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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 Julie Oyler, talking about the evolving doctor-patient relationship.
[00:00:12] Dr. Oyler: On a typical half day of clinic with 12 patients, I probably see three or four people over 90 and a couple over 100. And do I think that's because I'm a good doctor? No, but do I feel proud that like, I've had 25-year relationships from people starting at 60 and 70 and getting them to 90 to 100? I feel, you know, I feel proud of that. I feel proud of like, the relationship that we've had over time.
[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 excellence in clinical medicine. I'm Adam Cifu, and today I'm joined by Dr. Julie Oyler. Dr. Oyler is a general internist, professor of medicine, and a colleague of mine for a very long time.
Besides being an internist who is treasured by her patients, she is an associate program director of the Internal Medicine Residency. She's also a fellow of the Academy of Distinguished Medical Educators. A past president of the Midwest Society of General Internal Medicine, and a senior faculty scholar in the Bucksbaum-Siegler Institute for Clinical Excellence.
Julie, thank you so much for joining me today, your third visit to the podcast.
[00:01:29] Dr. Oyler: Yeah, thanks, Adam. I'm excited to be here.
[00:01:32] Dr. Cifu: So we're going all in on the doctor-patient relationship this season. To start, you know, you've been doing this for a while, you're kind of a pro. How has your relationship with patients changed over the years?
And I'm interested in kind of the evolution of how you relate both to new patients and your own patients, and how you've kind of seen this changed over time.
[00:01:52] Dr. Oyler: Yeah, I was thinking about this, Adam. I mean, I started in residency in 2001, seeing patients independently, and I feel like it's really come full circle. You know, back in the day, we had a computer, we didn't use the computer so much. We dictated notes, and so it was very... And I did spend a lot of time in the social history. That's important to me. And, you know, then we went to this computer era where I feel like we were typing a lot during the visit. I was still asking about the social history but there's so many... The medical problems have really kind of doubled and tripled in knowledge in medicine, and you know, things like screening and so many things that you needed to do. And then I think I've come full circle back to spending more time on that social history and who people are outside of the hospital.
When I reflected on new versus return patients, I mean, probably like you, Adam, I don't get a lot of new patients because my panel is pretty full and most people that I get are, you know, the spouse of one of my current patients, the mother or daughter or, you know, husband of one of my current patients, or someone that I get a direct referral from, you know, in a family. And so I feel like sometimes I already know a little bit about them. And I always struggle, like, do I list who I know and how they came to me? Because it is relevant, but it's not really relevant to their health, but they bring it up. And so I think... Oftentimes, I know something about the patient before they come to me now, but I still do spend a considerable amount of time like, looking through their chart and kind of trying to get a much more thorough picture of who they are medically, but also who they are socially. I think, started with that in the beginning and still ending with that. And return patients, you know, I have to spend a little less time pre-charting. I know them pretty well, and yet sometimes I do force myself to pre-chart because there are things that I miss and I tend to spend... I was thinking about this balance between social versus medical talk during the visit, and how much time you spend on both of those things. So, it was interesting to reflect on.
[00:03:58] Dr. Cifu: Yeah. Hey, let me pull on kind of two threads of things you've said because it's interesting. It rings true to me, too, and I haven't really thought about why. You talked about somewhat being, you know, freed from the computer, which I feel the same way, where it wasn't an issue, and then it was an issue and it feels like less of an issue now. Is that because, like, are you using any of the AI documentation? Are you just better at it? Do you recognize what's necessary to put in the chart and what's not? Like, what is it for you?
[00:04:29] Dr. Oyler: Yes. I am using the Abridge technology, which is the ambient listening scribe, and so I feel like I open up the computer, but I'm not, like typing down the HPI like what they tell me directly. I'll take little teeny little notes to remind myself to make sure that the Abridge is correct, but I don't spend... I'm like, looking at the patient and I'm talking to them for at least, like, you know, half the visit. And so I do think that that has made me less computer-focused, and then I go to the computer and I engage with the computer with the patient. Like, "Look at all these meds that have gotten added since your last visit. I'm sure you're not taking this pain medicine and this antibiotic anymore. Let's clean this up together so it's the best for you and for me." So I feel like I still engage the computer, but that initial interaction is much more kind of back to the patient-doctor relationship.
[00:05:16] Dr. Cifu: I think cleaning up the medication list so plays into our obsessive compulsive disorder. You know? It's like, it makes me happy no matter what.
[00:05:24] Dr. Oyler: Exactly.
[00:05:25] Dr. Cifu: The other thing, you know, there's a lot of discussion out there as, you know, we make our way through a period in American medicine where there aren't enough of us, right? Aren't enough primary care doctors, and one of the many solutions people are throwing out is that, you know, we're just being asked to do too damn much and all of this screening stuff, right? That we're asked to do from actual medical screening, you know, colon cancer screening, breast cancer screening, prostate cancer screening, whatever, to you know, gun safety screening, alcohol, home violence, like everything, that maybe that shouldn't even be part of what we do. You know, maybe that's like, you don't need to go to medical school for that. I'm not asking you to kind of weigh in on that...
[00:06:22] Dr. Oyler: Debate?
[00:06:23] Dr. Cifu: Right, but I don't know, how do you keep that from taking over your life when you're with a patient?
[00:06:31] Dr. Oyler: I mean, mostly I order the stuff in pre-charting. You know, I just like automatically order it and then I say at the end like, "Oh, I ordered your mammogram, your flu shot, you already got," do you know what I mean? And the things that take discussion, like PSA screening, I feel like would be a little harder to take out of because it's such a discussion. So mostly I do it in pre-charting, and I just don't have a huge discussion about it, you know. And like if... Yeah, I don't discuss it. Mostly, I'm discussing their medical problems that are in front of us as opposed to the screening, but it does take a considerable amount of time that I feel like we don't necessarily get reimbursed for. Not that I'm there for reimbursement, but I'm doing a lot of pre-work and I'm doing a lot of post-work, and I've done a lot of in-between work that I feel like it's a big challenge.
[00:07:14] Dr. Cifu: Right. Yeah. And I guess also with a kind of mature practice, there are lots of screening that's kind of not necessary. You know, it's unlikely... I'm not sure I have data to back this up, but I feel like it's unlikely that you're going to miss undiagnosed depression in a patient you've known for 20 years. You know? You know who's going to potentially get depressed and you also know people so well that you're gonna pick up pretty quickly if something has changed.
[00:07:44] Dr. Oyler: Yeah. "You're different today." I agree.
[00:07:47] Dr. Cifu: So one of the great things about medicine is that it keeps you humble, right? You never really master it. What about the doctor-patient relationship sort of continues to challenge you? Like what is like, "Ah, I'm still not great at this!" You know, or "I really have to work on this."
[00:08:02] Dr. Oyler: Yeah. Yeah, I have three things that I wrote down. One was the too much social. Like, if we're like eight to nine minutes in and we're still talking about kids and family and things, I feel my heart rate go up 'cause I have a lot of things to accomplish. And I don't want to shut somebody down, but I'm like, "Okay, that was enough social." You don't need that many details, and I don't need... but I want to hear all those things, of course, but I think I have a 20-minute clock in my head that feels the pressure. That's one of 'em.
I think there's still too many people in one room. Like I still have two people, like, you know, husband and wife that come together, or husband, wife, and mom that come together. And like the emotional energy that that takes is really... To keep everything in the right chart and to transition from one to the other. And then we're like switching back to the person that we forgot. That still takes me a lot of mental energy. And not enough to say like, "I want to switch you into separate rooms", 'cause they obviously are choosing to be together, but I struggle with that. And I think still mental health disorders. Not the, you know, single, "I have depression or I have anxiety and I need a medication," but like true schizophrenia. And like, the conversation is not linear, but you've known them long enough to like understand. And also like when to call family because it's just not sinking in, but they don't... Like, does that take away their autonomy? And so like, how to manage pretty severe mental health disorders in a visit. I think I always feel like, "Did I try to go back to the medicine? You know, try to listen? And like, try to really understand what they're trying to say to me?" I struggle with that.
[00:09:50] Dr. Cifu: Right. Yeah. And the personality disorders, where it's something else, which just makes every single decision more difficult and takes more work and maybe takes more time, either within a visit or like, instead of this being a decision that takes five minutes in one visit, ends up taking three or four visits, you know?
[00:10:10] Dr. Oyler: Yeah, yeah. It's just more time. And I do notice that with our trainees too, is like, just really challenging. Like, those are the people that cause us to get less sleep at night 'cause we're worried. We're worried about them, that are we taking the best care of them?
[00:10:23] Dr. Cifu: Right. I have a similar experience, and actually, Jason Alexander, who was on this podcast a couple of weeks ago, talked about it too.
You know, the multiple relationships that you often need to manage within the room with multiple people, or sometimes the multiple relationships with people who are not there who you're managing. I've had the interesting experience lately with people who I've always seen alone, who then, you know, as they age, then they start pulling other people into a room. And often, initially, that's really difficult because it's like I have a relationship here. We've now added sort of a third person who has maybe just been dissatisfied, you know, for years, and I've never heard about it.
[00:11:14] Dr. Oyler: Or I think that person... I've had a couple times recently where that person's on the phone. Do you know what I mean? And like, then there's a little disagreement on the phone between the patient and the, usually, child. Do you know what I mean? And like, so I'm trying to manage that relationship plus my relationship to each of them. So it's interesting. I've debated, should we call the family member on the phone during the visit? Or should I call after the visit? I think that's my... Sometimes I say like, "We need to call right now. Like, I don't understand what you're trying to get to me." Or like, "We just need to involve the family member right now", but I'd say, many times I'm calling them afterwards just to be like, "These are the things that I ordered, I just want to tell you, so they get done," you know?
[00:11:54] Dr. Cifu: This is a joke. Do you ever reach over during the visit and just like hang up and say, "Oops, we got disconnected?"
[00:12:01] Dr. Oyler: No. No, I don't. It's usually not my phone. My phone's recording and their phone is calling, so yes, I never, never hung up on a family member.
[00:12:12] Dr. Cifu: There's a lot of technology there.
So at this point in your career, what do you sort of appreciate most about your role in the doctor-patient relationship? And when I say appreciate, I think I mean, one, just enjoy about it, but also, you know, to jump into a deadly sin, like what are you sort of proud about it, like, you know, what I do well, what I've grown to do well?
[00:12:34] Dr. Oyler: Yeah. I actually... I was thinking about this, and I feel like, you know, on a typical half day of clinic with 12 patients, I probably see three or four people over 90, and a couple over 100. And I... Do I think that's because I'm a good doctor? No, but do I feel proud that like, I've had 25-year relationships from people starting at 60 and 70 and getting them to 90 to 100?
I feel, you know, I feel proud of that. I feel proud of like, the relationship that we've had over time. I feel proud that I'm able to pour into like... Oftentimes, when they're declining, the end of life, you know, like how to help them transition into this. How aggressive to be, what do they want, you know, how do they feel, like what their desires are, what's appropriate for their medical care, when to choose palliative care.
I have a lot of patients walking through, you know, dementia in that time period and how to bring in families, and have them support. And so... And also that I'm able to stay on time with like...
[00:13:31] Dr. Cifu: Yes, yes, yes.
[00:13:33] Dr. Oyler: Because the older you are, the more medical problems you have. And I do think like, you know, we can have extra time, but I sometimes don't have extra time with those patients.
And so how to like, see them frequently, continue to develop relationships, walk with them towards the end of life, like I think that's kind of the things that I was... And also just to enjoy them outside the hospital, to know who they were and what their values are. I think I've learned much more to... You know, go to the things to celebrate their lives.
[00:14:00] Dr. Cifu: It's funny, you know, I think there is... So many things are like bimodal. This might be the theme of our conversation today, but you know, people start out easy, right? And then they get difficult, and then if they're around long enough, they get really easy again, right? Because like once you pass 100, it's sort of like, I'm not doing anything. Right? This might be pathologic. I have the same response often that like, "Wow, you know, I'm proud of myself that this person is 95." And I constantly sort of check myself that like, it is such association and not causation. Right?
[00:14:37] Dr. Oyler: A hundred percent.
[00:14:38] Dr. Cifu: It is the things that have made that person be able to stick with one doctor, both financially, you know, social stability, the ability to relate to a person well, are all the things that have like, made them able to get...
[00:14:55] Dr. Oyler: Not the medicine that they're taking or the screening that they had.
[00:14:57] Dr. Cifu: Exactly. Exactly.
[00:14:59] Dr. Oyler: Yeah. It's interesting. I find it easier at the end, but also more challenging.
Like, there's more family involvement. And more like... Sometimes specialists wanted to be aggressive, and you're saying like, "Really? Like, is this what the patient wants?" Like, yes, this is possible, but like, is this right? Does the patient understand that? Because you know, patients respond to somebody saying, like, "Yeah, we could cut that out." And I'm like, "How fast is that going to grow?" You know what I mean? Like, is there anything else? Like, "I don't know if you could go through that surgery? You're 99." Do you know what I mean? "Should you have that knee replacement at X, Y, Z age?" So I find it takes a little bit more interaction with specialists and also patients to just ask the hard question like, "Are you sure you want this at this age? Like, I'm a little worried, I just want to tell you, I'm a little worried about this." Do you know what I mean?
[00:15:49] Dr. Cifu: And absolutely, your comment about more people being involved because in the best of circumstances, you know, these people are often like the matriarch or the patriarch of a family. And man, you've got like three generations sort of concerned about what's going on.
[00:16:04] Dr. Oyler: Granddaughter comes into the visit. Daughter emails you afterwards. Somebody else is on MyChart with you.
[00:16:10] Dr. Cifu: And everybody looks the same. You're like, "Have I met you before?" You know, because they clearly all say...
[00:16:14] Dr. Oyler: i'm recording names. So and so is in the visit today. Talked to so and so after the visit.
[00:16:19] Dr. Cifu: I love it. So Julie, thank you so much for joining me today. This has been a really great conversation, which made me think of a lot of new things.
Before we finish up today, a quick addition about this year's National Clinical Excellence Award. As you know, the Bucksbaum-Siegler Institute for Clinical Excellence at the University of Chicago is dedicated to fostering compassionate doctor-patient relationships and advancing clinical care. Each year, the institute recognizes extraordinary healthcare professionals through the National Clinical Excellence Award. To learn more about the award and nominate a deserving clinician, please visit the Bucksbaum Institute webpage. That's bucksbauminstitute.uchicago.edu.
So thanks for joining us for this episode of The Clinical Excellence Podcast.
We are 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.