Caring for Colleagues

What needs to be considered when caring for people with whom you work.

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. David Rubin talking about being a doctor caring for doctors.

[00:00:11] Dr. Rubin: One of the most profound doctor-patient interactions that I witnessed was sitting at the bedside of my grandmother who was very ill, and the pulmonologist came into the room. He was so compassionate to her. He knew that I was a young physician but he took care of her and told me, "Don't worry, I've got this."

[00:00:35] 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 Dr. David Rubin. Dr. Rubin is the Joseph B. Kirsner Professor of Medicine and the Chief of the Section of Gastroenterology, Hepatology, and Nutrition at the University of Chicago.

He is regarded as an international expert in diagnosis, management, and understanding of inflammatory bowel diseases. Fun fact, when I Googled David to prepare for this introduction, Google suggested the question, who is the best IBD doctor in the world? And then answered it with David.

[00:01:14] Dr. Rubin: Wow.

[00:01:15] Dr. Cifu: Dr. Rubin performs clinical and translational research related to outcomes in inflammatory bowel diseases, with particular interest in the areas of biosensor monitoring in IBD, prevention of progressive complications from uncontrolled inflammation, and a variety of collaborative studies related to the microbiome and cause of IBD and its complications.

David has been the recipient of dozens of rewards, recognitions, and accolades during his career and most importantly of course, he is a senior faculty scholar in the Bucksbaum Institute for Clinical Excellence. David, thanks so much for taking the time to talk to me today.

[00:01:50] Dr. Rubin: I'm really happy to be here, Adam, thanks for inviting me to have this conversation.

[00:01:54] Dr. Cifu: So, despite all of your, you know, diverse work and accomplishments in your career, I want to focus on one like very narrow aspect of just your clinical work. So I'm sorry to waste some of your expertise here but as an established physician at, you know, kind of a major medical center, I know you take care of a lot of doctors, a lot of colleagues, and I want to ask you, you know when you think about caring for a colleague, and maybe we'll just talk about, I don't know, doctors, nurses, you know, other health care professionals, what are the sort of positive things you anticipate in the relationship, and what challenges do you prepare for going into it?

[00:02:32] Dr. Rubin: Well, this is a topic that I have great interest in, because in my experience, it's... My perception of this has changed over time. When I was a younger colleague and expert, when a physician or a family member of a physician came to see me for my expertise, I was a bit anxious about it, it was especially important that I didn't make an error. Not that it's ever okay to make mistakes, but you recognize that on the receiving end of the advice and the management is going to be someone who knows more perhaps than the average patient and that certainly colored some of my approach to those individuals. However, I'll tell you that as I've become more senior and experienced as a physician and as an expert, I have reflected on it and realized that the type of care I provide people who are in the medical field or scientists or family members of those who are in the field should not differ in any way from the people I see otherwise.

And in fact, that's a really important guiding principle, I think, to taking care of our colleagues, not just because everyone deserves the same level of care, whether they're a physician or scientist in general, but also because it enables you to think clearly about what's the right approach to taking care of this person in front of me with this particular problem.

[00:04:07] Dr. Cifu: It's a great point and unfortunately, you've, you know, you've undermined my third question that I had prepared for you about sort of the change in this over your career. That is something I've thought a lot about, right? We go into this sort of knowing, okay, listen, we don't take care of family members because it's going to sort of cloud our decision-making, right? But it is true, it happens with a lot of the people we take care of. Is there a way that you, I don't know, sort of check yourself when you're thinking, "Huh, you know, I'm tempted to do more of an evaluation here than I normally would because this is, you know, doctor X or patient X or, you know, very important person Y?" How do you, you know, how do you work through that in practice?

[00:04:52] Dr. Rubin: It's a really important question, and I have to be completely honest to say that I need to check myself with everyone I'm taking care of. I'm not trying to be evasive in my answer here.

[00:05:05] Dr. Cifu: Yeah.

[00:05:05] Dr. Rubin: I would say that I think that we're... In my specific area of expertise, which is in Crohn's disease and ulcerative colitis, there's been so many changes and advances in the field that with every patient we see, we have to be thinking carefully about what's the right approach for this individual. And frankly, the field has become so complicated that even a person who's a gastroenterologist who suffers from one of these problems may not be up to date on some of what we're trying to do. So I think thinking about this is important and treating people the same is important, but actually, from just a systematic way of handling this, I've made it clear to my team, the people who work with me, my nurses, my nurse practitioner, my pharmacist that when we're taking care of someone who is in our own hospital system or medical system or at the university here, or another colleague physician from somewhere else, that they should be going through the same channels as everybody else. That I don't want aside or peripheral conversation that's happening by texts and emails that loses track of where we are with somebody's management. That doesn't mean that we're not available. I do give out my cell phone number to my colleagues. I give it out to other patients all the time as well, as my patients will attest but I also want to make sure that we stay within the confines of the protected medical record, not just for their privacy and confidentiality, but also really because then we don't forget that, "Oh, we didn't check the labs on this person or we had... It's been a while since they had their colonoscopy that they were due for," and that's because I've been managing them on the side by email and when I see him in the hallway for the last year, so that's a really important lesson. And I think that, to be honest, the patients on the receiving end, physicians and colleagues appreciate it and actually respect that when you tell them that this is a better way to handle it. Most of our colleagues actually, I think, are somewhat relieved when they realize they're going to be managed in that regard, and we're not going to be doing a one-off.

The flip side of it sometimes comes up, which is where our colleagues are trying to manage themselves, come to me and say, "Well, I prescribed steroids," or "I had my partner dermatologist give me another course of X, Y, or Z, and he took care of it, so I didn't have to bother you." And that's where you get into some trouble. And you know the old adage, the physician who takes care of himself is a fool for a patient.

[00:07:34] Dr. Cifu: I think all of us have had the experience when you try to do something different for someone because you think it's going to be helpful or you think it's, you know, "Oh, you know, this person is someone I know so I can do this a little bit differently," that's when mistakes get made, right? Because it throws you off, sort of, your routine. And I think your point is terrific to think about is that these days when we work as so much of a team that if we're doing something sort of special, it often undermines that team care that works so well for our patients.

[00:08:07] Dr. Rubin: I'll just add that I'm privileged to also take care of some of my team members who are patients of mine. So if I'm managing a colleague physician or a medical student, for example, differently than I'm taking care of my own team members, that also has its own implications. Now, I want to distinguish how I take care of people's medical problems from the separate issue, which is that we share, um, a kindred in our training and our experiences becoming physicians and living a life of taking care of others or trying to pursue scientific answers, because I certainly have that connection to my colleagues, and I consider it an incredible privilege to offer them medical advice or to take care of them.

That is no different, I do feel that connection. We do connect on a different level. I may share a PowerPoint presentation that I've made or a talk I've given with one of my interested patient colleagues but when it comes to the actual management of their problem, that's where I try to set boundaries. And that's not something I knew from the beginning in my career. And so I think this conversation on a podcast is important because frankly, I never heard someone discuss this. And I think that it's important for people at different levels of their own careers to recognize how to manage some of this.

[00:09:27] Dr. Cifu: I think that's an interesting point, to be honest about the fact that all of us interact with different people in different ways, right? That's true outside of medicine, that's true everywhere. And when you sit down in your office with people, you have kind of different levels of human connection, right? The communication is different. And I think it's critical to recognize that because in order to sort of give that equal care that you're talking about, you actually have to acknowledge that, like, "I'm going to interact with a physician in a different way than I'm going to act with someone, you know, from a job or career that I know nothing about from a very different background to me.

[00:10:09] Dr. Rubin: Yeah, I think that's right. And I think it's even worth saying that to the individual too, sometimes. And saying to them, "Listen, I want you to know that this is how I would approach your problem, regardless of who you are. I want you to know that upfront." Sometimes though, they come back and say, "Well, I just read the latest issue of New England Journal of Medicine and there's this new trial that's out and what do you think of this?" I value those conversations, but frankly, I have the same conversation with a patient who comes to me and says, "I Googled this problem, and here's what I came up with."

We have to have a conversation about, well, what does this mean? How valid is the findings and does it apply to them as an individual and how do we move forward? And I think that in the modern age, the internet has been an equalizer in some ways about information. It's the interpretation of it and the communication about it that we as the provider have to figure out, I think.

[00:11:04] Dr. Cifu: Are there...? And I think I know what your response is going to be and maybe it's sort of flogging a dead horse here. I have tried, more or less successfully, I think, over years in my practice to actually sort of state with physicians that, "Listen, I'm going to take care of you, you know, in much the same way I take care of other people. It will occasionally seem like I'm talking down to you because of that, but I kind of need to assume the same level of understanding." Are there kind of ground rules that you lay out with people or things you feel necessary to say off the bat, or is this something you say, "I'm going to see how this works out with each individual like I would with anybody?"

[00:11:47] Dr. Rubin: Actually, I would have to say that thinking about the many different colleagues that I've taken care of, most of them come to me with that almost implicit.

[00:11:59] Dr. Cifu: Yeah.

[00:12:00] Dr. Rubin: I don't have to say it. Um, maybe there are exceptions, I'm sure there are but honestly, most of our colleagues by the time they come to see a colleague and they need a medical problem solved, especially for something chronic like what I do, they are somewhat relieved when they end up being in a situation where I'm going to take control for them and help them make these decisions and manage them through the questions and problems they may have. And I think that's really important to take some of that burden off of their shoulders, or if they've asked us to see a family member but they themselves are a physician to feel relieved of the burden of having to be in charge of checking every lab and making sure everything's fine. If they know that they're in capable hands by a team that knows what they're doing. And I think that one of the most important messages we can give a patient who's a colleague or the family member of a colleague is that we've got this, you know, now you can be the spouse, you can be the child, you can be the sister, brother, and you don't have to be the care provider any longer. And I think that that's really important.

I know personally, one of the most profound doctor-patient interactions that I witnessed was sitting at the bedside of my grandmother who was very ill, and the pulmonologist came into the room. And it wasn't here at U of C, it was at a community hospital and he was so compassionate to her. He knew that I was a young physician but he took care of her and told me, "Don't worry, I've got this." That was a really powerful message. And I won't forget that. And that influences how I care for people.

[00:13:42] Dr. Cifu: Yeah. It's great to hear you say that because I have certainly felt times in relationships that have been a struggle and sometimes a struggle with you know, who's in control here, who's managing this, that it is so rewarding when you have sensed that the person has really turned things over to you, you know, that I trust you enough that, you know, this is yours, and as you say, that I can attend to dealing with how I'm dealing with my illness rather than treating myself, which seems like a gift almost to a patient to be able to say, "Okay, I need to deal with being a patient and living with a disease rather than doing that while I'm worried about how it's being managed."

[00:14:31] Dr. Rubin: I think that's right. And I think that as our colleagues who are listening to this, who may be earlier in their careers, think about things and experience it, one of the great blessings and privileges of being a doctor, and I will continue to say this, I think, for the rest of my career, is being in a position where we can have these relationships with people and take the burden off of their shoulders and take good care of our patients, all of them.

I have an example of a patient who came to see me with ulcerative colitis whose husband is a primary care physician and when I first met her she was sick from her condition and we made some decisions about her management and her husband very respectfully asked me lots of questions, wanted to know about new treatment options, wanted to see primary data, and I didn't feel threatened by that, I welcomed that conversation. It took a little more time, but here we are now, I've been taking care of her probably for 15 years and occasionally a new treatment comes out and there's a new article published, and I always think about him, even though he's not a gastroenterologist, I will occasionally send him an article, say, "Listen, this might be of interest to you for your wife." And we also have the opportunity to do that with colleagues who are in the field. We can be proactive about it and not necessarily on the defense or wait for the questions. If you know someone has a particular interest in this and I think they very much appreciate that and then that leads to a more positive experience the next time you have to make a management decision.

[00:16:13] Dr. Cifu: My last question is a little off-topic, but before we started the podcast, we were talking a little bit about medical education, and I think that when I think back to my training, both in medical school and residency, there was this very clear you know, you don't take care of friends, you don't take care of family, you really separate yourself from your patients. And I had mentors who I had great faith in and learned a ton from, who were sort of like, no weddings, no gifts, maybe a funeral, but you should even really think about the funeral. And I think one thing that has changed over the course of my life and my career is that that would not be workable for me in the sort of medical center we're in, in the community we live in, and I wonder if by taking such sort of a black and white stance in training, we do a little bit of a disservice for our you know, students and trainees because it takes a little bit longer to kind of grow into the role that a lot of people are forced as physicians to grow into.

[00:17:22] Dr. Rubin: Well, there're few things in life that are black and white as you know very well and I agree with you. I would say that it also depends on some humility. If there is somebody who's better suited to take care of or equally suited to take care of a family member or a trainee that you're mentoring, then let them do so and identify that person or help them so that you can manage the conflict but that's not always the case. One of my own family members, my nephew had a medical problem and it's one that I could have taken care of but I actually identified a colleague here and asked that person to take over for me and then stayed the distance. My sister would call me occasionally to ask me questions, and of course, I would answer and help but try to stay out of the way. But if you don't have that option, that's a different story but when there are capable colleagues who can provide the same care or better, then it's your obligation, I think, to try to help people find those individuals. But there are lots of examples where we can take care of friends, we can become friends with our patients in social ways, and still provide professional care.

And we just have to understand where those boundaries are, and we can't let those relationships lead us astray from our professional obligations to make sure that they get the right care and that we adhere to the ethical principles in the doctor-patient relationship.

[00:18:50] Dr. Cifu: I have to say, I've never had somebody respond badly when they've asked me to take care of them and I've told them either why I'd be uncomfortable doing it or why I'd be happy to do it, but here are some issues we should consider before stepping into the relationship. I always think those sort of statements are well-received and actually make things easier down the line.

[00:19:14] Dr. Rubin: 100% true. There's also the situation when my... One of my sons was sick as a child and had a stomach ache, and my wife said, "You're a gastroenterologist. Go fix it." And my excuse, of course, was I'm his father and I'm not a pediatrician but of course, I should have thought about it a little differently perhaps back then, but those things come up all the time. And I think it's important to acknowledge these conflicts when they exist and that there are ways to manage them without being completely opposed to getting involved at all.

[00:19:47] Dr. Cifu: This is probably one of the places that more of the sort of mentor-mentee relationship in training is probably so important, right? That having trainees spend time with a mentor to see how that person practices is probably critical.

[00:20:08] Dr. Rubin: I think it's really important for our trainees to see how we interact with our patients. And one of the challenges that can arise is, "Oh, I'm going to go see Dr. So and so, who's my patient. None of you can come in the room."

[00:20:23] Dr. Cifu: Right.

[00:20:24] Dr. Rubin: And then they don't get to see how that interaction unfolds. That doesn't mean that we shouldn't have the same permission from the patient/colleague before we bring trainees into the room or engage them in the care but I actually think it's really important. I'll have to give another personal example but when my wife was in labor with our second child, the obstetrician sent the medical student out of the room. She said, "Oh, well, this is a physician's wife". And I actually said, "Please let him come back in." And then I handed my camera to him and said, "Don't touch her." But in all honesty, you know, I think we have to not be hypocrites about how we train people and it's very important not just so they learn medicine, but that they also learn how we manage these interactions.

[00:21:12] Dr. Cifu: It's actually a wonderful souvenir I have, our discharge documentation from the newborn nursery, it's a physical exam signed by one of the medical students who I supervised as a third-year, and I sort of love that as, you know, he was involved at the beginning of his career with the beginning of life of one of my children.

[00:21:33] Dr. Rubin: It's amazing. I mean, that's really another reason why it's just, we're in such a great profession. It's really, really a privilege.

[00:21:42] Dr. Cifu: Well, David, thank you so much again for talking to me today.

[00:21:44] Dr. Rubin: It was absolutely my pleasure, it's such an important topic and I'm grateful to be involved.

[00:21:49] Dr. Cifu: 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 on the Bucksbaum Institute Twitter page.

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