Patient Doctor Discussion #4

The patient's side of the patient-centered longitudinal care experience.

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 Ms. Sherry Steinberg and the students she works with as part of the Patient-Centered Longitudinal Experience.

[00:00:09] Ms. Steinberg: Part of the motivation for me was the fact that I have had so many really bad experiences and very punishing experiences at the hands of the system and providers who were not patient-centered.

[00:00:25] 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 Ms. Sherry Steinberg. Ms. Steinberg participates in the Patient-Centered Longitudinal Experience at the University of Chicago.

This is a program that was developed by Dr. Joyce Tang, who we had on a previous episode of the podcast. In the program, first-year medical students are partnered with patients. The students co-navigate their patient's clinical care experience across multiple settings. Ms. Steinberg, thank you so much for joining us today.

[00:01:04] Ms. Steinberg: You're very welcome.

[00:01:06] Dr. Cifu: Also joining us are the two students Sherry works with, David Deshpande, who I realize I should have checked on the pronunciation of your name.

[00:01:13] Mr. Deshpande: That's okay. It's Deshpande.

[00:01:15] Dr. Cifu: Deshpande. And Nihar Rama.

[00:01:18] Mr. Rama: Perfect.

[00:01:19] Dr. Cifu: David and Nihar just started their second year at the Pritzker School of Medicine at the University of Chicago.

David came to us from the University of Wisconsin-Milwaukee and Nihar from the University of Cincinnati. Guys, thanks so much for joining us and for actually helping to organize this today.

[00:01:36] Mr. Deshpande: Happy to be here.

[00:01:37] Mr. Rama: Thanks so much for having us.

[00:01:38] Dr. Cifu: So, Ms. Steinberg, thanks so much for taking the time to record the podcast and really, more importantly, for volunteering for this whole Patient-Centered Longitudinal Experience.

Before we get started, just to get to know you a bit, can you tell us a bit of your story? Sort of where are you from? What kind of work have you done? Do you have family in the area?

[00:01:56] Ms. Steinberg: I actually was born just a couple of blocks from here and probably pretty much in this setting itself. It used to be a lying-in hospital. I lived here the first five years of my life until I came into the house having found a razor blade in the alley and my parents thought perhaps this would not be the best place to raise children. But my dad was working on the Manhattan Project. He was working with Fermi and did his PhD work here.

So, I grew up in the South suburbs. I actually did cancer research here in my senior and... After my first year of college with Dr. ... Oh my God, his name went right out of my head. You can edit this out. Um, anyway, he was a guy who was working with erythropoietin ... Eugene Goldwasser, that was his name. And, um, so...

[00:02:48] Dr. Cifu: I didn't realize we had such a lifer joining us today.

[00:02:51] Ms. Steinberg: Yeah, so I have connections. And I lived on the North side of the city for like 40 years. I was a writer and editor, started out medical and scientific work, got into educational publishing. Ended up, my second career was as a birth doula, which is kind of the total other end of the spectrum, but amazing. And from birth work, I got into death work and became a death doula and volunteered in hospice. And so, yeah, that's kind of brought me to where I am. I have, as these guys know, a very complicated medical history. I've been kind of a victim of the system, you might say, in some ways.

But I'm just so thrilled to be here and have the medical care at the University and especially, it's been just such a boon because I met you guys shortly after I came, right? Yeah, so I mean, I have... They've been with me, or I've been with them the whole journey.

[00:03:54] Dr. Cifu: I left out in the introduction that the Patient-Centered Longitudinal Experience specifically picks patients who have sort of complicated medical issues and who are known to... You know, will have at least a lot of contact with the system because it would sort of be a waste of time if the person never saw the doctor.

[00:04:12] Ms. Steinberg: Like, yeah, like Stan, like the man I'm caretaker for.

[00:04:16] Dr. Cifu: Right. So maybe you have sort of already answered this next question, because listening to you, it sounds like you're sort of a medical educator almost as a career, but what led you to get involved in this program?

[00:04:31] Ms. Steinberg: Um, we were asked by our primary care doctor, who is just incredible, Dr. Kostas. And I think part of the motivation for me was the fact that I have had so many really bad experiences and very punishing experiences at the hands of the system and providers who were not patient-centered. And so I think the chance to, you know, work with these amazing, really, really incredible people just as human beings, you know, I mean, they're just very caring.

[00:05:13] Dr. Cifu: It's interesting though, I mean, some people, I think maybe, having the experience that you've alluded to, would sort of pull back but it sounds like...

[00:05:22] Ms. Steinberg: That's interesting, yeah.

[00:05:23] Dr. Cifu: Right. It sounds like your reflex is almost to, you know, I'm going to try to make this better by helping educate people.

[00:05:30] Ms. Steinberg: Yeah, I think that is kind of my M.O. in a way in the world, and I mean it's turned out to be just fantastic because I don't think there's a specialty that I haven't been involved with yet. And um, so, they've gotten a good... You've gotten good exposure through me anyway.

[00:05:52] Dr. Cifu: Before I start peppering them with questions, what has the experience been like for you? You sound like, you know, you've had a lot of contact with medicine. Has it been different having students with you, kind of joining you for appointments?

[00:06:10] Ms. Steinberg: Oh, it absolutely has. Just one small story. I think this was when I was at Kaiser in California. I was seeing someone, I think it was for some gastrointestinal thing, some rectal thing maybe. And he literally, he was on a roller chair, and he literally rode backwards out of the room as I was talking about it. He said, "You mean I have to look there?" So, I mean, I really have had kind of the back end of it, but it's almost been for me like I have two concierge doctors. And I mean, these guys are only first-year students and the depth of their knowledge and their ability to listen, you know, and to care, and to be holistic, you know, which you don't get that with specialists.

[00:07:04] Dr. Cifu: Have they helped with, do you think, with the communication with the physicians, or helped just by their presence with sort of affecting physicians' behavior with you, given, you know, years of experience in doctors' offices?

[00:07:17] Ms. Steinberg: I think both. Actually, I never thought about affecting the physician's experience or treatment of me anyway, but a number of times the doctor would be asking, the provider would be asking me something, and I would say, "Oh, I don't know. I never had that," and these guys would say, "Oh, yes, you did on September such and such."

I mean, they're totally familiar with my record. They've come to almost all my appointments. And I think possibly their presence there makes the doctor more, I don't know, attentive, possibly. And they also are knowledgeable enough, which I have... It's just beyond my understanding how they all have this breadth of knowledge already, to ask really excellent questions.

[00:08:06] Dr. Cifu: Yeah. I'm interested to hear this because I know, you know, as a physician that, I behave differently when I have people, you know, shadowing me in the office. And we always talk about, you know, the Hawthorne effect, which is this idea that just by studying something, you change it. And this certainly has that potential.

And it's interesting to hear from you who kind of have a before and after experience to understand that. So David and Nihar, for you guys who are, you know, I don't want it to sound, you know, disparaging, but you're kind of newbies in the field, right? And how has the whole program kind of fit in with the rest of your education so far? Are there things that you've kind of learned, experienced that you think you would have missed without this program? Has this kind of been, I don't know, additive or, I don't know, beneficial to you so far?

[00:08:59] Mr. Deshpande: I would say that it's been a highlight of the first-year curriculum. We have just started our second year, and although the patient-centered longitudinal experience technically ended at the end of our first year, we've continued because we've learned and enjoyed it so much.

One of the special things about it is that it's so different from the other things that we do during our first year. We spend a lot of time in the classroom, a lot of time studying, but even after a long day of studying, Nihar and I were always so excited to go to the clinic or come to the hospital to go to an appointment with Sherry. And this came into our learning in a few different ways. I think one piece was that we could see things we had learned about directly happening in practice, whether that was the pathophysiology or the doctor-patient relationship class or the medical ethics component but it's so different to also learn and reinforce knowledge in the context of a human and especially somebody that we've come to really care about. So it's been a very special and unique part of our first-year experience.

[00:10:12] Dr. Cifu: That's so exciting to hear. The thing which comes to mind for me, and this will be a huge distinction, was where I went to medical school, we got a stack of the new New England Journals delivered to the library every week. And I thought it was amazing that as first year progressed that I could understand more and more about what was in the Journal but boy, to hear, you know, I understand more and more about an actual person's actual medical care, you know, puts that to shame, that sort of experience.

[00:10:44] Mr. Rama: Yeah, I have to really echo what David just said. I think this is, as we reflect on our first year, been one of the most important highlights because I think it's ultimately a reminder of why we went into medicine.

You know, I think, in medical school, you're going to be able to learn about the anatomy and the pathophysiology and the diseases that affect our patients, but having the opportunity to learn about the person behind the diseases has been so impactful. You know, reading a medical note in the EMR and then being able to see the person whose name is in that record makes such a difference. Seeing, you know, such and such, you know, SI joint, whatever issue, and then seeing the person who's dealing with that issue. It's just, it really helps to, from an educational standpoint, solidify the pathology in your mind, but also I think more importantly give you, how does it affect the person. How does it affect the things they do day-to-day?

And then I think listening to Sherry speak in the first few questions, it just really brought a smile to my face. And I know it's a podcast so that listeners can't see my smile but it really... I think we share a lot of the lessons that Sherry shared with you in that the way that providers interact with us as students has been really interesting, you know, and I think, there's a lot of lessons to be learned probably from the medical education, big picture standpoint of how do we ensure that students as they go through medical education get to experience the patient side of thing early on so that when they're in the role of a provider, when they're in the role of somebody writing a medication or explaining a therapy to a patient that they can explain it in a way that comes across to the patient and is compassionate, but also getting the job done.

[00:12:40] Dr. Cifu: My next question I think is probably for all of you, but Sherry, I'll ask you first. You know, this is a pretty unique program because, in medical education in general, we usually assign students, you know, to medical teams, right, rather than to patients. And so this really switches things around. Do you, as your role in this situation, as the patient, do you see a benefit to this as a way of educating students from what you've watched?

[00:13:11] Ms. Steinberg: Oh, absolutely. Absolutely because I think, I could never imagine going to medical school. I mean, my brother did, and just filling in all of that information... And also, I think I would be too... Or, you know, if you make a comma fault, nobody dies. But I think the major benefit to this is that, you know, you go to medical school and you get a lot of stuff being poured in. There's a lot of knowledge. And the tendency with a lot of providers I've been with is that they are the authority.

And one thing these guys already just have innately is learning from the patient and that you have to listen and you have to learn, you know, as be a learner in that situation. And I think that's just crucially important for good, you know, productive interactions, you know.

[00:14:13] Dr. Cifu: I may have to have you guys back in, you know, a year and a half after you've sort of finished a year, you know, embedded in medical teams, but you guys have certainly had those experiences already. I've rounded in the hospital with you, you know, you spent time in clinics kind of on the other side. What is the big difference to this?

[00:14:39] Mr. Deshpande: Here's one example that comes to mind. In no other situation that I can think of in medical training is there a formal opportunity to sit in the waiting room with a patient for 45 minutes or to sit waiting after the resident sees you for another 40 minutes until the attending physician comes back.

And that is really valuable because we have this position of being able to see both sides here of what Sherry's experiencing, waiting in the waiting room, um, waiting for the doctor to come see her, and then, also being with the medical teams, we spend time in the hospital shadowing. Next year, we'll be immersed in the hospital. And so we also understand the complexities that are happening on the care team's side of making sure that every patient gets appropriate care. The everyday administrative and logistical challenges that slow things down. And I've just been so amazed to see both sides of those things, but then see how Sherry is still so friendly and patient and gives so much grace to any provider, regardless of their attitude when they walk in the door.

And we've had experiences on all ends of the spectrum with providers and other members of the team who are in any mood, great or bad, and it seems like in any situation, we've been able to come out with a more positive start than we started with, even in the best ones.

[00:16:18] Ms. Steinberg: That was you, David. That was you with that nurse. That nurse came in with a real attitude and David, you just asked her something about herself or something, I don't remember what the specifics were, and it just turned everything around. And that's an innate sensitivity that can't be taught that is so crucial.

[00:16:39] Dr. Cifu: Well, it sounds like you guys, I mean, just listening to this conversation, it sounds like you've sort of learned things from each other, right? About these interactions, you know, which are just human interactions, but it's sort of a special kind of human interaction, that I wonder, you know, if we look back in 10 years that, you know, you guys as medical students would say, "Boy, I interact with patients differently because of this." And that you as a patient say, like, "Boy, I learned things about, you know, how to work the physicians and nurses and get the best out of them."

[00:17:09] Mr. Rama: I'll just offer another possibility of how supplementing medical education with patient-centered experiences like this might be valuable to students. I think that having the limited experience we have of having been on medical teams, rounding, in clinic, or in the hospital, when a recommendation is made or a plan is made, you know, often you don't get that follow-up in as robust of a manner. You might see a patient again in six weeks or three months or something like that. But I think that with Sherry, we've had the privilege of being able to see how a plan gets executed in real time, and kind of the real-time effects of the follow-up. And I think that that's really valuable because when I think about how that could shape how I practice as a doctor in the future, I think it'll make me more cognizant of the way that I paint those recommendations to a patient, the way that I discuss them with the team, and ultimately consider how it might impact my patient, not just from the standpoint of their health, but from the standpoint of how they interact in their life, you know, outside of their health. And so I think that... I think that it would, you know, it would be incredibly valuable to students.

[00:18:28] Dr. Cifu: David, you and I have had conversations about empathy and how we develop empathy in practice and whether it's something that can be learned or whether it's just something which develops with time. I wonder, Nihar, hearing your thoughts about that if just being in this situation where you kind of see the medical impact of recommendations, treatments, procedures, whatever, on someone who, you know, is not you but someone who you've clearly grown to care about. Do you think you're kind of growing empathic strength faster than you would otherwise through this?

[00:19:09] Mr. Rama: Yeah, that's really interesting. And I think a lot about this idea of is empathy something that's innate or something that can be trained? And I actually do think that it is being trained through this experience in a lot of ways because, you know, I think that if you're innately empathetic, you can definitely, you know, imagine what it's like to carry out a plan to have all these things happen but I think being such a kind of close part of that process, having somebody relay the struggles that happen or relay the kind of victories when those happen, it trains that empathy in a way that I think is again, a reminder of why you go into medicine in the first place. And I think when you're on a medical team, it can be easy to lose sight of that because you're taking care of so many patients and you're... In a way, you can lose sometimes the human aspect of it because a patient as we talked about earlier, can get reduced to a name that's in a record. So I think being able to put a face to it, being able to put a body to it, an experience to it, that lived experience trains the empathy for sure.

[00:20:26] Dr. Cifu: Sherry, I'm going to kind of finish up with you, you know, as our guest, you should have the last word. You see Dr. Kostas, who is a truly, you know, gifted clinician and educator, and your relationship with her will go on, you know, after your relationship with these guys, and because they've made silly decisions and gone off and left us and trained someplace else. Do you think this left sort of an ongoing impact with Dr. Kostas in ongoing care? Um, I'm not sure what I'm looking for in the question, but sort of just thinking about maybe it gives you something outside of the usual doctor-patient relationship and experience you guys have had together. Do you think that's true?

[00:21:13] Ms. Steinberg: Oh, absolutely. And one thing that had just occurred to me is that the healing effect for me of just knowing that these guys care, you know, just the fact that I matter and, you know, I walk in, they say, "How is your leg?" You know, they know what particular thing they're dealing with at a particular time. And that's so crucial because so many specialists particularly are... They're not as involved, and I mean, some of them care in a much more technological way. They care in terms of a disease or in terms of a procedure or whatever, but this experience, I think, for me and for the man I'm caretaking for, Stan, has been just remarkable. It's given me a sense of grounding, you know, and that there's somebody I can call, you know, and that they will answer and they will know what I'm talking about. I won't have to explain my whole history to them. And it's a remarkable experience. And Dr. Kostas, as busy as she is, manages somehow to even do that. You know, last week when I went into the hospital, I mean, she called. You know, she called me on the telephone, I mean, you know, um, but, and I know that she's there, and she answers, you know, she answers the messages right away, but this is different, and this is more, she does not go with me to my, you know, other appointments.

[00:22:56] Dr. Cifu: She would lose her job, I think.

[00:22:59] Mr. Rama: In a way, she does because you may not know this, Sherry, but we actually send messages to her and summarize what happens when we go with you to these appointments. And so I'm just thinking an idea that might be interesting to maybe study for the future, you know, as we're thinking about what's the role of a program like this in medical education might be not just educational outcomes for students, but does it, in any way, improve patient care? Does it foster more trust between a patient and their doctor? Does it improve outcomes? I think that would be really interesting to see because even though Dr. Kostas isn't there for Sherry's appointments, she gets all the updates. And she gets them in a kind of high-yield, director's cut kind of way from us, you know, from David and I.

[00:23:49] Dr. Cifu: Yeah, I imagine like you say paints a lot more detail and color than reading a clinic note in Epic, which we're all doing in 30 seconds after the visit. So Ms. Steinberg, again, thank you both for your time today for the podcast and also for your time educating our students, which is wonderful.

And 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.