The Social History

Knowing about the patient who has a disease is as important as knowing about the disease the patient has. But how well do you need to know them?

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. Julie Oyler talking about aspects of the social history.

[00:00:12] Dr. Oyler: But I realized that I was really mostly cherishing and trying to spend kind of a golden two or three minutes at the end of the visit and just to be like, "How's the family?" Or "Tell me more about that book or your dog that you showed me pictures of last time." And just kind of cherishing that, you know, we talked about the golden minute at the beginning of like letting the patient talk. And I kind of use this like golden minute at the end. Sometimes they bring it up like, "Dr. Oyler, how are your kids?" You know, and sometimes I bring it up like, "How's your family?" Or "What's going on with your life?"

[00:00:50] 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 today I'm joined by Dr. Julie Oyler. Dr. Oyler is a general internist, professor of medicine, and colleague of mine for, well, decades.

Besides being an internist who is treasured by her patients, she was a previous guest on the podcast with one of those patients. She chairs the Women's Committee here at the University of Chicago Medical Center and is an Associate Program Director of the Internal Medicine Residency. She is also a fellow in the Academy of Distinguished Medical Educators and a past president of the Midwest Society of General Internal Medicine.

Julie, thank you for joining me today.

[00:01:41] Dr. Oyler: Great to be here, Adam.

[00:01:43] Dr. Cifu: Joining me again, I should say.

[00:01:44] Dr. Oyler: I know, it's our second time.

[00:01:46] Dr. Cifu: You are one of the few return guests. So, your appearance on the podcast today grew out of one of those clinic conversations, which we're always having. And this was about kind of getting to know patients. So we're both primary care internists. We've both taken care of patients for years and years, but then have occasionally kind of recognized late in a relationship how little we actually know about those patients. So just to ask a very open-ended question to begin, like, how do you think about that kind of disconnect, I guess?

[00:02:22] Dr. Oyler: Yeah. You know, I think our conversation in clinic kind of went like this. And I do remember you mentoring me through this. Around 10 or 11 years into my career, I had a number of patients that I'd seen die kind of back to back about 2017. And I... You know, it was really upsetting to me, I'd had patients die, we've obviously dealt with death before, and I had gone to a few funerals for these patients that I sometimes try to do if I can. And I just realized how little I knew about the patients having had seen them for 10 years. And I could reiterate their diabetes, their hypertension, their COPD, their heart failure, but I knew so little about like, what they had done, they mostly were retired, what they had done for their work. I knew maybe one family member, but there was like a multitude of family members that they often were close to. And so I sat in these funerals and read their, you know, summary of their lives. And I was like, how did I not know this? This would have been so impactful if I... You know, I could have been a better doctor for them, and I could have had a better relationship with them if I had known this. And so really at that point it kind of drove my practice a little bit in a different direction, having gone through kind of the series of funerals that I went to.

[00:03:33] Dr. Cifu: It's interesting hearing you say that because the two things that come to mind is, for me, I think it's reading obituaries sometimes. We're like, "Oh, wow, this person was incredible in a different way than maybe I knew them," but the thing that popped out when you said it is, I think so often when we work with trainees, whether they be residents or students, and we're seeing one of our patients, often the person we're working with is sort of impressed at how quickly we know about the person. And we're like, "Oh yeah, they're on this, this, this. And they've had these problems in the past." But that still doesn't represent a huge gap in our knowledge, right?

[00:04:13] Dr. Oyler: Yeah. Yeah. So we definitely know there are medical problems like off the back of our hand. I think we've seen them and talked about those problems so many times every three or four months over years and years. And yet, it's hard to impart like the other things, the intangible things that we know about the patient and how important we feel those things are, you know.

[00:04:31] Dr. Cifu: Do you think this is surprising to us? I don't want this to sound like I'm patting you or me on the back, but I feel like as general internists, we sort of think of ourselves as, you know, the holistic doctor who spends a whole lot more time with the patient, who is a whole lot more accessible to the patient. And so, maybe some of these realizations are a little bit more jarring to us than the person who did the appendectomy and then sees the person for a single follow-up.

[00:05:00] Dr. Oyler: Because we have such a long kind of relationship with the patient and we expect ourselves to know more. And yet we only knew like what medications they were on. Yeah, I do think, you know, we hold ourselves to the standard of like having a long-term relationship with patients but there are so many doctors that have long-term relationships with patients. And I just, at that time, was questioning like I should be having this relationship with patients that I'm not.

And I'm an educator and am I teaching other people to do this and how am I modeling this for people? And so it became more and more... It's becoming more and more important to me.

[00:05:31] Dr. Cifu: Yeah. You mentioned that with that realization, whatever, you know, 7-10 years ago, that it led to a little bit of a change in your practice. Can I ask what that was?

[00:05:39] Dr. Oyler: Yeah. Yeah. So the first thing I started doing is just really recording like data about people's lives. I have this, you know, a little book that I... I call it Patients Loved and Lost. And I give it to all of our chief residents. It's just a notebook, a moleskin notebook. And I, you know, write notes about people when I... You know, they've moved to another provider or states or passed away, just to kind of document who they are and like, what value they held in my life because, of course, every patient touches you, but the other thing really is, you know, in a 20-minute visit, I think I always open with, "What do you want to talk about today?" And that often is something medical. And then, you know, I run through, you know, history and physical and medications and all the kind of health maintenance things, but I realized that I was really mostly cherishing and trying to spend kind of a golden kind of two or three minutes at the end of the visit.

And just to be like, "How's the family?" Or "Tell me more about that book or your dog that you showed me pictures of last time." And just kind of cherishing that, you know, we talked about the golden minute at the beginning of like letting the patient talk. And I kind of use this like golden minute at the end. Sometimes they bring it up like, "Dr. Oyler, how are your kids?" You know? And sometimes I bring it up like, "How's your family?" Or "What's going on with your life?"

[00:06:54] Dr. Cifu: This may sound like an obsessive question, but do you document that stuff? I mean, maybe not in your note, but in the social history or?

[00:07:01] Dr. Oyler: You know, I used to be very... I used to do it always in the social history but now I'm so practical and like, I'm already typing in the daily note that I just put like, number one, hypertension, number two, diabetes, number three, COPD, and then I have this little text and I'm always like writing something at the bottom, like recently came back from, you know, Branson, Missouri, or, you know, so and so just passed away or their dog's ashes are in the necklace around their neck, or it could be anything. It's just like, whatever came up during the visit. And then you know, I try to bring that up in the next visit, like, you know, "Did you get a new dog?" You know, something like that. So I put it in the actual note now, not the social history just because it's more practical than anything else. It's not clicking into another function.

[00:07:49] Dr. Cifu: Sure. I love that. It's almost like you, you know, repossessing notes that have so much become building documents, right? And to going back to a little bit like, you know, this is a prose document, which is supposed to represent, you know, or record a moment in time. And you're actually doing that. And it sounds crazy.

It's funny. I asked a patient I saw last week just to make them feel comfortable. I was like, "Oh boy, I really liked your necklace." I really did like the necklace. And this woman said, "Oh, my grandmother's in it." And I was like, huh. And it was the same thing.

[00:08:27] Dr. Oyler: Yes. That happened to me yesterday. I said, "What a beautiful necklace." She had shown me a picture of her dog. And she said she had just got a new dog and she said, "Oh, my dog's in the necklace." I was like, "Oh, I didn't even know that was an option."

[00:08:39] Dr. Cifu: This is wonderful. The grandmother, she had some, you know, 18 children, and a little bit of her ashes went in necklaces to every kid. That's wonderful. So I obviously am enthusiastic about everything you just said, and it makes me think about how I want to go forward, you know, doing a better job recording this. So this next question may sound like totally sacrilegious, but as a doctor, you know, should we really care about this? Like, you know, I know you, I've seen your patients, I know you do an incredible job with your patients as far as their medical management. And that was true before you were having a golden minute at the end of your visit. And yes, I think this is nice and this is what we think we should do as primary care physicians and we're primary care physicians because we generally like people. But I don't know...

[00:09:33] Dr. Oyler: Does it really matter?

[00:09:35] Dr. Cifu: Yeah. Could we show outcomes?

[00:09:38] Dr. Oyler: You know, there, I feel like the recent outcomes about like seeing your primary care doctor more often leads to better morbidity, mortality, and less hospitalizations. I think I would argue that that is the data there. But I don't know if I, you know... I don't know if I do it for their medical care, but I do think it makes a difference, you know. I'll say when people push back and they're like, "Why do you...?" Mostly people push back, not in my clinic, but when I'm on inpatient medicine is like, "Why does that matter to you?" You know, "Why do you need to know where I live or who I live with? Like, why do you care about that?" I'm like, "Oh, absolutely. I just... I'm a curious person and I care about you." So I don't ever push like if... Because it's really not essential to their medical care. Like I can treat vitals and labs and medical complaints without it but does it...? Do I think it makes me a better doctor and make my care better? 100%. I'm able to think about you as a whole person, what matters to you. And like, we're making choices about medications and tests based on, I mean, whether your dog passed away? No, but are you more or less depressed this time, do you need to titrate your depression medication based on things that have happened in your life? I absolutely think it matters.

[00:10:46] Dr. Cifu: That's interesting. And maybe, you know, when you said that it's obvious that it might make a patient feel better you know, at the visit, feel more comfortable going to see you, feel more comfortable opening up if they feel like you're interested in them more broadly, and feel like they have more of a relationship than just a doctor-patient relationship. But maybe, I mean, as we think about our own, you know, wellness, um, it probably does make the job nicer when you feel like you are seeing people who you know better. Even if we can't measure outcomes, because all the data you talked about is totally confounded, right? We don't randomize people.

[00:11:25] Dr. Oyler: Said it like a true Adam Cifu.

[00:11:28] Dr. Cifu: Totally. So, this is a question that I really want to hear your answer because I think I've evolved over the course of my career. You know, so we're talking about people's lives outside of the office. Some of those things may be medical issues. Some of those people, things may affect medical issues. Some of them might just be about the person themselves and may or may not impact our relationship. But often, you know, once you get involved in these things, you kind of start getting invited to things. And maybe in chronological order, you know, those go from circumcisions, baptisms, weddings, retirements, funerals, whatever. How do you handle those kinds of invitations?

[00:12:10] Dr. Oyler: Yeah, I get them a lot, you know, now that I'm farther into my career and it has definitely evolved over my career. I think at first I thought like, I'm a physician, I'm in your medical care, it should happen in the office and I shouldn't see you outside of the office. And I have just kind of evolved since that time. I think especially around this 2017 time when I obviously chose to go to these funerals. And for me, I started thinking, I'm spending time at these people's funerals. Like, why am I not going to the things when they're alive to like, get to know them and to spend time with them and like, see how amazing they are before they pass away. Like, why not celebrate in life? And so, when I get an invitation, I never say like, "I'm sorry, I can't go. I'm your doctor." I say like, "That is amazing. Tell me more about it. Tell me about the day, you know, let me put it in my calendar." They give me a piece of paper. I never promise to go because I think that's a balance, you know, you and I probably have kids and lives and like, I never promise but I do... If it's a day that I can at all make it and I can take the time away, I do try. And I have really found great joy in it. I've gone to musical, you know, piano concerts and blues concerts and 95th birthday parties and have I gotten to every one of them? No. And I feel sad when I can't because I have to, you know, give a gracious sorry, but it definitely impacts my care for patients when I now know a little bit more about them. Like I went to a 95th birthday party and the caregiver was like... Multiple caregivers that I had seen over 10 years and came to her 95th birthday party and I understood the family dynamics more and what the family values, so...

[00:13:52] Dr. Cifu: And it's not completely... I think anything that we do routinely is not completely altruistic, right? You're also generally welcomed at those places as like, maybe a rock star is too strong, but as a special guest.

[00:14:06] Dr. Oyler: Yeah. I mean, oftentimes you definitely stand out. I think that's what's sometimes hard is like, "Why is that person here? That person is not in our family, is not in our culture." And often, that is the hardest for me sometimes.

Like, sometimes just go and listen and observe and then try not to, you know, change the dynamics of the situation because of my presence. And I think learning how to be in those situations, be appreciative, celebrate the person and not make it about you is really important because that's important to me that it is not about me being there, but it's about me celebrating the patient.

[00:14:42] Dr. Cifu: Yes, I have sat at the back of a lot of churches and, you know, funeral parlors, and I like to try to exchange a nod with someone, but that is sort of the ideal, if that's all it is. I think I've gone through a similar transition with you. The line that I frequently repeat is, you know, the longer you spend in your career, the more your patients become your friends and the more your friends become your patients, right?

Which is just, I think, an unavoidable truth. One of my mentors in residency who I, you know, respect enormously, he really taught very kind of strict separation. And even looking back on it, I think maybe his teaching was a little bit extreme because he was teaching residents and he was saying like, "This is a good place to start and then you'll figure out how to evolve. When you know enough that you don't get yourself into trouble." But one other thing that he always brought up was... And I guess now we might think about it as equity, that like, one of the hard things is that if you start saying yes to these kinds of invitations...

[00:15:52] Dr. Oyler: You're going to say yes every time.

[00:15:53] Dr. Cifu: Right. Do you say yes every time? Do you start only saying yes to some people? And is that one more thing in our relationships with patients which just sort of break down the equitable care that we're trying to give? What do you think of that?

[00:16:06] Dr. Oyler: Yeah. Yeah. I just... I struggle with it.

[00:16:08] Dr. Cifu: Just trying to make you feel uncomfortable.

[00:16:09] Dr. Oyler: No, no, I struggle with it. I mean, I think the line that I've drawn is I go when I can and not because this person's closer to me or this person's in this... You know, I just... If I can go and it makes sense for my schedule, I go. That's very self-centric, not patient-centric.

I will say the other thing I do is I definitely funnel most things into like appropriate communication channels. I'll say like...

[00:16:31] Dr. Cifu: Oh, interesting.

[00:16:33] Dr. Oyler: I feel very strongly about, like, if you text me, I might chart you back. If you email me, I'll respond, because sometimes it's hard to get on my chart or whatever, but I will also put it in my chart, so it's not sitting in my email. And if you mail me an invitation or you hand me an invitation, I generally document, like, "Saw the patient in the recital." You know, like put it in the medical record. So it's clear that I was there as a physician, not as a friend, even though I do have, you know, now that I've been in there, friends who are my patients.

And the other thing I noticed when I was looking through my book, Loved and Lost, is that how many patients that are in my book, I still take care of someone in their family because, do you know what I mean? Because of that, so I'm still in connection with this family group because of that. And I think that I value, but that was off-topic for your question.

[00:17:20] Dr. Cifu: No, but your answer to the question was great. And I think very good lessons, you know, about how to separate things, how to balance things, how to keep yourself in your traditional role, even as you carefully venture out of that. I think your last point is a wonderful one. And maybe, you know, when you're back for a third time in another year, something to talk about.

I find it so interesting when one person in a group, you know, passes away, let's say, and you know, maybe you're taking care of spouses, nieces, whatever, and you know, sometimes those people feel like it's too painful to continue with you...

[00:18:03] Dr. Oyler: To come back into the building, to be in the place where their loved one was the sickest. Yeah, sometimes it is. And they're honest like, "I gotta leave you." And sometimes people know that you are a good, attentive doctor and they're like, "Yes, they were sick, but I need you because you were very good and attentive with them and I know you'll be very good and attentive with me." People have different reactions.

[00:18:22] Dr. Cifu: And thinking about those communities that we get involved with, and the communities themselves evolve, it's kind of a gift, right? It's one of the things, the reason why we do it. I remember actually when, soon after my dad passed, my mother and I were walking from our house to the subway. And we went in this weird route, and I was like, "What the hell?" And she's like, "This is the block the oncologist is on, I can't walk there," you know? And I was like, "Oh, how...?" You know?

[00:18:46] Dr. Oyler: Yeah, that big of a memory.

[00:18:48] Dr. Cifu: Right, right. Dr. Oyler, thank you so much for joining me again. I look forward to our next conversation.

So thanks for joining us for this episode of The Clinical Excellence Podcast. We are 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, X.

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