Subscribe
Share
Share
Embed
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 Dr. Michael Drazer, talking about the evolving doctor-patient relationship.
[00:00:12] Dr. Drazer: And I think people can tell if their physician really enjoys being there. I think that's very apparent and I've been, as we all have, in rooms with, you know, your family members or your friends, and you're the third pair of ears or eyes and it's so obvious that that physician does not want to be there, and I get it. Like we all have bad days. It's a tough profession at times.
[00:00:41] 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 am Adam Cifu, and today I am joined by Dr. Michael Drazer. Dr. Drazer is a hematologist oncologist and geneticist, specializing in the care of people with blood disorders, blood cancers, hereditary blood disorders, and hereditary cancer syndromes. He runs one of the only clinics in the world focused on the care of people with hereditary blood syndromes. Dr. Drazer is also a researcher whose lab focuses on determining the mechanisms that drive hereditary blood cancer and cancer syndromes with a particular emphasis on developing high-fidelity cellular and mouse models of these disorders. Michael, thank you so much for joining me today.
[00:01:34] Dr. Drazer: Thanks for having me. I was telling Adam that I'm a huge fan.
[00:01:37] Dr. Cifu: Thank you very much. I like just mentioning high fidelity. It reminds me of the old movie.
[00:01:44] Dr. Drazer: Yeah. Well, I think about the cassette tapes.
[00:01:47] Dr. Cifu: That's right. That's right. We're going to date both of ourselves. So Michael, I'm dedicating like this entire year to really thinking about the doctor-patient relationship. And so to start for you, you know, you've been doing this for a while now, I've got to say, I've sort of known you for your entire career. How has your relationship with patients kind of changed over the years? You know, when you think of either new patients who you're just meeting in your clinic, or patients who you've cared for for a long time, what's evolved in how you relate to the patients you work with?
[00:02:21] Dr. Drazer: Yeah, so we were talking right before you hit record and, which actually is a record button, which is very cool, and you know, I was thinking about this because, I'll spill it a little bit, you sent me a little bit of the questions beforehand and I was contemplating as I was walking over here that, you know, when you're a resident and for the trainees out there, you're so inpatient-heavy, right? And you kind of are exposed to the attendings that you work with, caring for whoever walks into the hospital, right? And, you know, on the road to recovery, but for me, this really changed when I was a fellow. And I mentioned Phil Hoffman's name. And you know, one of the wonderful things about being a fellow is that's where, in my opinion, the apprenticeship model really goes on steroids, at least for internists. I think the surgeons see a little bit more of this phenomenon than we do.
[00:03:06] Dr. Cifu: Yeah, I agree.
[00:03:07] Dr. Drazer: But you know that first year of fellowship, at least at U of C, you rotate through all these clinics and heme/oncs is a crown jewel. I'm obviously biased, but at U of C, and you know, you're working with these world-class physicians and you start to see almost guardrails on the way that these attendings behave. You know, and I remember the first time, my first bone marrow biopsy was with Phil Hoffman. And I remember I walked into the room, I'm a nervous first-year fellow, and he says to the patient, whose... This is her first bone marrow biopsy. I'll never forget this. He looks at her and goes, you know, "Do you want me to use the new needle or my favorite needle?"
[00:03:48] Dr. Cifu: That's a great line.
[00:03:48] Dr. Drazer: And I'm just, you know, and I've heard him use this now multiple dozens of times. I mean, Phil has great jokes, but you know, he does repeat them. And I remember thinking, "Oh my God!" But this patient just starts laughing and it puts her at ease. And you know, that was the first time I saw that type of, kind of, I would say, gallows humor. And then on the alternate side or the far extreme of this, you know, as I got more into the rotations, you have people, you know, like my boss, Sonali Smith. And she would never make a joke like that but her patients adore her, just like Phil's patients adore her. And you know, you start to see these kind of barriers, you know, for how people interact with their patients and you realize at the end of the day that all of these people have a high level of competence, right?
They're world experts in what they do and within those bounds, once you get past that level of expertise, you can kind of bring your own personality to the encounter in a way that I hadn't really seen that until that first-year fellowship. And, you know, and then I ended up doing really my advanced clinical training with Dick Larson who's, you know...
[00:04:57] Dr. Cifu: A third style, right?
[00:05:00] Dr. Drazer: Yeah. A voice of God, you know, and authoritative. Clearly, you know, Dick is one of those people I'm going to tell my grandkids I was able to learn from, right? And all these different styles, the patients just adored them. And so, you know, when I first started at clinic now in 2018, you kind of realize, okay, I'm able to do this on my own now. How do I want to incorporate these different elements? Right? I'm not as funny as Phil. I'm not, I can't be as warm as Sonali is. I see her, you know, hold the hands of patients and things like that. That's just not me. I think that would come across weird.
[00:05:35] Dr. Cifu: You're not as much of a deity as Dick Larson.
[00:05:37] Dr. Drazer: And I'm not as much of a deity as Dick Larson, you know? And, but within those confines, right, you can start borrowing these elements and bringing in your own personality, and your weird sense of humor and things like that. And your patients will appreciate them their own way as long as you have that baseline level of competence, which, you know, obviously, I hope that I do. And you know, that was how I started back in 2018 and then there's this kind of feeling out process where you really start to evolve your own style.
[00:06:02] Dr. Cifu: I think it's so interesting to hear you talk about that because, you know, the way I always think about the patient-doctor relationship is that we do fine with, I don't know, 85%-90% of our patients just being, you know, the warm, empathic people who we are supposed to be as doctors. And then there's 10-15% that you have to like, play a role, you know, like pull tools out of your pocketbook to like, how are we going to work with this person? But I think you're right to bring in the complexity of that 85%. Right? Because we are all very different. We behave differently with people and sure, some people that rub the wrong way and they leave us but for most people, like we all do fine with an array of people in our lives and our patients probably adjust to us as much as we adjust to them.
[00:06:50] Dr. Drazer: Well, I think the adjustment is exactly right. I mean, I think of patients who I met and... You know, for the most part, my patients are either they carry a life-changing diagnosis, they suspect they may have a life-changing diagnosis and it's ruled out but they continue on with me for other reasons. Or you know, maybe they're a relatively brief visit, but I often think about these people when they first come to me, and I think their expectations oftentimes different from what the reality is. And then as time goes on and marches forward, you start to realize, oh, these people are kind of adopting my style. And I tend to be, you know, a little bit more of a less-is-more person. And I've had patients who... I saw a patient yesterday who said, "You know, that whole first year I was with you was all about me, basically overreacting, you know, to what I wanted to do and pushing against you to do more. And then we did that and now I realize I want do less," you know? And you know, we all kind of eventually, you know, tromping along together in some way, shape, or form but then I go to a different practice I might cover for one of my colleagues, for example, and I've seen things I would never do but the patients are getting, at the end of the day, very, very, very good care. They have great outcomes and you know, I wonder sometimes if that patient had been in my practice, would they be more along my style or, you know, would they eventually make their way to my colleagues' practice? Hypothetical. I don't know, but...
[00:08:15] Dr. Cifu: I'm already sensing... We're on the second podcast of the season and I'm already sensing a theme that, you know, a lot of medicine happens quickly. You know, you'll meet somebody. Plans get established, tests need to be done. And there are some things that you say, "Okay, look, you know, especially in primary care, I don't need to accomplish everything today." You know, a lot of this is going to unfold over a year, but to some extent, the doctor-patient relationship is one of those things that necessarily evolves.
[00:08:42] Dr. Drazer: Yeah, yeah. Yeah, that's a great point. I mean, in my assessment plan, and I tell all the students who work with me, "Don't do what I do for my assessment plan," because basically, my goal is never have to click around Epic. So all my thoughts are longitudinal. And then you've seen I think some of my notes and you know, this problem number one, when we met in, you know, August of 2019, this is what we were doing. August of 2020, this is what we were doing, and it's all right there. It's like the paper charts on steroids which I did use as a student here, but to your point, Adam, I mean, there are some problems where I say we will circle back to this, you know, over time. And for the trainees, I think that's one of the most important lessons, right? When I first started my practice, I thought, you know, for billing purposes, I have to do X, Y, Z and then I realized, "Oh no, I can do time-based billing." You know, and then...
[00:09:32] Dr. Cifu: I can make my notes the way I want.
[00:09:34] Dr. Drazer: Yeah, exactly. I'm the boss now, and I've never gotten pushed back and I passed all my audits. It's fine.
[00:09:39] Dr. Cifu: You know, one of the great things about medicine is that it keeps you humble. I always say, you know, you never really master this. Whenever you feel like, "Okay, I've got this," you know, then something terrible happens and you're like, "I don't have this yet." So thinking again about the doctor-patient relationship, are there things that still kind of always challenge you about relationships that you sort of know, "Wow, this is something I have to pay attention to."
[00:10:03] Dr. Drazer: So I'll turn this on its head a little bit. And the reason I want to do this is 'cause I think where I am in my career, you know, I've had my clinic open for seven years. I've been a, you know, full-fledged faculty member for about almost five years now. And there's this game that we all play as we're going through our careers, right? Where you look around and you see what your colleagues are up to. And the people who I've graduated fellowship with, you know, I had a prolonged training period. I was listening to Dr. Ferguson Bryan, you know, her episode and she's talking about the prolonged nature of surgical training. I thought to myself, well that actually doesn't sound all that different from what I did. You know, because, you know, I did my residency, I did my fellowship, and when I came here for medical school, I think I was like the second youngest in my class. And I'm one of the older attendings who has a clinic because you know, at the tail of my fellowship, I was fortunate to get a grant that said, you know, let's do some additional training. And I turned that into a PhD. So you know, when you and I... Actually, the last time you and I were in the same room, I was thinking about this, the last time you and I were in the same room, we were in clinic and you're finishing the proofs for ending medical reversal.
[00:11:06] Dr. Cifu: Huh. Wow.
[00:11:07] Dr. Drazer: Pretty cool.
[00:11:08] Dr. Cifu: I do remember that, actually. At Community Health.
[00:11:10] Dr. Drazer: Exactly right. And that was right after Obamacare went through. So we had no patients who were uninsured at Community Health. So I was just waiting for my one patient for the day. And you were finishing your proofs. But you know, so things change over time. And after you and I last saw each other, I would go back, I get this PhD, and then in heme/oncs for, you know, certain calibers in medical centers, you're expected to do this instructorship. And you know, I always tell people, instructorship, it's kind of like someone comes up to you and they say, "You're really good. Do you want to do the same job as your colleagues for half the pay?" And you say, "Yes, please, let me do that." But, you know, you do that for a couple years and then you open your lab after you get your funding in place. And that also coincided with the pandemic for me. So I'm going through all these hoops as my colleagues are opening their practices, you know, getting promoted. You know, we do really challenging work in my lab. So, you know, progress is slow but steady. And you look around and you start to realize, you know, should I be advocating for myself for a promotion? Or should I be, you know, looking at... There's a lot of opportunities for heme/oncs, right? You get calls all the time, should you go to industry or go private practice and have insane amounts of money? Right? And at the end of the day, what I think about for the doctor-patient relationship is, you know, why are we doing what we're doing here? And you know, all the projects in our lab, my team is... They know ad nauseam that I will say, if they come to me with a project, which they do all the time, they're fantastic, they say, "I'd really like to study X, Y, or Z." And I say, "Well, you know, let's say, this goes well. Let's take this to the ultimate conclusion. How will this impact a patient in my clinic, potentially?" You know, I've done blue sky science. I did crystallography for four years. I loved it, but emotionally, where I am in my career as a physician scientist, we need to have that direct applicability, right? And we're able to do that here. And that kind of keeps on bringing me back to, you know, the people in my clinic and what we're doing elsewhere but there's also external pressure, right? You know, maybe instead of focusing on your clinic that one day a week that I have it, you know, maybe you've come in unprepared because you're worried about your promotion packet or your grant or you know, whatever, right? The clinical trial documentation that you have to do, which I was doing right before I walked over here and, you know, that's okay. Like that stuff will take care of itself in due time but that one day a week, if you protect it, it's for me, at least, a source of kind of continued excitement and renewal and reminds me of why we're doing what we're doing, but also why what we're doing can only really be done in a place like this. You know, if I were to go into private practice, I would almost feel at a loss, right? Because I wouldn't be able to contribute to potential new advances in the field.
[00:13:48] Dr. Cifu: Right. That's a great way to think about it. And the benefit of what we both do is I think we have the time where we're focused on our patients, we're focused on the doctor-patient relationship, and then we have the time to do other things, which sort of keep us sharp for that experience.
[00:14:05] Dr. Drazer: Right.
[00:14:05] Dr. Cifu: You know, you very much as, "Boy, I'm going to go deep into the research on these problems." Me, it's thinking a lot of fru fru thoughts and writing things about it.
[00:14:15] Dr. Drazer: I read all your writing, maybe not all your writing, but...
[00:14:19] Dr. Cifu: But it is a treat. And you know, it appeals to people like us.
There are certainly people who are, you know, I can do better, you know, if I'm committing myself sort of full-time to the clinical side of things. And there are people really who can do terrifically with this sort of extra clinical activities without it, but I think maybe why we've kept in touch is because of the nice balance that we strike, but in different ways.
[00:14:45] Dr. Drazer: Well, I mean, I think about the DPR, right? One of the things I really... That really motivates me is when I'm in the clinic and I have a tough case, right? So I run a genetics practice and there are some families and patients who come to my clinic and I always tell the students, "You know that you should be thinking about a genetic evaluation when you have a patient who is newly diagnosed with leukemia."
And we all have our standard kind of spiel, what to go through, what to expect, this is what we're looking at as an approach to, you know, caring for this patient. And they say, "Oh, don't worry about this. My mom went through this, and her dad went through this." And, you know, that's it. Your mind is blown. And back when I was at Pritzker, we were kind of just taught, "Well, this is all bad luck." And you know, people from the Janet Rowley Tree of Science, you know, the natural fruit of that, you know, led to people like [unintelligible] and Lucy Godley and Jane Churpek, who were my mentors and they said to themselves, "Well, let's apply some of these novel genomics tools to really uncover what's going on in these families." And when these families come to my clinic now, I have the ability, if we can't figure out what's going on using the best tests as of 2025, we can take those samples back to my lab. And we say, okay, let's apply technology that we can use in the laboratory, but that's not really available in the clinical realm. Let's try to figure this out, right? And you can really dig deep. And there's a team of amazingly talented people behind the scenes who work with these patients and their families. They never even get to meet those people for the most part but you have that ability to really, really go in that direction. And you know, some people don't want that and that's totally fine, but for people like me, that's really fascinating. And that goes back to our high-fidelity avatars, too. You know, our avatars are our patients and our clinic in the lab that we make, it's amazing.
[00:16:34] Dr. Cifu: And it's so exciting with that history. I mean, you know, there's something there. Right? And it's just, are we going to be able to figure it out now, or is it going to be something that gets figured out in five or ten years?
[00:16:43] Dr. Drazer: That's exactly right. I tell people we're digging through a big haystack. I grew up on a farm in Indiana, and I tell them, you know, "I know what this is like. This is going to be hard." And a clinical test might take two to four weeks to come back.
[00:16:54] Dr. Cifu: Right.
[00:16:55] Dr. Drazer: I don't know what I'm looking for here. And we were working with a family that came to us back in about 2018. And we're still working with their samples, trying to figure out exactly why what happened to them happened. And that has continued to happen behind the scenes. And we just told the patients, "This might take years. This might take months. You might not hear back from me for a long time, but if you get a voicemail or a call from Chicago and it says Drazer, you know, spoiler alert, I care about you, but I'm not just calling to check in on how things are going. You know, I actually have an update for you, and I hope that you pick up the phone," because I might not see them for many years.
[00:17:31] Dr. Cifu: That's wild. That's wild. So my last question, which was sort of stimulated as you said, you know, we all sort of have our script that we use because I think we all get to the point where the phrase I used to use was, "Well, and something like that's about this," I'd sort of pop in a cassette and I give, you know, my spiel, and then we go on talking about it afterward. At this point in your career, you know, you've seen lots and lots of patients with lots and lots of problems. Are there things that you sort of most appreciate or maybe you're most proud of in sort of how you run the doctor-patient relationship? When you're with people that you say, "This is something I do really well."
[00:18:08] Dr. Drazer: I would... It's always hard to know, right? Looking at yourself from the outside, I think what people tend to say, I tend to bring a high level of energy to these encounters, right? And I think people can tell if their physician really enjoys being there. I think that's very apparent, and I've been, as we all have, in rooms with, you know, your family members or your friends, and you're kind of the third pair of ears or eyes, and it's so obvious that that physician does not want to be there. And I get it, like we all have bad days. It's a tough profession at times. And for me, I think when I walk into a room, I think people are generally able to tell that I want to be there. I enjoy what I do. I love what I do. I would do what I do for very low amounts of money. Don't tell my boss, but um...
I think that is apparent to most of my patients. By the same token, too, I think there are very easy things that you can do. I tell patients I'm not going to touch this computer if at all possible. You know, I'm not going to type out my note in front of you. I'm not going to make little notes myself.
What I do, and this is for the trainees, a little nugget is I have my little legal pad in the workroom, or I'll have the note open in in the workroom, and I'll just write four or five notes to myself. Four or five-word notes, and then I just carry on about my day, and I don't worry about finishing my note before I go home.
So like, Dr. Larson, he finishes clinic and then he writes his notes immediately that night. And I just... I've always admired that. At the end of the day, I can't do that. I have to shut down, slam that laptop shut, and go home. But you know, when you're really present in that moment with the patient, it's just like any relationship, right? You know, you don't want to feel like your doctor, especially your cancer doctor, from something like leukemia is distracted or doesn't care. And then one final thing I would say that I think people would probably say I do pretty well is at the end of the day, a lot of this is about figuring out what the patient's expectations are.
So back when I started, I kind of had this idea of the way a clinic visit should go, and then I realized very quickly that sometimes I would go through the entire visit, and at the end I would ask, as I always do, "What questions do you have?" I don't ask, "Do you have questions?" I ask, "What questions do you have?"
I keep on repeating that until we get to the end, and sometimes the questions that I would get could have been answered 20 minutes earlier. You know? So now it's very common for me to walk in and just, especially with a new patient, I'll just say before I get going on my spiel, "What questions do you want to cover today?" Because some of them we might cover during the natural flow of this visit, but other ones might be a little bit unique to your situation. And my job is, I don't want you to be driving home on the Dan Ryan and say to your spouse or your friends in the car, "I really wish he would've answered this question or that question." Right? And at the end of the day, that sets up everything else in the ensuing relationship. Particularly for leukemia, because they might have questions, they get those addressed, and then we can move on to the nitty gritty of what are we doing here? What's the goal? But also those questions that they have give you insights into who that patient is. And sometimes patients will surprise you. You know, Phil Hoffman on his episode with you, he talked about all these metrics about, you know, no chemo within 30 days of a patient passing away in the hospital. Leukemia is so hard to predict in many, many ways. And because of that, you have to really feel like you know your patient and what they would want, because sometimes you might be surprised, in the heat of the moment. And I've had patients where I thought to myself, this patient might not want aggressive care, but it turns out no, they want very, very aggressive care. More aggressive than I would typically to provide because you know, they're a young mother or they're trying to hang on, as Phil mentioned, you know, there's a family event coming around and they want to make it to the family event. And if you don't really figure that out relatively early on in your relationship, you really do a disservice to these patients.
[00:22:11] Dr. Cifu: Right. And it interferes with your communication because you're both thinking of something different, of a different endpoint. Right? I love this because it just shows how many different personalities, you know, a working doctor-patient relationship can take. And it's not only the person, but, you know, it's what we do.
You know, it's so interesting that you can sort of start visits on what questions you need to answer, because usually you're seeing people where there's a lot of information already there. Right?
[00:22:41] Dr. Drazer: Sometimes. Or by the same token, sometimes patients walk in and I have a perception in my mind, oh, they're here for a very benign, hematologic process, and they see on the schedule, I'm seeing a hematologist oncologist.
[00:22:55] Dr. Cifu: Right. Right.
[00:22:55] Dr. Drazer: And their first question is, what kind of a blood cancer do I have?
[00:22:59] Dr. Cifu: Right, right, right. Why am I even here?
[00:23:00] Dr. Drazer: Yeah. And I say, "Oh, oh, there's been a misunderstanding. You're here because X, Y, Z, we can treat this very easily. You're going to feel better and you and I will see each other once a year for perpetuity, but we're going to grow old together, but we will grow old."
[00:23:13] Dr. Cifu: Right, right, right, right, right, right. Yeah, I'm sort of contrasting it with the fact that, you know, most of my visits when a person's coming in because they're ill, you know, the questions are just, "What do I have?" You know, "When am I going to get better?" And usually, a lot of times I can't answer that at the visit, you know, it's like, "Well, let me figure this out and, you know, we'll be back together." I think that's why this is so interesting, right? Because it's different what you do. It's different who you are, it's different who you're seeing. It keeps it interesting.
[00:23:43] Dr. Drazer: And I tell my colleagues too, you know, it's pretty uncommon, thankfully, to see my patients in the hospital. You know, for the most part, and there's a lot that goes into that. And you know, one of the challenges for me is sometimes you might have an approach that you've adopted that goes against what the textbooks would say. And a classic example of this would be one of the drugs that was partly developed here at U of C, Venetoclax. We participated in the initial clinical trial. And Venetoclax, a fantastic medication, has changed the treatment for many of our patients. The dosing on that clinical trial was you give this continuously around the clock for 28 days, and you never really get a break. And when we ran the clinical trial here, it was so obvious that 14 days, maybe even a week, was more than enough. But then what happens is, it gets FDA approved as it should have, and it's FDA approved for the full month. And you start taking this approach where, especially if you have older patients in your clinic, like I have many older patients in my clinic who get this drug, I'll say to them, "When you look this up, you know, online and your family looks this up online, they're going to think I'm undertreating you." And I remember when I first started doing some of these kind of tweaks to my treatment approach, even some of my own colleagues who are world-class would say, you know, "What are you doing here?" And I said, "This is based on what we've seen." Right? I think everything we know about this drug in terms of the PharmaConnects and the pharmacodynamics, and what we see with our own eyes, I think a week or two weeks is more than sufficient for these patients.
And you're able to keep them out of the hospital because you're avoiding some of these side effects. By the same token, you know, sometimes my patients do come into the hospital and people say, "Oh, you know, this is unanticipated, or..." And then I say, "No, this is actually anticipated. This person really wants aggressive care. Normally, I would've made them hospice... You know, I would have, you know, sent them to the hospice team months ago, but based on this relationship that we have, I know you think that maybe I haven't had this conversation with them but we have talked about this. And this is... They want full bore. In this situation, they, for reasons that might not be clear to you right now, you know, they are okay with dying in this hospital if they have a chance to turn this around.
[00:25:48] Dr. Cifu: Yeah. Yeah. Yeah.
[00:25:48] Dr. Drazer: And you know, it's just a unique part of what we do in leukemia, I think, in particular.
[00:25:54] Dr. Cifu: Michael, thank you so much for joining me. This is great because to start this season with, you know, a conversation last week with someone doing sort of long-term relationships with a lot of healthy people or healthier people, and then talking to you with relationships, which, you know, involve entire families and their genetics, is an amazing contrast. I want to really thank you for sitting down with me.
[00:26:17] Dr. Drazer: Yeah, well, I was an English major and Hemingway always said, you know, "All great literature about love and death," and Tolstoy said, "All happy families are happy in the same way, every unhappy family is unhappy in its own way." That's what we do in leukemia.
[00:26:32] Dr. Cifu: So 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.