17:41] Dr. Schwartz: You know.
[00:17:43] Dr. Cifu: We should probably cite, just because this has come up like twelve times in my mind during our conversation, Faith Fitzgerald, who I know you know well, she wrote an amazing thing I think called Curiosity years and years ago, which was very... You know, she was an amazing writer and made everybody on her team tell her something interesting about the patient and the patient in question here, the intern was like, "I'm really sorry, I tried, I couldn't come up with anything interesting." And Dr. Fitzgerald like went to the bedside, worked and worked and worked, couldn't get anything interesting. And then finally, sort of went into an injury that the patient had had when she was 12 years old and the patient was like, "Oh, you know, a trunk fell on me." And I was like, "What do you mean a trunk fell?" "Well, the boat shifted," and it turned out that she was on the Titanic and was injured but it took, you know, like 90 minutes to get this out of her. It was just a wonderful story and hopefully something that she wrote in the past medical history.
Last question, where do you document these things? Do you put this in the electronic medical record? Do you put this in some sort of shelf file?
[00:18:54] Dr. Schwartz: You bet your life, it's right in the EMR and what you have to do is open the history tab, at the very bottom it says social documentation and you can free text.
[00:19:04] Dr. Cifu: It's funny, I do exactly the same thing and I've actually sometimes pasted in people's Wikipedia pages, um, to know who they are.
[00:19:12] Dr. Schwartz: Okay.
[00:19:13] Dr. Cifu: So, Mindy, thanks so much for taking the time to chat this morning, and thanks to everybody for joining us for this episode of The Clinical Excellence Podcast. We are sponsored by the Bucksbaum Institute for Clinical Excellence at the University of Chicago. Please feel free to reach out to us with your thoughts and ideas on the Bucksbaum Institute website or Twitter page.
The music for The Clinical Excellence Podcast is courtesy of Dr. Maylyn Martinez.