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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 Dr. Anna Volerman talking about measuring clinical excellence and the impact of the Bucksbaum Institute for Clinical Excellence.
[00:00:15] Dr. Volerman: I've had patients break up with me, I mean, frankly. And at first, when I first started, I was like, gosh, this is a horrible feeling.
It sometimes feels worse than breaking up after dating because you feel like there's something wrong with your skills, the skills that you use every day.
[00:00:40] Dr. Cifu: We're back with another episode of The Clinical Excellence Podcast, sponsored by the Bucksbaum Institute for Clinical Excellence. On this podcast, we speak to patients and doctors about all aspects of excellence in clinical medicine. I'm Adam Cifu, and today I'm joined by Dr. Anna Volerman.
Dr. Volerman is a primary care physician for both children and adults and an associate professor of medicine and pediatrics. Anna completed her internal medicine and pediatrics residencies at the Brigham and Women's Hospital and Boston Children's Hospital. She is committed to reducing health disparities through innovation in healthcare delivery, in the health system and community settings.
Her scholarly interests focus on improving systems and reducing the factors that drive inequities for patients and the workforce. Dr. Volerman is a senior faculty scholar in the Bucksbaum Institute for Clinical Excellence and as of July 2024 is our Director of Research and Assessment. Anna, thanks so much for joining me.
[00:01:41] Dr. Volerman: It's great to be here, Adam. Thank you.
[00:01:43] Dr. Cifu: I have what I think are some like, particularly impossible questions, I was very proud when I came up with them, for you today, but first, I just wondered if you could tell us a little bit about your research and kind of common threads maybe that you see through your research, like what makes it all yours?
[00:01:59] Dr. Volerman: You know, much of my research has really focused on understanding how do we deliver care or how do we care for people and people and their health, both in the clinical setting, where much of my training and your training has been, but also stepping outside of that clinical setting and thinking about where do people live every day, right?
People spend so little of their time actually in the four walls of the clinics and the hospitals. And it's so important to think about where they are every day and how we can help them be healthy and reach their goals as it relates to their health on a daily basis.
[00:02:39] Dr. Cifu: I think that's neat because when we think about sort of inequalities and outcomes, certainly, some of that is related to bias in the care we deliver but maybe I'm being overly optimistic. You know, I think we do a pretty good job sort of sitting with individuals, but I'm always sometimes overwhelmed. And I sometimes get depressed and sort of pessimistic because it seems like, oh my God, you know, there's so much else affecting my patients, which is leading to these unequal outcomes, and sometimes it feels hopeless.
And as I've sort of followed your career, I've sort of been impressed because you seem to be like, I can't do enough in the office and so I'm going to reach out to where maybe more of the problems are.
[00:03:30] Dr. Volerman: Yeah. You know, I think there's problems everywhere. I think there's... which is maybe my pessimistic view or my equivalent pessimistic feed to yours but I think people sit with us for a minute... I'm sorry, people sit with us for 20 minutes, right? Or at least that's, you know, what we get with them in our health system. And so, you know, people go about every day making choices as it relates to their health. And so it's important that we be really meeting them where they're at every day, rather than expecting people to come to us and help them magically realize you know, their health.
I think it's challenging because the reality is when we sit with people, you're right, there's so many things we can't impact, right? We can't change the red-lining policies that existed decades ago that still perpetuate today. We can't, you know, we can't necessarily put up new playgrounds or new sidewalks or new grocery stores but we do have the power to show those differences. Show the differences that exist in our communities, show the differences in access to care, show the difference in outcomes. And then think about not just, you know, how do we fix people, but really how do we fix the system that has created the outcomes we currently have, and created, you know, what we currently see.
[00:04:52] Dr. Cifu: So maybe it's fair to say that kind of the data that you try to pull together is almost the evidence to say that, look, if people are going to concentrate on, you know, making this a more equitable society, at least in terms of health care, right? These are the things which will have the biggest impact to make those changes.
[00:05:14] Dr. Volerman: Mm-hmm. I think so. And I think it's important to realize it's not one thing that will fix it, right? But the reality is, you know, I think people used to think we could magically educate clinicians and then our patients would know everything and would be able to reach the outcomes we wanted. And then we realized, hey, we can educate them, but they also need the order sets available. They also need the handouts available. We also need to pass that knowledge on to our patients and make sure that they understand it, right? And so what I really try to do is both understand what are the main places we can affect outcomes and how do those differ across different groups of individuals, but then also start to piece together, okay, if we do this, what is the effect that has? Okay, what if we do this and this together?
What is it if we pass or we advocate for a new law at the state level, what will that effect be and how will that differ based on, you know, where someone lives, what their race is? You know, how much money their family brings home, what their education level is, et cetera.
[00:06:22] Dr. Cifu: How do you decide what you sort of go after next? Is it kind of clinical experiences that bring things up? Is it just, oh, I'm studying one thing and as I do research on that, it opens up other fields and other interests that you decide to look into? How does that happen?
[00:06:40] Dr. Volerman: It's a really great question. You know, most of the work that I do is really in response to what I hear from people who live on the south side of Chicago and throughout Chicago.
So really try to form relationships with the people in our communities, with the organizations that are working every day with the people in our communities and understand where do the needs lie. And then help them think about it in a way that I can bring my lens as a researcher and as an educator and as a clinician.
So really most of the work is, you know, partnered with our community and in response to the specific things that are coming up as high-priority areas.
[00:07:24] Dr. Cifu: That's neat. So it probably keeps it tied to actual needs, since you're hearing it from the actual people who have that need, right? Rather than kind of making it up inside the ivory tower.
[00:07:37] Dr. Volerman: Yeah, you know, I think there's a lot that has been said about, you know, people deliver things on a silver platter and bring it out in the community and then the community doesn't choose to participate because it's not really based on what they need and what is going to help them with the issues that they are facing every day, the choices that they're needing to make.
And so, you know, I try to ensure that whatever we're looking at is informed by what has been done in the past, you know. Whether it's in Chicago, whether it's other cities, whether it's somewhere across the globe, where under-resourced, you know, countries can be similar to the under-resourced settings that we live in our urban city.
And I do use my clinical hat to inform, you know, how we might approach the specific issues that are coming up.
[00:08:25] Dr. Cifu: Okay. So that's kind of the research side of you. You know, if we can say that's the research side of you in, you know, five minutes. Now, kind of the clinical excellence side. You know, at this point in your career, you're kind of an old pro on the clinical side of things, right?
You've had experience with inpatient, with outpatient, with kids, with adults. What does kind of clinical excellence, I don't know, mean to you, look like to you? You know, when you feel like you do a good job or when you're working with trainees and you see them do a good job, what do you think of when you think about excellent clinical care?
[00:09:00] Dr. Volerman: It's a really interesting question. And one that's definitely I think, changed throughout my path as a physician. You know, what I would have defined as excellent clinical care as a medical student or a resident, you know, there's definitely some threads that continue today, but I think what I would say today is hopefully more nuanced and, you know, informed kind of by the experiences that I've had. I really think, you know, clinical excellence is delivering the best possible care in a way that really meets people where they're at. You know, I think we know a lot in the medical field about what works and what doesn't work. We have a lot of guidelines. We have a lot... We have evidence. We're developing evidence faster than most of us can keep up with as clinicians. And I think our job as doctors is to put those guidelines into practice, right? But if the person you're working with isn't interested or doesn't want something or doesn't understand what's happening, they may or may not, you know, be interested in what the guidelines are. Right? And so I think it's getting to know people. It's knowing them, their goals, their journey, the people that are supporting them on a day-to-day basis. And then, you know, really helping them work towards health. That's health in their body. And what health looks like to them is different than what it may be to me or even be to their spouse, or their sibling, or their child, or the person in the next room over.
[00:10:36] Dr. Cifu: Right. I like hearing you say that because I'm a little older than you, not that much older than you. I feel like, you know, we both trained in an era where collaborative care, you know, collegial care with patients was really highlighted.
And so, although I feel like I would have said a lot of those things, right? Coming out of training, I think I feel the same way as you that actually sort of what that looks like has changed for me, right? I understand so much more what those interactions with patients have to be to actually make that a reality.
And I think about that a lot, you know, when we're with trainees and like, yeah, they can probably articulate it back to us, but how do we show it to them in a way that maybe is a little bit more mimicable?
[00:11:30] Dr. Volerman: You know, I think the interesting piece is also when we are working with trainees, we're often watching them, and there's so few opportunities for them to watch us. Or even as I go along in my career, I think about, you know, I've been in the room with my medical assistant and my nurse. I rarely spend time in the room with my colleagues. And so it's something that's, you know, continued to change and something that's continued to grow for me, but I think there's a lot of learning that happens even among ourselves or among the groups that we're in.
[00:12:05] Dr. Cifu: I'm going to read you a quote, which I was going to save for later, but that was such a good like entree into it. And I think maybe as I get to my third question and sort of the third point. I have a talk that I've given about kind of assessing physicians and I recently was in a conversation with, let's say, leadership, and someone asked, you know, like, how do we train master clinicians?
And I walked out of the room being like, I don't know, like, do we even know what a master clinician was? And as I did some reading, I found this amazing article by Lawrence Weed back in 1981 from The New England Journal, and he said, thinking about kind of, I don't know, physician excellence or judging physicians, this is a quote. "To say that physicians are good or bad would be to imply that there are well-accepted standards of performance and random audits to judge them by. But there are none. Their nearly total freedom to determine the context of their professional activities and their own standards within this context, especially in the private office where much of medicine is practiced, precludes any rational conviction about the effects of their effort." And I sort of feel that, like, we do things, we have a sense of our colleagues, we have a sense of our trainees, but it's really amazing how independent our own practice is to such a great extent.
[00:13:29] Dr. Volerman: Mm-hmm. It is. And you know, I'm thinking through this quote you just gave because I really want there to be a way to measure it, you know. And I want to be able to say, these are the five components of, you know, clinical excellence. These are the five things that we should all aspire to.
And the reality is, there are some metrics. You know, if you asked our hospital administrators, they'd list off the quality metrics or the readmission rates or... You know, and sometimes those metrics are actually frankly wrong, I would say. You know, how much time you spend with a patient is probably not a metric of clinical excellence, you know, because there's so many different factors that go into it.
But I think there's also this immeasurable gut feeling of clinical excellence. And to some degree, it's what is the patient's definition of excellence? What do they need? And how does that match with the clinician that they're with?
[00:14:37] Dr. Cifu: Right.
[00:14:38] Dr. Volerman: Right? And so...
[00:14:40] Dr. Cifu: And the difficulty is that, you know, the physician who they're with, is somewhat by choice, right?
And I think we all, at least those of us who, you know, have done this for a while, accept that like, yeah, we can do a good job with most people, but not everyone. Right? And there are some people who I know I'm just the wrong doctor for.
[00:15:03] Dr. Volerman: I've had patients break up with me. I mean, frankly. And at first, when I first started, I was like, gosh, this is a horrible feeling. It sometimes feels worse than breaking up after dating because you feel like there's something wrong with your skills, the skills that you use every day. And then I realized, you know, every doctor-patient relationship isn't going to be a perfect fit and I'm not going to be the perfect, you know, doctor to take care of every patient.
And I think realizing that is just as important as realizing this is the perfect relationship. And this is... You know, and continuing that and building on that perfect relationship.
[00:15:41] Dr. Cifu: So one of your roles at Bucksbaum is going to be to sort of help with assessment. And so we talked a little bit about, you know, is it possible to assess clinical excellence in the individual?
And then what we've been dedicated to since before either of our time, you know, at Bucksbaum, is designing programs to encourage clinical excellence, to teach clinical excellence. And I wonder, you know, early on your sort of thoughts about how do we do that? How do we know that we've spent our money well?
[00:16:15] Dr. Volerman: Yeah. You know, I think a big piece to start is measurement because if we can't measure it, we can't improve it, right? We don't know where we're at, where the baseline is, where we're beginning to get to the next step. And so I think, you know, early on, my goal is really to take some time to measure, not always just the numbers, sometimes in words, to understand what are the programs? Who have they reached? How have they impacted those individuals? How have they impacted the second and the third-degree individuals, right? Which are usually our patients. And then try to understand, you know, where are the opportunities to improve? Where are the opportunities for growth or for innovation? And go from there. You know, but I really kind of fundamentally believe that you can measure any program and you should measure any program because I think that's the only way that we're going to make them better.
[00:17:15] Dr. Cifu: Right, right. And there probably a lot of neat stories out there, right? That people have about things that truly didn't exist or wouldn't exist without these programs, you know, which have probably affected the way they practice. For me, it's you know, I think both about coaching programs, and interestingly, I think it's maybe something internal about, you know, the recognition and the involvement with this group that maybe changes my approach a little bit to patients. And maybe changes how patients see me, which are really hard to articulate, probably even harder to measure but probably something that can be talked about.
[00:18:00] Dr. Volerman: Yeah, I think a lot of the... I'm confident that a fair amount of the impact that we'll see will be through ways that none of us will be able to predict because I think being selected to be as part of something like the Bucksbaum Institute, right? Brings along an understanding of, you know, hey, people recognize me as being clinically excellent, and I carry myself that way on a regular basis, right?
And so I think it empowers people. And that empowerment, I think, can encourage our clinicians, our researchers, our educators, you know, to then have kind of ripple effects on other people. And I think those are the types of things that we're going to capture. You know, sure, will people be satisfied? You know, will we look at satisfaction? Yes. Will we look at the effects that it's had on their development as clinicians or as professionals. Yes. But I think there's also this effect on wellness, on decreasing burnout, on reaching for something you may not have, you know, thought about otherwise. And, you know, even thinking about how do you deliver care, you know, to your patients on a regular basis.
[00:19:27] Dr. Cifu: When you talk about the recognition, I think about, I'm sure you had these experiences, that you know, that some of the teachers who motivated me the most, boy, going back to elementary school, right? Are the people who kind of compliment you or are invested in you, but then you feel like, "Oh my God, this person thinks something of me. I have to sort of keep up with their expectations," rather than the people who like yell at you and don't think anything of you when you're just like, "Yeah, it's a lost cause. You know, I'm just going to play around in this class for the rest of the semester."
[00:19:59] Dr. Volerman: Those people that champion you, right? Those people that, you know, are like, "Oh, I believe in me. I think. You believe in me. That's going to make me believe in me and the things that I can do. And the person that I can be and strive to be."
[00:20:14] Dr. Cifu: Yeah. That's good. Well, Anna, thank you so much, I guess, for being here with me today, but then also thank you in advance for the work that you're already clearly thinking about doing. I think it's going to be very exciting.
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.
The music for The Clinical Excellence Podcast is courtesy of Dr. Maylyn Martinez.
[00:20:46] Dr. Volerman: Thank you, Adam.