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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, I'm joined by Sarah Stein, talking about the evolving doctor-patient relationship.
[00:00:12] Dr. Stein: I really shy away from making problems where they aren't. And if an individual is not perceiving that their teenage acne is a problem for them, then to bring it out and start talking about it and acting like it is a problem can be a big problem.
[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'm Adam Cifu, and I'm joined today by Dr. Sarah Stein. Dr. Stein is a pediatric dermatologist here at the University of Chicago.
She's a professor of medicine and pediatrics, a master in the Academy of Distinguished Medical Educators, and a senior faculty scholar in the Bucksbaum-Siegler Institute for Clinical Excellence. Sarah, thanks so much for joining me today.
[00:01:17] Dr. Stein: Thanks for having me.
[00:01:19] Dr. Cifu: So we're going all in on the doctor-patient relationship this season.
I was really interested in talking to you because your interaction with patients is so different from my own. While I'm usually in the room alone with an adult patient, you're usually in the room with a patient who's a child or an adolescent, the patient's parent, sometimes more than one caregiver, and often a trainee of some sort, a resident, or a student.
So I imagine our kind of clinical lives are actually quite different.
[00:01:49] Dr. Stein: Yes, definitely. Sometimes there's a grandparent, siblings, sometimes the two parents are separated or divorced, came together.
[00:02:00] Dr. Cifu: And probably also siblings climbing the walls at times.
[00:02:04] Dr. Stein: Absolutely.
[00:02:05] Dr. Cifu: So, in general, how has your relationship with patients sort of changed over the years?
I'm interested in, you know, how you relate to new patients, returning patients, or maybe you know, it's patients themselves and their parents, at the same time. What do you think?
[00:02:24] Dr. Stein: Yeah, I've been thinking about this, and I think that one thing that I've become more and more attentive to or tuned into is the challenge of dealing with adolescents and maybe preteens and their parents at the same time when we're discussing a skin condition. You know, generally we're not discussing life-threatening issues, but these are conditions that are really tightly tied to people's self-image and self-confidence, and so that I feel is very delicate, especially for these young people who are still developing their self-confidence and their self-image.
You know, when I walk in, I usually try to start the conversation, start the visit by, you know, really addressing directly the young person, the preteen, or the teen when it's appropriate. And I ask them, you know, "Why are you coming in to see me today?" But sadly, at least half of the time, maybe more, I feel like the individual then looks toward their parent or their caregiver, and that person then begins to speak for the teen or the preteen. And so then immediately the conversation is sort of thrown into the third person. And now, we have a parent describing what they see as the issues. And that might not be the same as what the patient themselves is thinking about.
And they might now actually be hearing their parents' assessment of something for the first time. You know, assessing, you know, what their acne looks like or how their hair is behaving. And that might be really jarring or antagonizing or upsetting for the child themself. And now, you know, I'm sort of stuck in the middle of that. And I don't want to feed into that, but I want to be very sensitive to that. And again, try to bring the patient themselves into the conversation. And it gets as sticky as, you know, exactly what are you doing for your skincare? The parent may think it's one thing, where it could be a completely different thing, and then often the child won't want to admit maybe what they're doing, so it's all very hazy.
I mean, I think the obvious answer to this is, well, you should separate the patient from their parent, but I don't find that to be very practical in a dermatology practice. Everything is very fast. We only have a few minutes per patient, and to separate them is... Really requires much more time because then you have to bring them back together, and you still have to talk to the parent. So really, it doesn't necessarily solve this.
[00:05:21] Dr. Cifu: It seems like a clinical excellence randomized controlled trial, just dying to be dying. Right? The dynamic you talked about, I found interesting because, you know, they're coming to see you. So somebody's made the decision, right? That something warrants care. And I'm interested, like how often does it seem like the teen or preteen is driving the need for the visit? How often is the parent? How often is there conflict? Do you get that sense?
[00:05:55] Dr. Stein: Absolutely. And I think it's highly variable. So there's a large percentage of times when it's clear that the parent scheduled this appointment, decided in their mind that this needed to be addressed and almost didn't even talk about it with the kid. You know, and I definitely get that sense when the kid looks at the parent like, "I don't know why I am here." And that's so tricky because I really shy away from making problems where they aren't. And if an individual is not perceiving that their teenage acne is a problem for them, then to bring it out and start talking about, and acting like it is a problem, can be a big problem. On the other hand, of course, there's going to be those individuals who are bothered by something but have never felt empowered enough to bring it up. And so, you know, clearly want to give those individuals an opportunity to voice their concerns, but it is very different when the teen themselves is the one who was driving the visit, because they're usually then much more immediately ready to talk to me and to be open about what it is that they perceive to be a problem and how they want to address it.
[00:07:16] Dr. Cifu: The more you think about it, the more complicated it is, right? Because these kids are at the period where they're developing their whole sort of self-image. Right? And they're also at a time where, you know, I feel like people talk about agency too much these days, but there are some kids who are very much able to speak for themselves and have real agency and are able to sort of argue for their own interests, you know, at 12. And there are other people who, you know, it's 25 before they can do that. And so some people need the parents to speak for them. Other times, probably the parents speaking for them is only making things worse.
[00:07:55] Dr. Stein: Right. Absolutely. Absolutely. And of course there's... It goes both ways, too, with the teen perceiving problems where there aren't any, and the parent being an ally in those cases to try to convince the individual that what they're experiencing is normal, but that is, I feel like, definitely the minority of the time.
[00:08:18] Dr. Cifu: So I always think one of the great things about medicine is that it always keeps you humble, right? You never really master it. Whenever you feel like, "I'm doing great at this," and something always goes wrong. When you think about the doctor-patient relationship specifically, what is it that still tends to challenge you? What are the things that like, "Ah, this happened again"! You know?
[00:08:40] Dr. Stein: Yes. I think that the interaction with families is the most challenging part of our job, and no matter how many years I've been doing it, I still have some really bad days, and I fail to connect satisfactorily, and then it's eating at me for a really long time. You know, a most immediate example I can give is when a family comes for evaluation of a rash that is no longer present. It was, you know, there when they made the appointment, and now it's gone, but they want an explanation and a specific answer. And often they don't have any pictures, and the descriptions that I'm able to elicit are still baffling. And I feel like I'm being asked to make something up just to tell them so that they go away with some feeling of satisfaction. And I'm, of course, not going to do that. And they're not satisfied with a non-specific generalization or reassurances that when something goes away, that's a good thing. So I have to lean on, you know, that promise that if it comes back, we'll get them in urgently, but often that's, you know, very unsatisfactory.
So that I find to continually be a major challenge in my line of work. Also, there's so many derm conditions that we have a name for, but we don't have a good explanation for them. We don't have a good treatment for them, and they're going to be a chronic problem for people. And that's a really hard thing to discuss.
And then, especially if you have to do that through a translator, or in a situation of very poor medical understanding, that's really, really challenging.
[00:10:25] Dr. Cifu: Do you think that, because I certainly experienced that in my line of work as well, where people sort of come, you know, after whatever the problem was has been solved. And I wonder if that comes from, boy, it's just hard to get in to see us, and so like, ugh, it seems like such a waste to cancel this appointment. Or does it get back to kind of the overmedicalization of society that we've been somewhat responsible for, that people feel like everything is sort of an issue and everything... You know, we can do something about everything or name everything, even though the reality is, you know, in primary care and derm and ortho so much just gets better on its own, and you know, you don't need a doctor for those things.
[00:11:12] Dr. Stein: Yeah, I agree. I think a little bit of both, and I think sometimes it's because they saw another practitioner for the problem in the acute setting, and then they were told, go and see a specialist for this. And so then, when they get to the specialist and there's no answer, it's even more aggravating and frustrating to them. But yeah, it's...
[00:11:42] Dr. Cifu: So the last thing, you know, at this point in your career, you're kind of a pro, right? I'm not going to date you, but you've been doing this for a long time. What do you think you sort of appreciate about your role in the doctor-patient relationship most, or kind of what do you take pride in?
You're like, "Oh, you know, this is something I'm good at. And when I'm with trainees, I recognize, you know, how much better at this I am than someone who's just starting out."
[00:12:09] Dr. Stein: Well, I think part of it is, you know, a comfort of really feeling like you've seen a ton of stuff and majority of what comes in, you do have an answer for, and you know what it is, and you know how you want to manage it.
And so that's, I definitely sometimes walk away feeling like, "Wow, you know, I saw all these things today. I knew exactly what they were, I knew exactly what to do, and I don't have any second-guessing about it." But the other part I think, which is really fun is with the population I see getting to see the kids grow up.
So these kids who came as babies and toddlers and maybe had really difficult-to-manage atopic dermatitis, and now they come in as a pre-teen or teenager, and that's gone away or it's gotten a lot better. They know how to manage it now, and now they have, you know, acne or something else.
[00:12:58] Dr. Cifu: Got another problem.
[00:12:59] Dr. Stein: But that's really fun to have these snapshots in time of people and how they've evolved into real personalities and individuals. And it's not just the patients, it's often the parents too, because when they come with the little babies, they're often very young parents, and they're anxious, and have, you know, concerns. And then, 10 or 15 years later, they're coming in, they're an experienced parent now. They're older, they're more mature themselves. And so that's also fun to see that whole evolution.
[00:13:32] Dr. Cifu: Right. And the relationship with the kid has changed, too. Right? It's kid changes, parent changes, relationship has changed. You have to sort of be on top of all those things as they mature.
[00:13:42] Dr. Stein: Yes. Yeah. And in dermatology, we've been really lucky that we've had an amazing evolution of treatments. And so some things that I couldn't offer a lot of treatment for 10 years ago, now, I can. And I'm thinking about one patient who has had alopecia areata since she was, you know, two or three years old, and she really hardly ever had any hair. And they would come in every six months to a year, and we would talk about it. You know, very reasonable thinking in terms of, you know, we don't want to overmedicate, but we'd want to know what we can do for this. And now we have medication, and she's on an oral medication, and her hair is growing. And she's, you know, 12 or 13 years old. And so that's been incredibly rewarding kind of relationship.
[00:14:33] Dr. Cifu: I've been struck... You know, I'm sort of using more or less the same three questions with all our guests this year, and I've been struck when I've asked people about, like, what they sort of appreciate about their role in the doctor-patient relationship as they've gone on their career. And like you, so many people mention the kind of confidence that comes, you know, once you've been doing this for a long time and you feel like you're just better at the job, that the confidence you feel that's apparent to patients actually makes a real impact on the relationship you have with people. I feel like, maybe it's good to not know that early in your career, but it's just striking how important that seems to be for people.
[00:15:17] Dr. Stein: Yeah. It's very uncomfortable to feel like someone's doubting you.
[00:15:22] Dr. Cifu: Yes, yes.
[00:15:23] Dr. Stein: And so I still have some of those interactions. And those are the ones where you walk away the most unhappy about how things went.
So, having done this for a long time and really having the absolute experience to be able to say, "Look, I've been doing this for 25 years. I have treated this condition repeatedly, and this is what works. You know, this is how we manage it. This is how long it takes to get better, whatnot." That just, for some people, does make the relationship go better. Not everyone responds well to that.
[00:16:00] Dr. Cifu: Right. It's interesting, there are sort of two... Like, I can think of two bad visits, right? There are the visits where you are not confident and the person's not trusting you because you're not confident, and then there are the situations where you're like, "I know what's going on here," and the person's still not confident in you, which is, you know, almost troublesome in a whole other way. And it's sort of thinking about like, boy, how can you do each of those things better? Right? The first way is probably just being honest that like, "Hey, we don't know anything and we're going to work together on this." The second thing is probably more difficult because there's probably such complexity in that, where is this mistrust coming from? What are the gains this person's looking for, you know, a different answer. And that may take, you know, more than a 10-minute derm visit, a 20-minute internal medicine visit. It may be, you know, six weeks of interactions.
[00:17:01] Dr. Stein: Yeah.
[00:17:02] Dr. Cifu: A depressing way to go out.
Sarah, thank you so much for joining me today. This was terrific. Really got to the questions that I was interested in asking someone with a different sort of clinical life than me.
[00:17:14] Dr. Stein: Well, thank you. It's always fun to talk with you and think through these sorts of issues that we deal with on a regular basis.
[00:17:21] Dr. Cifu: Before we finish up today, a quick addition about this year's National Clinical Excellence Award. As you know, the Bucksbaum-Siegler Institute for Clinical Excellence at the University of Chicago is dedicated to fostering compassionate doctor-patient relationships and advancing clinical care. Each year, the Institute recognizes extraordinary healthcare professionals through the National Clinical Excellence Award. To learn more about the award and nominate a deserving clinician, please visit the Bucksbaum Institute webpage. That's bucksbauminstitute.uchicago.edu.
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. That's bucksbauminstitute.uchicago.edu.
The music for The Clinical Excellence Podcast is courtesy of Dr. Maylyn Martinez.