The Clinical Excellence Podcast

Dr. Jason Alexander joins Dr. Adam Cifu to discuss how the doctor–patient relationship evolves once you’re no longer a new physician. He reflects on the confidence that comes with experience, knowing when to listen and when to step in, and how caring for colleagues and families adds both complexity and meaning. He also shares how embracing uncertainty and being genuine help build trust.

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 am joined by Jason Alexander, talking about the evolving doctor-patient relationship.

[00:00:13] Dr. Alexander: I felt like I was able to convince people to get their first vaccine for the first time because they trusted me and they trusted that I could examine the data, that I would be... What I would say is what I would not just say to them, but it would be the same thing that I recommended for a family member. And those people that were on the fence about whether should I get it, should I not? I was able to kind of get them on the other side to get their vaccine. I think I did good in that time, whereas other people may have struggled.

[00:00:46] 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. Jason Alexander. Dr. Alexander's an associate professor of medicine and a general internist at the University of Chicago. He's also a treasured colleague of mine. He's a clinician educator focused on the related topics of teaching learners how to critically appraise the medical literature and teaching general internists how to practice evidence-based medicine. He is also a co-author with me on the upcoming fifth edition of Symptom to Diagnosis and deputy editor of JAMA's Clinical Guidelines Synopsis series.

Jason, thank you so much for taking time away from everything you do to join me today.

[00:01:37] Dr. Alexander: Thanks for having me.

[00:01:38] Dr. Cifu: So we're going all in on the doctor-patient relationship this season. And so I have a few questions. Kind of first off, you've been doing this for a long time now. I've, you know, seen you practice, I hear you precept resident students around their practice.

How has your relationship with patients changed over time? And I'm interested in kind of the evolution of how you relate to new patients and returning patients and kind of how that's evolved over time.

[00:02:05] Dr. Alexander: I think that's a really interesting question. I think, you know, thinking back to when I was first on faculty, all the patients that I saw were new to me.

So, you know, the approach that I took was really trying to get to figure out where people were at, who they were, and what made them tick. And then from there, kind of building on okay, what's most important that I think is in terms of their health, what things I want to prioritize, and you have a much wider net that you're casting.

Now that I have lots of patients, and I'm seeing far fewer new patients, I find that I'm much more dogmatic on that first visit.

[00:02:49] Dr. Cifu: Interesting.

[00:02:50] Dr. Alexander: And part of that, too is you know, just kind of what we do, right? Part of what we do is grow together with our patients. And so my practice is different now than it was when I started, you know, on faculty ten years ago. And those patients that I've had for over a decade, I've evolved with them over time. And I've become more, I think, nuanced in my approach to specific problems that come up.

[00:03:21] Dr. Cifu: Yeah. I have two questions, sort of about what you said. One is that I also assume that the new patients you see now are different. You know, you are the kind of doctor who, you know, I hear your name spoken around the hospital. I imagine that a lot of your new patients come already with some sort of idea about who you are. Do you think that's true?

[00:03:43] Dr. Alexander: A hundred percent.

[00:03:44] Dr. Cifu: Yeah.

[00:03:44] Dr. Alexander: So, you know, at the beginning, right, I'm just seeing all the new patients we had. Dr. Anne Hong retired. She had been in practice for 38 years. They had to hire two faculty in order to replace her. I was one of them. And so I came in with, you know, kind of as a new face, establishing, but even still taking over those new patients. Now, as you say, I get referrals and so sometimes it's from my own patients, right? Can you see my sister? Can you see my brother? Can you see my mom, my dad, my son, my daughter? And I think that's a pretty special type of recommendation. And I always say yes to those. And then I also get colleagues that come up and say, "Hey, can you take me on as a new patient?" And you know, we've perhaps shared multiple patients together or you know, it might be somebody related to one of my kids. You know, their parents that want to have a doctor. And so yeah, they do have some preconceived notion of who I am. Regardless of that, I think you're still having to, particularly in those situations, set some boundaries and say, okay, this is how I'm going to approach this and how I'm going to approach our relationship here.

And so it takes a little bit more effort in defining what that relationship is going to be in the office as opposed to what it may be outside the office. As opposed to patients who came in earlier where we didn't have a relationship outside the office, and so it's easier to kind of set those boundaries.

[00:05:08] Dr. Cifu: And then when you talk about sort of going in and, I don't want to put words in your mouth, but it sounds like almost, you know, being yourself right off the bat, like, this is how I am. Does that come from just, you know, I've got confidence in how I do things. I'm obviously going to adapt to patients' needs, but you know, I am who I am and I recognize that that's a good way to care for patients. Or is it also like, we know how things go. We know that not every patient is right for every doctor, that people are going to move around if they're not satisfied. And we may as well just figure it out right off the bat. That might sound a little bit harsh, and it might... I mean, I don't think any of us go into a relationship thinking about that upfront. I don't know. Is that part of it?

[00:05:57] Dr. Alexander: No, I think you're right. I think it is. I think it does come from a place of confidence in the sense that not that I've figured everything out, far from it, but...

[00:06:10] Dr. Cifu: That's my next question.

[00:06:11] Dr. Alexander: Okay, but I have a trove of anecdote of patient experiences to draw from. And I can be more facile about maneuvering a particular complaint or problem as it comes up. And with that, I think I'm able to inject a little bit more of myself. Patients love authenticity. And so if I get a sense early on and encounter with a new patient that we're on the same wavelength, and I can't put a number or a scientific thing on that, but you can get a feeling of it in the room, then I'm going to inject a little bit more of myself earlier on. Whereas, earlier in my career, I would be a bit more, you know, professional is probably not the right thing, but not that I'm not professional now, but I might be a little bit more objective in my approach to the patient and less likely to inject a little bit of myself, but now I have the confidence to do that 'cause I know people relate to that and that can be beneficial.

[00:07:16] Dr. Cifu: Right. It's interesting, I mean, listening to it, it sounds like it's actually developing a little bit more mindful practice because instead of just going in and like, I'm the same with everybody, it's, you know, you are also the third person in the room, you know, looking at the interaction between doctor-patient relationship and thinking about what's going to work here. And you've probably developed different tools to be able to adapt to that.

[00:07:43] Dr. Alexander: I've got some patients that frankly just need to be listened to. And I'm not necessarily going to be offering a ton of changes in their care, but that listening in itself, for a lot of people, can be therapeutic. I've got other patients that aren't talkers, that just, you know, they're coming in for... They want A, B, and C done. And so I'm going to approach that differently.

And that's not, you know... I can operate in both of those environments, but I'm going to think about how I can utilize both of those facts. And how I approach new problems that arise.

[00:08:22] Dr. Cifu: Yeah. A total aside, I find a challenge is that those people who just need to be listened to, I have to always make sure that because there's very little of an agenda going into most of those visits, there is the temptation to, you know, shortchange those visits to get yourself back on schedule. And you have to recognize that like, even though there aren't going to be a lot of tests ordered, there aren't going to be changes in therapy. That it is actually like that whatever, 20 minutes, which is therapeutic and you know, needs to be defended even if you're falling behind.

[00:09:00] Dr. Alexander: No doubt.

[00:09:01] Dr. Cifu: I sometimes screw that up. And I have to kind of remind myself of that frequently. One of the great things about medicine is that it keeps you humble, right? You kind of alluded to this. You never really master it, right? I think probably the day you're closest to mastering it is the day you stop working but what about the doctor-patient relationship sort of still challenges you? Do you still feel like, "I got to work on that?" Or maybe the other thing that, you know, at the end of the week when things haven't gone perfectly, you reflect and it's like, "Ah, it's that Shakespearean flaw!" And is there something...

[00:09:36] Dr. Alexander: There's always plenty to reflect on at the end of the week, so you're like, "Eh, that could have gotten better," or, you know, "That actually went pretty well."

Well, okay. Well then, what made that go bad? Or what made that go well? I think the things that come up consistently for me are, which we touched on a little bit earlier, is how the intersection of other people related to the patient impact the visit. And it gets more complicated when those other people are also your patients. And so it can be patients. So it can be like the doctor patient, you know, surrogate plus also a patient. And how... So those interactions can get really blurry and complex. It also applies to colleagues, and how... So, for example, if I get a referral from a colleague saying, "I think this is going on. I think, you know, their main issue is they're having, you know, signs of cognitive impairment. And I think you would be great in order to establish with this patient to try and get a sense, because I know this person and they told me that this stuff is going on at home and it's, you know, really impacting my other patient's care." And so I'll meet them as a new patient to me. You know, and I may not necessarily be able to address that on the first visit because I'm getting to know them. And so I had this come up recently, which is why it's on my mind. Patient reaches out, I think cognitive impairments, or a colleague reaches out, "I think cognitive impairments issue. There were financial repercussions that happened. And so if you could address that during the visit." And I'm taking the history, the guy has pretty longitudinal thinking, or he has concrete thinking. He's able to, you know, string multiple sentences together, and I don't get a sense that there is anything going on.

I want to be able to, you know, maintain the respect of my colleague who's referring for this. I'm not getting a general sense of it. I'm not going to say, "Oh, by the way, let's do, you know, a cognitive assessment on our first day." That's not going to help with the patient care, but those intersections where you have competing interests and different... When it gets beyond just you and one patient. I think those intersections can get really thorny.

[00:12:01] Dr. Cifu: I love it that when you talk about that, you know, when you first started talking, I immediately went to Yeah, that's right because it's often not just doctor, patient in the room, right? It's doctor, patient, spouse, daughter, niece, whatever.

But you are right, it's that, you know, the doctor-patient relationship actually includes like a whole community around, family members that you never meet or maybe never meet until the funeral, right? But then also doctors and, you know, sometimes those relationships go well, sometimes those people help you, but sometimes they're the most difficult part of the doctor-patient relationship, even if they're never around.

[00:12:42] Dr. Alexander: More often than not, it's really helpful. And it's what... I mean, it's frankly, one of the things that contributes to my own professional wellness is the relationships that I've built with colleagues, and it feeds back into, you know, if I have a patient that needs a referral and they need to see a cardiologist, I'm not thinking of just blanket cardiology referral. I'm thinking of a specific person because I know that person and I know that person's subspecialty and interest. And so patients feel like they're really getting really good care by me referring to a specific provider. My colleagues are happy 'cause they're getting to see patients with things that interest them.

And it's this whole, you know... They can get overbooked 'cause, you know, as a primary care doctor, everybody owes you and, you know, it's good all the way around, but there are these times where these really complex social structures can make the individual patient interactions really difficult.

[00:13:35] Dr. Cifu: The other thing I just wanted to kind of highlight in what you said, because it's something that coaches do, but I don't think we do enough for ourselves. You know, when something goes wrong, I think we're really good at reflecting or maybe just drowning ourselves in errors and thinking about those, but I think we spend a lot less time reflecting on when something goes well and why it went well. And that's kind of, you know, the coach's mantra is to recognize that. What went well? How can you use that in different ways? But boy, I feel like I rarely do that and say like, "I've got a great relationship with this person. How did I build this relationship? Can I use that with other people?" And it's probably just one more thing to keep in mind as you practice.

[00:14:21] Dr. Alexander: It goes back to the, you know, tell me about one good thing that happened that day and one bad thing. I try and do that in my interactions, too. It's helpful for... I don't know. And it could be small things. I remember there was this one time this patient whom I've known for years in really kind of stressful life events that occurred. And I'm sure it's similar for you. There's not one clinic session that goes by where I don't have to not reach for the tissue box. And, you know, I just listened to this lady for about 20 minutes talking about a variety of different things and, you know, at the end I made some comment about, "Well, I did a lot for you this visit." You know, it was just... And she said, "You did. You listened. And that's what I needed." And I think about that a lot. Because those are... You know, those pay dividends for, you know... It was helpful for the patient in that moment, but it also pays dividends to the relationship, the doctor-patient relationship itself for when you need to leverage things to help you and the care of that patient.

[00:15:27] Dr. Cifu: That's one of those comments that makes you reach for the tissues for yourself. So just to sort of finish up, at this point in your career, what do you think you appreciate most about your role in the doctor-patient relationship? You know, not to get into, you know, one of the seven deadly sins, but like kind of what are you honestly proud of? About like, you know, what I bring to relationships that I think I do well, that I think my patients benefit from, and why people stick with me.

[00:15:57] Dr. Alexander: I think I do a pretty good job of acknowledging uncertainty when it comes up, and it comes up more often than not. And I think it helps me reframe. It's kind of you're always playing this game of, you know, patient autonomy versus paternalism and what the right balance of that is. And that answer is different depending on the scenario but I think, you know, being able to communicate when that comes up in a way that's helpful for patients, it decreases frankly, my own bias of what I would choose in that scenario. And I think it allows me to frankly, practice more honestly with the vast amounts of things we don't know versus the ones that we do, but what that does is it also gives me... Again, it gives me additional leverage to say... When I say, "I think you really need to do this," I think patients believe me more. I think a good example of that was when the COVID vaccine first came out. And obviously, this has changed over time, but in those early days when we had the vaccine for the first time, and a lot of patients still hadn't been exposed to COVID and there was good evidence to suggest that, you know, initial COVID vaccine series really decreased risk of hospitalization and death. I felt like I was able to convince people to get their first vaccine for the first time because they trusted me and they trusted that I could examine the data that I would be... What I would say is what I would not just say to them, but it would be the same thing that I recommended for a family member and those people that were on the fence about whether should I get it, should I not? I was able to kind of get them on the other side to get their vaccine. I think I did good in that time, whereas other people may have struggled. And so I think communicating uncertainty and being explicit about what risks are, what benefits are. Not being absent from that. Still offering what my suggestion or recommendation would be, but being okay if they go against that.

[00:18:00] Dr. Cifu: Yeah. There are so many visits in which decisions need to be made, right? And there are decisions that need to be made with tons of uncertainty, right? Which, you know, just... I agree, sort of needs to be acknowledged, and you say, "We need to make a decision. It's a tough decision. We're not totally sure." And then there are decisions that need to be made where you can say, "You know, medically, I got to say this is the right decision. You know, whatever, you may not do it. You know, and that's fine too. You know, it's your body, it's your healthcare." But being able to differentiate that, I do see why that would be something to sort of focus on, you know, be proud of, and also to kind of use going forward.

So Jason, thanks so much for joining me today. This was wonderful. It's great to hear your mind, how you think about it when you're in the room seeing patients. I feel like we spend too much time with all of our colleagues, not actually watching us do what we do well. So it's good to hear.

[00:19:01] Dr. Alexander: Thanks for having me.

[00:19:02] Dr. Cifu: 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.