Opioids, Homelessness and Crafting a Non-Traditional Career in Academic Medicine

Dr. Kertesz discusses the winding path to a non-traditional but productive and successful career in academic medicine.

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, we have Dr. Stefan Kertesz talking about homelessness, opioid use disorder, and crafting a unique career in academic medicine.

[00:00:15] Dr. Kertesz: Something to do with the payment and work structure has certainly incentivized general physicians especially, or physicians who have high salaries, to see patients quickly and to input a lot of information into a computer, and that job done continuously is a hard one to sustain unless you're built a certain way. But I wonder if we aren't nurtured in ways of connecting to patients that would help us enjoy those connections more.

[00:00:45] 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 am Adam Cifu and I'm joined by Dr. Stefan Kertesz. Stefan, thank you for joining me today.

[00:01:00] Dr. Kertesz: It's fun to be here.

[00:01:02] Dr. Cifu: Dr. Kertesz is an investigator and physician at the Birmingham VA Healthcare System and professor of medicine at the Heersink School of Medicine at the University of Alabama at Birmingham. Stefan began his career at the Boston Healthcare for the Homeless Program and later completed a fellowship in general internal medicine at BU.

After his fellowship, he joined the faculty at the University of Alabama, Birmingham. His work includes leading VA and non-VA-supported research focused on homeless healthcare and issues related to pain and opioids. He remains an active clinician, directing a primary care clinic for homeless and formerly homeless veterans. He is also an advocate. His research on poor access to care for homeless persons in Birmingham played a role in spurring a federal investigation. He also co-led the team that led the CDC to issue a major clarification of its 2016 opiate prescribing guideline. He's currently a principal investigator of the only national study to directly examine individual suicides that occur after prescription opioids are reduced in chronic pain. Stephan, I can't believe you have time to do this with all this.

[00:02:15] Dr. Kertesz: No, I really do. And despite being incredibly inefficient, some things get done and some things don't. And I love being here.

[00:02:24] Dr. Cifu: So my impression of your career, and you can tell me if I'm just totally wrong, is that you didn't kind of set out to be a researcher, certainly not a basic science researcher, but I kind of think maybe not even a clinical researcher. However, you've been like very productive over your career studying homelessness, addiction, and maybe the intersection of the two. So looking back, like, how do you sort of see how your career developed? Was it totally random? Or was there a thought that went into this?

[00:02:53] Dr. Kertesz: So, I mean, I think at the outset, what I really wanted to be is Adam Cifu. And then a number of things arose that prevented me from becoming you. So, probably from birth.

[00:03:08] Dr. Cifu: We won't get into that background.

[00:03:10] Dr. Kertesz: Sorry. Okay. So I definitely didn't set out to become a researcher. And I still think of myself as a clinician-researcher. And what essentially happened was the evolution of things that I care about and things that I was allowed to do, and things where I had skills, but yeah, it... In the process of going to medical school, I realized, hey, I'm really interested in care across cultural boundaries. I'm really interested in care where I don't know where the other person's life comes from and what it's like. That's interesting to me. I did a little research and pretty much resolved that I would not do any research in my career, which is a bit of an odd resolution to have in your background if you've, you know, published papers as much as I have, but that was the resolution. And then I went to work in a clinical environment, Boston Healthcare for the Homeless Program. It was very inspiring. I found that I was intrigued and hopeful that I'd be able to do maybe clinical program development, teaching, become a guiding voice, and not do research. And then I did a fellowship because it turns out when you get a clinical job, most of what they need you to do is clinical work. They don't have... There are a few people who are such natural administrative leaders that they get promoted to that job and then everyone else does lots of clinic and very little teaching. And it wasn't the balance that I really wanted so I did this fellowship thinking I could change the equation. I wrote a fellowship essay saying I wanted to do program stuff and teaching and I specifically avoided... See, I want to be honest, I wanted to avoid any implication at all that I would become a researcher because I don't like deceiving people.

And then I went into the fellowship and of course, you do some research in fellowship. And then I had a mentor saying "Hey, you know, this is pretty cool. You can write a paper. You can write a grant proposal. There's... The National Institute on Drug Abuse will be interested in this." And I kind of... I had a moment where I remember writing a grant proposal with full ambivalence as to whether the direction implied by the proposal made sense.

I also couldn't see where the next job would be that wouldn't be full-time clinical.

[00:05:22] Dr. Cifu: Understand.

[00:05:23] Dr. Kertesz: And so I said, okay, I'm not sure about this research thing, in fact, I previously resolved against it but I have mentors who want to work with me a topic that's pretty interesting. I clearly have some skill here that might be helpful in allowing me to pursue a mixture of activities and maybe one of them will be research. So I'll just go ahead and write the proposal. And this proposal was for five years of funding. And it was scored in such a way that it was likely to be funded. And at that point, I accepted that I would take on research in a serious way without necessarily considering myself primarily a researcher.

[00:06:03] Dr. Cifu: Got it. There were two things that I wanted to ask about, actually one maybe just reflect on. One thing you said earlier, which I thought was terrific is, it sounds like you've sort of gone to focus on the things that you found most difficult, right? You talked about the clinical relationships with people who you didn't really understand, you know, where they were coming from. A lot of people would do the opposite, right? A lot of people would say, "Oh, this makes me uncomfortable. I have a harder time taking care of these patients." You actually sort of went right after that.

[00:06:33] Dr. Kertesz: I get a thrill from that.

[00:06:34] Dr. Cifu: The hell's wrong with you?

[00:06:37] Dr. Kertesz: No, I'm sure this has something to do with my life and my psychology, but where there seems to be a complex conflict that I can move into and establish a connection that matters to me. I had this story which I will share. We may or may not keep it in the podcast but when I was a medical student in Africa in 1992 I guess, there was a patient who came in with pus-filled eyes and he had endophthalmitis. And there were two Swiss doctors who were in charge of the inpatient wards. He came in, he got some antibiotics for a while, it was pretty clear he was going to lose all vision in one eye and maybe preserve partial vision in another eye but three days in, he said he had to go. And the Swiss doctors yelled at him and said it was on him if he was going to go blind. And after that rounds session, I went and talked to him. And I said, "Well, how did this all start?" And he explained to me the story of developing an eye problem, going to a conventional doctor, taking drops, it got worse, then going to an indigenous healer, who said, basically, "There is a grudge in your family or in your tribe and for a certain price, which is fairly high, I can help you resolve the demon that's essentially been unleashed by this family resentment." And then he came back to the hospital because he couldn't afford that price. And then he said to me, "But while I've been sitting here getting antibiotics, I can feel this pounding sensation in my head, and I think it's the demon and he's saying that he's going to kill me unless I go back out and deal with the indigenous healer who's got the services." So I drew a little picture of him, stick figure, with a Western doctor with a stethoscope on one side and an indigenous healer with maybe a head dressing on the other, each pulling on him. And I put them on a piece of paper and I said, "You're caught between these two." And I said, "If you allow this to continue," and I carefully ripped the paper in half right down the middle, I said, "You'll be torn in two. My suggestion is that you allow this treatment to continue and then delay the indigenous healer and then decide after if you're going to go ahead and pursue that." And at that point, he decided to stay. And I got a thrill from the sense of, wow, I don't know anything about indigenous healers or Western Africa or family resentments. I don't really like the doctors I work with either but the feeling that I could make connections and address situations that are just really complicated was exciting to me. And that led to taking that job at Boston Healthcare for the Homeless Program and it led to a lot of the directions of my research.

[00:09:14] Dr. Cifu: Got it. You're also, it sounds like you're someone who your fellowship actually probably changed the direction of your career.

[00:09:21] Dr. Kertesz: It did, the general medicine fellowship.

[00:09:23] Dr. Cifu: Right. Right, because so many people go into fellowships with "I know exactly where I'm going and this is going to get me there." For you, it was sort of more time almost to explore and to get a different direction.

[00:09:35] Dr. Kertesz: All I hoped, I really did hope I would get out of fellowship and some hospital would say, "You can become our clinical educator who does program development." And I wasn't seeing it. And then I had this incredibly warm mentorship and research. And I had some skill there, like it was clear that I could do things, that part of that job that I wasn't bad at. I mean, writing, analyzing, obsessing over details. I'm not bad at those things. And that changed what I did.

[00:10:00] Dr. Cifu: It's interesting, and it's probably something for another time. You know, I hear it in the way you talk and I hear it in both the way I talk and the course of my entire career is that, you know, we are both dedicated clinicians, but we also realize that if that was all we did, it would kill us. And I don't know if that's just true to the field or if that's a problem with medicine today or it's a problem with us.

[00:10:28] Dr. Kertesz: It's probably all of those things. I do think that the uh... Something to do with the payment and work structure has certainly incentivized general physicians especially, or physicians who have high salaries to see patients quickly and to input a lot of information into a computer, and that job done continuously is a hard one to sustain unless you're built a certain way. But I also think we also... I wonder if we aren't nurtured in ways of connecting to patients that would help us enjoy those connections more. I'm not saying that you and I can't do that, but I'm saying that maybe the mainstream way in which we learn doesn't always help us realize how much there is to give and enjoy while respecting who the patient is as an independent individual.

[00:11:18] Dr. Cifu: Yeah. Okay. That to be continued. So you seem like someone whose goals really lay not only like, here's an interesting scientific question I'm going to answer but I want to answer questions which not only impact care, but it seems like impact the patient care that you're doing. Your research really seems like it grows out of your clinical practice.

[00:11:41] Dr. Kertesz: Correct.

[00:11:41] Dr. Cifu: So I want to kind of ask specifically, like, are there things that you've, I don't know, discovered, described, however you want to put it, that has, like, affected the way you look at patients, or the way you treat patients, or the way you advocate for your patients?

[00:11:55] Dr. Kertesz: Yeah, I'm thinking of one finding from research that really came out of the research and which I didn't particularly pay attention to before.

So we developed over a few years a survey for patients' primary care experience, focused on the experience of patients who've been homeless. It doesn't... It isn't crucial that they were without a house, rather what's crucial is that they're folks who are coming into the healthcare environment with relatively low power and some concern and some distrust. And among the scales we developed was one on their perceptions of whether the people taking care of them are cooperating.

[00:12:33] Dr. Cifu: Got it.

[00:12:33] Dr. Kertesz: So for instance, if they say, "My primary care provider and the others on the team need to work a lot better with each other," if they endorse that, that's a sign of trouble. And what we found is there is lots and lots of dissatisfaction on the perception of cooperation by the patients that we take care of who were disadvantaged. They believe that the nurse, the doctor, the clerk are all at odds with each other. So what happened as a result of seeing the finding is I started telling patients, "Now I want you to know, I'm going to be calling so and so now, I'm sending an instant message right now over to the clerk to tell them that when you go over, this is what I want to have happen." And then oftentimes in the visit, I'll say, "You know, it might help if we try to page the specialist you saw right now with you here, so we can have that company, would that be helpful?" So I changed my perception of that one practice a lot, that it wasn't an extra because apparently, the level of dissatisfaction with this is very high.

[00:13:32] Dr. Cifu: Right, right. That's so interesting because I've seen that, I sort of have responded to it in a different way because I see that the way we practice is the way we practice, right? For 99% of patients, you can't look at Harrison's or UpToDate and say, oh, this is what we have to do. Right? You're making it up, you know, and it's an educated making it up. You're using a lot of smart people, but there's a lot of negotiation in figuring that out. And that disagreement is how you end up with good medicine.

[00:14:00] Dr. Kertesz: Oh, I see.

[00:14:01] Dr. Cifu: But I've had exactly the same impression that you did, a lot of patients probably appropriately get kind of freaked out like, "Oh my God, you know, none of my doctors agree." Right? And I've often gone to explain, you know, here's the conversation that's going on, which sounds like it's a little bit what you do, but you're also really actively involving the patients in, you know, almost the communication with everybody, which is sort of an exciting way to do it.

[00:14:27] Dr. Kertesz: Yeah, I think it's to mitigate distrust. And I don't think all that distrust was induced by the healthcare system either. I think that sometimes you've grown up with lots of conflict that has screwed you over.

[00:14:38] Dr. Cifu: Certainly.

[00:14:39] Dr. Kertesz: And it would be helpful if your healthcare environment didn't reproduce all the terrible things you grew up with.

[00:14:43] Dr. Cifu: Right. Right.

[00:14:44] Dr. Kertesz: The other example I'll raise just in passing...

[00:14:47] Dr. Cifu: Let me say there, often people's way of dealing with that kind of conflict of their life is to become much more independent in how they, you know, care for themselves, right? And often in the hospital, it's one of the hardest parts about being in the hospital, you have to give yourself over to be cared for, for other people. And if what's happening is their miserable childhood, where they just had to hunker down and like, protect themselves, that's not a good way to act when you're being cared for, right?

[00:15:19] Dr. Kertesz: Right. So upon whom is the responsibility to earn trust?

[00:15:22] Dr. Cifu: Right, right, right.

[00:15:24] Dr. Kertesz: I enjoy earning trust. So maybe that connects the story from Africa. To me, it's thrilling when somebody says, "You know, I can work with you."

[00:15:33] Dr. Cifu: Yeah. So we know that a large swath of our listeners are trainees, going all the way back to kind of pre-med college students. And I was wondering, do you have advice for kind of crafting a career that combines clinical care and research? You know, is it important to think about that from the beginning? You're someone who seems to have come from it pretty late.

[00:15:57] Dr. Kertesz: There was nothing wrong with doing research in medical school. As I said, it kind of sealed my plan to not become a researcher. So I think it's a reasonable thing to chase down and try out things that you are not sure you'll enjoy. And to allow that the experience may either provide a skill that later on you find useful or it can be clarifying to say, "Well, I did that and I'm not going to do that further." And I'm sure there's many things I tried out that I didn't stay with and it was a great thing. I really do think there's some value in learning the skills that are used by researchers, even if you're darn sure you don't want to be one because at the minimum you can question those researchers when they tell you what they've learned. The other thing I'm thinking about about crafting a career, it's really important to understand that you don't get to be another person. I mean, I said at the beginning, I wanted to be Adam Cifu. There will be somebody next to you in medical school, who seems to be doing it all correctly. And among them, a few of them will actually be doing everything perfectly, and they'll just exist. And they will... If you look at them, you'll ask, "What the hell is wrong with me?" And a lot of the time, the reality is we've got to work with who we really are, and not the vision of what we wish we were. And that leads to some pain and some sacrifice or just some decisions about what we're going to become.

Maybe I could never have become Adam Cifu. That's what I'm thinking. And I would say to the student, "You can try out things, look to what you resonate with, and then allow that you're not going to become a radically different person just because there's a really cool thing that you saw, or there's a really cool peer."

Uh, I guess two other thoughts came to mind. I want to make sure I don't forget them. One is any aspect of the research career involves a lot of ostensible failure. That is part of the deal with submitting papers and grants is rejections that keep happening, and there are inevitably places in that process that if you decide to do it, you basically hate it.

[00:18:05] Dr. Cifu: Yeah.

[00:18:06] Dr. Kertesz: I remember turning in a grant and saying, I don't think I could ever do this again. And my mentor at the time, Jeffrey Samet said, "Yeah, after you turn it in, that is exactly what it always feels like." So a very, very unpleasant experience is not always a sign that you are not meant for this, but it's definitely worth paying attention to.

And then I think the other thing is that for me at least, it has helped a lot to try to make sure that the questions I pursue, the questions that I ask about are the ones that I resonate with ethically, emotionally, and morally, that doesn't mean that the answer is foreordained by... That the research answer is foreordained by my sentiments, but that I try to find the things that I really care about. And that allows it, even if the research doesn't win a big prize, and even if it doesn't change the whole world, I would like to be able to say at the end of my life, you know, "He moved forward on things that he really cared about that are actually meaningful."

[00:19:03] Dr. Cifu: Or maybe it's at least useful to you. A couple of things that I wanted to just sort of highlight that you said and feel free to correct me if you think I'm wrong. I mean, I think you're underlining bad experiences is so important, right? Learning from things that you do that turn out to be wrong for you. I mean, I think it's important as you go through training, right? You see a lot of great people who you're like, "Oh, wow, I want to model this," but you see a lot of terrible behavior and you can learn an equal amount from that Right?

[00:19:38] Dr. Kertesz: Absolutely

[00:19:40] Dr. Cifu: Your comment on research, I think, is so key because, you know, there's swaths of people who are never going to do research in their career but as you say, I mean, in medicine, right? You're either producing data or you're consuming data. And even if you just become a consumer, right? It's really important to understand, you know, how the sausage is made so you can figure out, you know, what is true and where are the flaws in these things and kind of what I should doubt.

[00:20:08] Dr. Kertesz: Especially in my domain, a lot of research is incentivized sausage. That is to say, there are incentives to draw your data to support the conclusions that fit with people's prior assumptions, their emotions, their ethical and political commitments. And you want to be able to see when someone is, you know, hiding the dice or swapping them or playing, you know, what is it called? Three-card Monte with the data. You need to be able to see that because there are incentives to twist your data to say what you wish it would mean. And it's great if clinicians can call that.

[00:20:40] Dr. Cifu: And then the last thing you talked about, which I want to ask you if you think we do better at this. And I'm going to say we, as our generations, now that we're shockingly becoming like the senior physicians. So I think it is so important to let younger doctors, trainees know how much you fail in your career, right? And I've been very open about my CV of failure, which goes back to, you know, all the awards I didn't win in medical school, all the colleges I didn't get into, all the medical, all of that. I feel like we do a better job at that than the people who were in power when we were students. I don't think we're transparent enough about it, but...

[00:21:26] Dr. Kertesz: No. But I agree with you. There is at least a... There's a trend line of disclosure that I believe has been moving in the right direction relative to the types of people we had training us. I think the vision I had for what an attending should be when I started as a junior faculty member was of somebody who knew everything. And somewhere about 10 to 15 years in, I realized, A, I don't, and B, it is incredibly unhelpful to the people around me to imply that I do. And moreover, they're also growing and changing and figuring out what they want to be. So I adopted a phrase that I heard from a woman who I interviewed as I was choosing residencies. And she talked about life by chemotaxis, which is you follow the direction of the thing that feels right that you can do. And then when it suddenly feels really wrong, you have to readjust. And some of those readjustments are failures. And it's really good to own them so everyone understands we're all in this together at some level.

[00:22:23] Dr. Cifu: Right. And that readjustment is also not recognizing failure but it takes a lot of courage, right? To say, okay, I am going to shift rather than trying to, you know, plow through this brick wall and be unhappy for the next decade or more.

[00:22:38] Dr. Kertesz: Absolutely. And I've talked to residents who I work with who said that hearing you say you don't know or... And unfortunately, I'm apologizing for ignorance right now but there it is, or taking pride in it. That's not good. But hearing you say, you don't know, let's figure this out together has been very liberating for us.

[00:22:55] Dr. Cifu: Yes, yes. Absolutely true. Okay, Stefan, thank you very much. I feel like there are about 12 other conversations we could continue here. And we could, of course, also talk about the miserable September of 1993 on B.FIRM together.

[00:23:09] Dr. Kertesz: Oh my goodness.

[00:23:10] Dr. Cifu: We'll leave that to another day. So thanks for joining us for this episode of The Clinical Excellence Podcast, we're 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 webpage or on Twitter.

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