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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, we have Drs. Julie Chor and Neha Bhardwaj talking about the complexities of family planning medicine in 21st-century America.
[00:00:16] Dr. Chor: I think that what's been going on kind of politically has engaged some medical students in particular, right? But I also recognize that there are some people who are like, "You know what? It's really hard." And then also, you know, in speaking about medical students, it's impacting where they want to go train, just as it's impacting people who are coming out of residency, who are already in practice in terms of where they're going to work. So it's very much shifting our field.
[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'm Adam Cifu, and today I'm joined with Drs. Chor and Bhardwaj. Dr. Julie Chor is an associate professor of obstetrics and gynecology in the section of complex family planning and an assistant director of the MacLean Center for Clinical Medical Ethics at the University of Chicago. Dr. Chor's academic and clinical work focuses on understanding and addressing barriers that adolescents and young adults face in seeking and obtaining reproductive healthcare. Julie serves as program director for the fellowship in complex family planning, the assistant director for the University of Chicago's obstetrics and gynecology third-year medical student clerkship, and co-director of the first-year doctor-patient relationship course. Julie is also a senior faculty scholar in the Bucksbaum Institute. Julie, thanks for joining us.
[00:01:43] Dr. Chor: Thank you. I'm thrilled to be here.
[00:01:44] Dr. Cifu: Can't believe you have time for this, given that list of things. Dr. Bhardwaj is an assistant professor of obstetrics and gynecology whose primary focus is on family planning and contraception. She is the medical director of the Ryan Center and the director of the University of Chicago's complex family planning fellowship. Dr. Bhardwaj is an expert in complex contraception, helping women and families who have trouble conceiving for a wide range of issues including seizure disorders, cancer, heart disease, miscarriages, clotting disorders, and uterine anomalies. In addition to her clinical work, Neha does research aimed at improving reproductive healthcare and access to care. Thank you for joining us.
[00:02:28] Dr. Bhardwaj: Happy to be here. I'm also just the associate fellowship director of the fellowship.
[00:02:32] Dr. Cifu: Okay, I am sorry to promote you this way. Thanks a lot.
Let me start with a pretty general question. Both of you are experts in complex family planning, which as somebody not in the field, I understand it as dealing with finding workable contraceptive solutions and terminating pregnancies. Can you briefly talk about kind of what are the common issues that your patients come to you with or struggle with?
[00:02:56] Dr. Chor: Yeah. You know, I would say that in our field of medicine, perhaps more than many others, there are some common challenges that a lot of our patients face, not all, but many, around funding, logistics, also the impact of external kind of political changes and legislative changes, I think more so than many other aspects of healthcare because our area of medicine is so highly regulated and restricted. And so that really does trickle down to not only people who are uninsured or underinsured but even people who have excellent insurance coverage, who have great resources, the kind of external forces that are starting to impact more and more aspects of medicine very much pose challenges for patients seeking our care.
[00:03:55] Dr. Bhardwaj: Yeah, there's been a slew of recent Supreme Court decisions that have directly impacted how we can help our patients and serve our patients. Just for contraception, because of the Hobby Lobby decision, we find a number of our patients are shocked that their insurances don't cover certain methods of contraception that may be sometimes the only option for them. And some are also equally shocked that their pregnancy termination is not covered by their insurance. You know, we've had a number of patients come to us and say, "But I wanted to be pregnant. I can't be pregnant because there's an anomaly or I'm really sick. How does my insurance company not see that?" And so it really has impacted our day-to-day interaction with our patients.
[00:04:45] Dr. Cifu: It's interesting. I think we all deal with the disparities as far as wealth in our practices. And certainly, in my practice, I feel like wealth makes everything, you know, a thousand times easier, and it sounds like in your practice things are almost a little bit more leveled given the restrictions that there are.
[00:05:10] Dr. Bhardwaj: There's still an equity problem. It is interesting though because you know, we have a large equity problem in general in healthcare, but it's interesting because those patients that come to us seeking pregnancy termination for, you know, maternal or fetal reasons, they are typically the ones that are shocked that their care is not covered, are those patients with higher resources. And so it's kind of sometimes the first time that they've been faced with that problem. And it gives them a little bit more... I think sometimes I kind of see how patients then say, you know, "I understand how this is hard now for everyone else as well, like if this is hard for me and I have all these resources, how is someone else going to do this?"
[00:05:54] Dr. Chor: But also let's absolutely not gloss over the fact that people who have resources will be able to access the care that they need. And, you know, we see this, I think most notably in patients who are now traveling across state lines from great distances. We see the people who are able to reach us. We don't see the people who are not able to reach us.
[00:06:15] Dr. Cifu: Right. It's funny, I deal with those inequities most, I think, at the end of life where money makes all sorts of decisions about how to have, you know, "a good death" really easy. And you guys are seeing it like at the other end.
[00:06:32] Dr. Chor: Yeah, absolutely.
[00:06:33] Dr. Cifu: This may be slightly off-topic or maybe undermine some of my other questions, but I often feel a struggle in my work between kind of what I see as medicine, right? And what I see as, ah man, this is... I don't want to say social work as like in some kind of dismissive way because that's often as important as medicine, but I guess it's kind of like, I learned to do all this medicine and this is not what I trained for but it becomes equally important. Listening to you guys who are obviously, you know, incredibly highly trained physicians, it sounds like a lot of that sort of work just to get people the care they need probably takes up a huge amount of your time.
[00:07:19] Dr. Chor: A huge! That is like, thank you for saying that because it's absolutely our daily and weekly existence. The amount of... We've talked about this, the amount of effort it takes us to get one person the medical care that they need is tremendous. And it's not just us, it's a team of people but we could probably, you know, use additional members to the team, right? Like, it feels like it's never enough. And again, we're only able to help the people who are able to make it to our clinic door, right? I think it does feel like a weight for us. I don't want to speak for Neha, but I'm sure that it's not so far off. We do certainly feel a weight recognizing that there are so many people out there who are trying to get in to get our care.
[00:08:08] Dr. Bhardwaj: It's kind of crazy because you know, we are physicians, right? We're not trained to do that kind of supportive care as well as other people can. Like as much as the years and decades of education that we've been through, we're just not good at that and so we do it inefficiently. And then when we talk with other colleagues in medicine, when we talk about how like, you know, one patient can take hours to coordinate their care, and when one patient comes through the door, they can sometimes be in our clinic for three, four hours, that's sort of unheard of.
So it's a very different style of practice that we... It's really an accommodation that we're doing to really pack all of the necessary care to be safe and also get them what they need in such a short, concentrated amount of time because this part of healthcare has really been taken out and is not really deemed as healthcare. It's kind of its own separate entity.
[00:09:09] Dr. Cifu: You guys are both very involved in training, sort of all across the continuum. I imagine this is something that comes up in discussions with, you know, trainees as you're kind of, let's be honest, you know, recruiting people into our fields, which we all do. And I imagine that seeing sort of the next generation, it's probably impacting who you recruit. What kind of people is that?
[00:09:33] Dr. Chor: Absolutely. You have to be pretty... You know, super motivated, right? I think that what's been going on kind of politically has engaged some, you know, medical students in particular, right? Because I work a lot with medical students, but I also recognize that there are some people who are like, "You know what? It's really hard." Like our field, OB/GYN has never been easy, but going into reproductive healthcare has changed pretty dramatically in the past couple of years in particular.
And so I think again, it's activated and motivated some to like want to get into this, but there are others who are like, "You know what? This is really hard." And then also, you know, in speaking about medical students and there's a lot more writing coming out about this, it's impacting where they want to go train, just as it's impacting people who are coming out of residency who are already in practice in terms of where they're going to work. So it's very much shifting our field.
[00:10:37] Dr. Bhardwaj: Yeah, it's not just getting like a prior auth... It's not prior auth problems. It's like transferring a patient from a referring hospital in another state to our state to get them care. And then for training, we've seen this, I mean, once the Dobbs decision hit, we got a number of inquiries from a number of programs outside of Illinois asking if we could help train their residents because it really is kind of an education vacuum a little bit. You're seeing this whole next generation of OB/GYNs depending on what state you live in not being trained for a very common procedure.
[00:11:15] Dr. Cifu: Yeah. So you're not the person I should go and complain to that I have to do a pre-authorization for ozempic? Is that the...
[00:11:21] Dr. Chor: We can all feel that pain too.
[00:11:23] Dr. Bhardwaj: I'm here for the venting.
[00:11:24] Dr. Chor: We can appreciate that.
[00:11:25] Dr. Bhardwaj: I'm here for the venting.
[00:11:28] Dr. Cifu: So that's probably a good segue. Obviously, over the last few decades, I feel like certain fields specifically in medicine have really been like drawn into the culture wars, right? I think about trauma surgery and its relationship to gun violence and obviously, you guys in family planning and its relationship with both contraception and abortion.
So you know, speaking as doctors, do the debates that we like hear about constantly affect, you know, not what you've just talked about, but more sort of in-the-room affect the conversations with the patients, or are most of the patients you've seen kind of unaffected by those debates?
[00:12:10] Dr. Chor: Yeah. I mean, we actually have a paper that has been accepted and will be published shortly, if it's not already published, about conversations that we've been having with patients in the wake of the Supreme Court decision, how it's impacting their decision-making around desiring permanent contraception.
Young people who have, you know, no children who have felt for a long time that they did not want biological family building, but who in kind of assessing the state of the country have felt more of an urgency in accessing permanent contraception, for example. So it's absolutely trickled in and those are spontaneous, right? We're not... This is not something we're eliciting, people are scheduling appointments to see us for this. So it's absolutely coming up organically in our conversations with patients.
[00:13:02] Dr. Bhardwaj: And that misogyny and history of sexism and racism has really come into, I won't say every patient interaction that we have, but many patient interactions that we have. Especially when we look at how there was a huge report that came out a couple of years ago about black maternal morbidity and mortality. And then also our ongoing conversations with contraception and coercion that are also reaching kind of a newer conversation. So it really is, I would say, not all of our patients, but a good number.
[00:13:36] Dr. Cifu: Hmm. It's interesting to think about because we're used to the fact, I think, both as doctors and as educators, right? Preparing people for that medicine is going to change over your career but it's interesting to see your practices change so much from kind of external forces.
[00:13:55] Dr. Chor: Yeah. And I would say that like our specific field has always been impacted by external forces and politics but what I find really amazing is that instead of that kind of external pressure decreasing, it's not only increased in our field, but spread and not just to medicine, but so many aspects of work, right? If you think, you know, who would have thought, I think, maybe 5-10 years ago that librarians, for example, would be really impacted and honestly, sometimes fearful of threats, danger. You know, so unfortunately, more people in medicine, so for example, pediatricians, endocrinologists who are being impacted by movements against gender-affirming care, but even again, librarians, you know, all sorts of people are being really impacted and, you know, people who work at voting stations. So it is really sad, I think, to see how more and more people, unfortunately, are experiencing what we've been experiencing for quite some time.
[00:15:04] Dr. Bhardwaj: And you can see that fire in that resident's or medical student's eyes. And then, especially with residency being over four years, you can see over the four years how burnout has already started to hit them when talking about these issues, and just the frustration. You know, no one... When you get into politics, you know that your life is going to be impacted by these decisions but like Julie was saying, when you get into medicine, you're really there to help your patients.
[00:15:32] Dr. Cifu: Right. Especially with so many of our, you know, trainees who have made decisions about their career choices. I mean, when people make them in college, that's late, right? We have a bunch of people who've made their decision, at least to go into medicine in general, you know, in sixth grade and this is a little bit of a shock.
So I've been interested for a while in kind of the role of doctors in political advocacy. And we actually had an episode about six months ago with Monica Peek and Will Parker talking specifically about that. And your field certainly is one that decision-making around advocacy is, you know, salient or maybe fraught. And so kind of how do you think about your roles? You know, do you think... You obviously spend huge parts of your careers advocating directly for the health and contraception rights of your own patients. How do you think of advocacy on a broader scale? Or do you? Or you feel like, "Oh God, I've kind of given it at the office. I don't have space or time or energy for anything else."
[00:16:41] Dr. Chor: Yeah. I think about this a lot in terms of medical education and preparing the future of medicine. And, you know, I think for a long time, we've... The model for academic medicine has been like a three-legged stool, right? So research, teaching, and clinical care. And I really think that going forward, it has to be a four-legged stool, and that fourth leg is advocacy. I don't think that people going into medicine can be complacent at this time. And advocacy looks different, and I think that that's our role as educators is to teach future physicians what that can look like. And absolutely, you know, day by day we advocate for our individual patients but one thing I say to my trainees is that you know, advocacy can look different for different people, but also at different points in your life, you know, it may be that you're not in a place where you can go to, you know, Capitol Hill or, you know, go on TV, for example, and do a TV interview about certain things. You may not want to be that vocal or public. There are so many ways to advocate behind the scenes. Legislators are really eager to... Well, some are eager to hear from people who are actually doing the work. And so that has been a really gratifying way of being involved is kind of helping to educate people who are actually crafting good legislation, being part of amicus briefs. So there are so many, you know, op-eds, there are so many ways of being involved that don't require super public-facing approaches, that could be more behind the scenes, but certainly, there are people who are skilled and who will excel at being those public faces. So I think that exposing people to like the wide range of what that can look like is really important.
[00:18:35] Dr. Bhardwaj: And we're so lucky in Chicago to have Governor Pritzker, Lieutenant Governor Stratton. So the University of Chicago is actually part of a larger abortion referral line called CARLA, the Chicago Abortion Referral Line for Access. And Governor Pritzker and Lieutenant Governor Stratton gave about 10 million dollars in partner with IDPH to start this referral access line for patients either in Illinois or coming to Illinois for abortion care. What we are seeing is that we ourselves are burnt out as providers, right? And patients are really panicked when they have lack of access to care. So they make appointments at all the major institutions for care. And we can now, with our electronic medical record kind of synced in a lot of institutions, we can see that. And so we would have a number of appointments that people wouldn't come to, our volume was varying day by day and so with their help, we've set up this kind of larger abortion referral line, where it's very centralized, and patients go where their insurance is covered, or where they prefer to go, you know, if they have all their doctors at one place, that's where they prefer to go, or someplace else. So we're in a very lucky state.
[00:19:52] Dr. Cifu: Julie, specifically, I really liked the way you kind of outlined the various ways that advocacy can look because I sometimes, and feel free to push back on this, you know, I do sometimes worry in our field where there's like, everybody needs to be a political advocate and, you know, A. there are some people who are just, you know, bad at that. And there are some people, depending on, right, where they practice, how they practice, who they see, you know, that advocacy can make the in-office relationships difficult. And I do like the way you sort of talk about teaching that, you know, advocacy can look a whole lot different to different people at different times in their careers.
[00:20:38] Dr. Chor: Yeah. Yeah. And I think you know, one other thing that's really important is how does that fit into your life also, right? So, you know, family life and all those types of things. And so, you know, as I said, I think advocacy is an integral part of academic medicine, but I also don't want that to be an undue pressure for people to feel like, yeah, they have to do, you know, advocacy with a capital A, you know, there are so many ways to do this.
[00:21:07] Dr. Cifu: Let's give you a third job, you know, in addition to what you're already doing.
[00:21:12] Dr. Bhardwaj: It's not really well accounted for in your FTE.
[00:21:14] Dr. Chor: No, that's true. Nor in, you know, I say again, I think it's an integral part of academic medicine, but it's also, not only do we not get, you know, our views for it, but it's also not as respected and recognized in academic medicine. It doesn't really help us in terms of, you know, like promotion and all those types of things. It's just, we do it because we know that it's essential to ensuring the care of our patients.
[00:21:42] Dr. Cifu: Sure. Yeah. It's interesting when there are promotion decisions, you know, I think it's one or two people in an institution who are kind of recognized as, "Oh, wow, you know, this person has a national advocacy base and looks good for us. They should be promoted," but there are a whole lot more people working at it, taking time, you know, using up their energy, but it's completely unrecognized. That's a great point.
Guys, I wanted to really thank you for this discussion. I think it raised obviously, a lot of great issues and it's great for people to hear, you know, sort of what you do and how the larger picture affects the medicine. So I really thank you.
[00:22:22] Dr. Chor: Thank you so much for having us.
[00:22:24] Dr. Cifu: 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 via the Bucksbaum Institute webpage or on Twitter.
The music for The Clinical Excellence Podcast is courtesy of Dr. Maylyn Martinez.