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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. Jennifer Brokaw taking us through a wonderfully varied career in medicine.
[00:00:13] Dr. Brokaw: There was such an advantage to be an outsider and it took away a lot of the suspicion on the part of families that, you know, somehow the medical system wasn't offering their loved one what they should, or there was some financial incentive not to do X, Y, or Z.
[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 today I'm joined by Jennifer Brokaw. Dr. Brokaw started her career with an emergency medicine residency at UNM.
She later worked at the San Francisco General Hospital Emergency Department and California Pacific Medical Center. In 2010, she left emergency medicine to start a multidisciplinary private practice called Good Medicine, which focused on advanced illness management and advanced care planning. She later worked as an independent consultant to families and organizations around communications at the end of life.
In 2020, she became the department physician for the San Francisco Fire Department, and that's the job that she retired from in the spring of 2024. Jennifer, thank you so much for joining me today.
[00:01:40] Dr. Brokaw: So glad to be here.
[00:01:41] Dr. Cifu: I asked you to join me on the podcast just because you've had like one of the most varied careers within medicine of any doctor I know, and I just kind of wanted to, you know, get a sense of that career.
So I guess before starting, are there things that I missed as far as kind of what you've done over the last, I don't know, 30 years?
[00:02:03] Dr. Brokaw: No, not really. I didn't include... I did do a first foray out of the ER working for a health plan...
[00:02:12] Dr. Cifu: Okay.
[00:02:12] Dr. Brokaw: ... for about nine months. Again, we will talk about it more, but I had this sense that there was something missing for patients who were coming to the ER.
So I tried to go the health plan route to do case management and medical direction and didn't really find what I was looking for there. So went back to the ER again and then launched myself out in 2010.
[00:02:40] Dr. Cifu: It seems interesting, sort of, you know, from afar, you know, observing your career, reading about your career, the transition from emergency medicine to what sounds like sort of very complicated management of, you know, complex patients at a complex time in their disease. What was it that sort of made you want to make that transition or get interested in that? Was it something from your clinical experience?
[00:03:09] Dr. Brokaw: Yeah, absolutely. So, you know, if you talk to any emergency physician, they'll give you a laundry list of things they wish they could solve in society. And they would put them out of business, but they wouldn't mind.
And you know, those things I don't have to tell you, but just for the listeners, you know, if we had better gun laws. If we had better housing for all people. If we were able to somehow solve alcohol dependence and alcohol misuse. And then the other big bucket is elder care and advanced illness. And the difficulties around what kind of care those people should receive when they're coming to the end of their lives.
[00:03:59] Dr. Cifu: It's so interesting to hear you just enumerate those because as you went through them, I think of colleagues of mine in emergency medicine whose kind of non-clinical specialty is in a lot of those things you just ticked off. And I never really put it together that like, this is what we deal with every day and I shouldn't have to deal with this, and what can we do better, kind of in medicine and society, whatever, to deal with these problems?
[00:04:27] Dr. Brokaw: Exactly. No, I was going to say that there are many, many physicians, emergency physicians, especially in academia who attack these problems from an academic standpoint and public health standpoint. The last one, the elder care and end of life was not something I saw a lot of emergency medicine academicians trying to tackle but since I did my practice, I now know a lot of emergency physicians who are becoming double-boarded in palliative care.
[00:05:03] Dr. Cifu: Interesting.
[00:05:04] Dr. Brokaw: So, you know, it is a bucket of problem that I know emergency physicians would like to have better answers for and exists now.
[00:05:14] Dr. Cifu: And I do think, I mean, I don't need to tell you this, you know, I always say it is one of the most difficult things, but also one of the most rewarding things to, you know, be able to bring a patient through the end of life in sort of, you know, a thoughtful and empathic way but it takes so much for it to go well, right? Not only the medicine, but communication with the patient, communication with the family, sort of agreement within the family. And often I feel like having, I don't know, an outsider to the relationship would in fact be sort of helpful.
[00:05:54] Dr. Brokaw: Definitely. Definitely. That was the rock and the hard place I found myself between. There was such an advantage to being an outsider and it took away a lot of the suspicion on the part of families that, you know, somehow the medical system wasn't offering their loved one what they should, or there were some financial incentive not to do X, Y, or Z. And our team, as you know, was paid... They were our clients. You know, so they were paying us directly and we could say to them, "Look, you know, we're being paid by you. We are here to tell you what we think is best and to advocate for that. And if it's more care, we will advocate for that."
[00:06:44] Dr. Cifu: I was going to ask you about the design. You know, it seems a little, I don't know, awful to talk about, but as I was kind of reading about this setup, I was like, who pays for this? Because it doesn't seem like something that insurers, be they private or government, would pay for but it also seems a really odd model for the kind of, you know, direct primary care, concierge care, something like that, because it seems like they're relatively short relationships. Is that true?
[00:07:20] Dr. Brokaw: Yeah. You know, ultimately that's why the practice didn't work from a business standpoint. On the one hand, we charge directly for our services and you know, for really sick people. You know, those families racked up, you know, a lot of charges by us. Toward the end of the six years that we had Good Medicine, we moved to a model where people paid an upfront fee for the advanced care planning process. And that sort of was a "get to know you," and we will communicate with you and your family about what your wishes are, and have that document on file. And then if something happens to you in the next X amount of time, we will be there to help you interpret the advanced care plan and what should happen.
[00:08:16] Dr. Cifu: How interesting. Could you imagine, given your experience with it and in conversations we've had in the past, it seems like there were, you know, multiple kind of patient relationships that you felt like you brought real value to...
[00:08:33] Dr. Brokaw: Absolutely. I tell people... You know, I was giving talks about this when I was doing the practice, and I really feel like I can think of as many times that I saved a life or saved somebody's emotional health, whether it was the patient or the family member, in the Good Medicine practice, as I did in the previous 15 years that I had been doing emergency medicine.
[00:09:01] Dr. Cifu: Wow. And I'm sure there are probably some doctors, right, who were also thankful for, you know, your presence.
[00:09:11] Dr. Brokaw: Absolutely. That was the biggest surprise. I mean, some of it was, I think, not to be immodest, but I think I did that well. I worked with other physicians. Well, I immediately knew that I had to introduce myself and tell them I was there to help them, as well as the patient and family, and that I was respectful of them. Sometimes I would find things I thought they had missed or I'd clear up a misunderstanding and treating  doctors were always so grateful.
And only occasionally did I have some prickly interactions with other physicians but by and large, it was very collaborative and really an asset to the treating team, which always made me wonder why, you know, there wasn't a way for the system to pay for my services.
[00:10:03] Dr. Cifu: Sure. And I guess, I mean, when I think of this, you know, in a way it's built into our system with, you know, palliative care consultation, with ethics consultations, but it's not sort of a single group, which is really in the patient's camp, I guess is the difference. Right?
[00:10:27] Dr. Brokaw: Yeah, I think when the referral comes from the system, they're just off to a bad start in a way, if it's a tough situation. And usually, it's a tough situation because there are some outsized expectations or there's a lot of, you know, grieving or emotional issues that haven't been resolved.
[00:10:49] Dr. Cifu: Yeah.
[00:10:49] Dr. Brokaw: And a lot of distrust happens.
[00:10:52] Dr. Cifu: Yeah. You know, I'm sort of leaving this conversation thinking about, boy, how could we set up a consultation service, you know, in an academic medical center, which would be
you know, a group that is not consulted by the physicians through the electronic medical record, right, but is consulted by the patients. You know, many hospitals have the sort of, you know, patient relations office but that's just sort of for complaints. It's not for like, you know, clinical expertise.
[00:11:23] Dr. Brokaw: Well, trust me, I went to the hospitals in town and pitched that very idea. And got pretty far with one of them, but ultimately, you know, medicine is a turf war and you know, it was hard to get anybody to agree that they should bring an outside group in.
[00:11:45] Dr. Cifu: That's what I was going to say. The benefit of being an outsider in the clinical situation probably undermines you in negotiating, you know, with a hospital where you're going to take business away from some consultation services.
Tell me, thinking about kind of your career, you know, doctors are I think one of the few breeds that still occasionally join a practice or join a hospital and spend like an entire career there or, you know, maybe move once but if they move once, they're moving from, you know, the division of rheumatology at one hospital to a division of rheumatology to another hospital. What is it that kind of led to your moves? Was it always, you know, like running away from something that was terrible, or was it being drawn into something that seemed, you know, like an exciting challenge for you?
[00:12:38] Dr. Brokaw: I've worked at many hospitals I absolutely loved. I mean, I loved working at San Francisco General.
I don't think I regret leaving because I knew I wanted to try and solve this problem but I really loved it. I wasn't running away from it at all. You know, back in New Mexico, we were there for eight years, so I worked in several emergency medicine practices there, and a couple of situations I could have easily seen riding out my career in.
Just great nurses, great, you know, everything.
I think I was really almost offended by the way that society leans on emergency departments and hospitals. And maybe it was a little grandiose of me to think I could, but you know, coming from my background and my father being pretty prominent, I knew that I could talk to people at a high level. I was confident in my ability to communicate with people. I started writing immediately. One of the best things I ever did was take an op-ed writing class while I was still working at San Francisco General UCSF, and it was designed to get women to write more op-eds. So I did it. I just started diving into writing op-eds and, you know, I got a lot of things published during my time doing Good Medicine. And I also got some really good speaking opportunities, so I feel like in addition to working with families one-on-one, I also got a bigger platform and some of that was because of my father, Tom Brokaw but it was the one time in my life I didn't mind using that connection, you know?
[00:14:38] Dr. Cifu: I think a little bit of grandiosity is actually, you know, not a bad thing to give one, you know, the confidence to sort of make these changes, right? And also think bigger about what you can accomplish, right? What one can accomplish.
I guess that gets into a question that I had jotted down, which maybe you've sort of already answered, but, you know, I think one of the things that always keeps people from making changes, and I'm thinking specifically in medicine, but it probably goes anywhere, right? It's that it really takes courage to move away from something you know to something which you don't know as well. You're not sure how good you are going to be at it. When you made these changes and you know, whether it was out of emergency medicine to kind of the Good Medicine practice or even, you know, later in your career, you know, to the fire department, were these particularly like, you know, anxiety-rich periods for you? Or did you feel like, "I am ready for this, I want to give it a try, and the worst thing that can happen is I fail?"
[00:15:45] Dr. Brokaw: Yeah. I think that's kind of how I've gone through life. I am a "jump in both feet first." And in fact, you know, you and I both do ceramics, and I have a... This is a little bit of an aside, but I will come back to how I was able to, you know, make these changes. But one day in ceramics class, and I'd only been doing it for, you know, a year and I hadn't done it since high school, but I took a big hunk of clay, like seven pounds, which as you know, on the wheel is a big hunk of clay. And I just had this idea that I was ready to throw a really big bowl. And there I was, you know, wrangling it, trying to center it but I actually like pulled up the walls of this really big bowl and, you know, ultimately, it didn't work because, you know, when I was trying to get it off the wheel, it... My ceramics teacher walked behind me and chuckled. And like two weeks later, she made these little pins out of clay that she would put sayings in and then put glaze on them and make pins for people.
And she made me this pin that said "intrepid." And I think that was so meaningful to me because that is the kind of person I am. I think I am a little intrepid. Sometimes I get in over my head, but as I've gotten older, I know when I'm over my head and when to pull back a little but I think I've had incredible experiences because of it. Yeah, I'm not being fearful.
[00:17:30] Dr. Cifu: I love that, and it's probably the first time ceramics has come up on the podcast. I often use it as a metaphor for how different it is from medicine because one of the things that physicians lack, and I think it's to the detriment of medicine, is, you know, rapid feedback on a lot of things that we do, both from the patient and from outcomes.
And one of the things I love about ceramics is, you know, if you screw up, you know, immediately.
[00:17:59] Dr. Brokaw: Yeah.
[00:18:00] Dr. Cifu: So asking you for one piece of advice. I mean, for people out there who are thinking of making changes, either hoping to get away from something they're doing, or who, you know, have a grand idea that they want to go after. Having lived this sort of career, do you have advice for people about what you would say, like, "You know, this is what's going to make you as successful as you could be in your next endeavor?"
[00:18:25] Dr. Brokaw: Yeah. I think talking to a lot of people is really important. So getting feedback from your peers about your ideas or what you want to do, and meeting with people who are working in various... I mean, there are really a lot of different careers that doctors can pursue other than clinical medicine and academics.
There's, you know, a lot of administrative jobs. There's, you know, of course, we all know there are physicians in industry, but there's a wonderful world of public health too. And talking to people who are working on the health plan side or working in administration on the business side, working even in med mal.
There are just so many ways that physicians can work in the world other than directly with patients. Although, I think if you get your MD, you're really robbing yourself blind if you don't spend some years in clinical medicine but...
[00:19:27] Dr. Cifu: Right. I was going to say, I think that's a great piece of advice because
to underline, I mean, as much as I have, you know, loved my clinical life, you know, there are a lot of people who are not happy with that. And I think some of the most burnt-out people, right, are the people who really have a lot to give, but maybe not in what they're giving. And the sort of exploration that you talk about like, wow, you know, there's so much that a lot of our training, talent, and experience can be used for, you know, if you explore and figure out where you'd fit.
[00:20:02] Dr. Brokaw: Exactly, and I think I don't have the names in front of me, but there are consultants and coaches for physicians out there who will help people kind of figure out what their next move should be or what the opportunities are. You know, looking back at how I approached it, there are some things I would do differently.
I should have taken more time to explore how to do it and specifically talk to people with medical business backgrounds. You know, medical practice management company or, you know, go to my medical society and see if I could get hooked up with some of those practice manager consultants, et cetera.
What I did do was, I spent a lot of time talking to lawyers about the legal entity I should set up. And I don't think that was exactly the right move. I spent time and money talking to lawyers. I should have spent more time talking to business people.
[00:21:05] Dr. Cifu: Yeah. Yeah. The more time you talk to lawyers, the more you've wasted. Right?
[00:21:10] Dr. Brokaw: I hate to say that, but I did spend a lot of time and money on legal advice, and...
[00:21:18] Dr. Cifu: It's a doctors' show. We can take a swipe at lawyers.
[00:21:21] Dr. Brokaw: Yeah, okay.
[00:21:23] Dr. Cifu: Jennifer, thank you so much for taking the time to join me today.
[00:21:26] Dr. Brokaw: I'm so glad that we did, and thank you. If any of your listeners want to talk to me more, you're welcome to send them my email and I'd be happy to talk more.
[00:21:40] Dr. Cifu: 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.