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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. Stefan Kertesz, the 2025 recipient of the Bucksbaum-Siegler National Award for Clinical Excellence.
[00:00:15] Dr. Kertesz: You should distrust that people-pleasing instinct a little bit. Just seek the information and allow that somebody might be very displeased with you and see where that leads without worrying as to whether you're a failure or a success. That was an issue with your parents. It's not an issue with your patient. You just need to use what you gain toward their benefit over time.
[00:00:41] Dr. Cifu: We're back with another episode of The Clinical Excellence Podcast sponsored by the Bucksbaum-Siegler 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. Stefan Kertesz. Besides being this year's Bucksbaum-Siegler National Award recipient, Dr. Kertesz is an investigator and physician at the Birmingham VA Healthcare System and professor of medicine at the Herzing School of Medicine at the University of Alabama at Birmingham. Stefan began his career at Boston Healthcare for the Homeless program and later completed a fellowship in general medicine at Boston University. After his fellowship, he joined the faculty at the University of Alabama at Birmingham. His work includes research focused on homeless healthcare and issues related to pain and opioids. He remains an active clinician, directing a primary care clinic for homeless and formerly homeless veterans. He is currently a principal investigator on the only national study to directly examine individual suicides that occur after prescription opiates are reduced for chronic pain.
Stefan, thank you very much.
[00:01:55] Dr. Kertesz: Hello, Adam. It's nice to be here. I'm really happy.
[00:01:58] Dr. Cifu: After I get to talk, then you get to say something.
[00:02:00] Dr. Kertesz: Yeah, you spoke.
[00:02:01] Dr. Cifu: You're a second-comer to the podcast.
[00:02:03] Dr. Kertesz: That's true.
[00:02:04] Dr. Cifu: You were on for sort of a regular discussion, and now you're here as the Bucksbaum-Siegler National Award recipient. So congratulations and welcome.
[00:02:13] Dr. Kertesz: Thank you. I'm honored. I think it's wonderful to get awards. I'm always aware that lots of other people could have also gotten the same award.
[00:02:20] Dr. Cifu: So you stumbled into a season in which I'm going sort of all in on the patient-doctor relationship, and I've been asking everybody who visits sort of the same three questions and getting very different answers based on who people are and what they do in medicine. So to begin with, I just wanted to ask you, you know, you've been doing this for a long time. For exactly as long as I've been doing this. How has your relationship with patients changed over the years? I'm kind of interested in what's evolved and how you relate to people you're seeing for the first time, people you've seen for a long time.
[00:02:55] Dr. Kertesz: I think I'm a little less stressed at the start. That is, when I met a patient in the first 10 years, I was strongly aware that I should know everything and that I should be ready to go, like my wonderful faculty were in residency. And now, when I see a patient for the first time, I think I should collect information, which is a bit more like what you do as a medical student, actually. And I think, okay, I'm going to see this patient. We are going to set the table. I need to be totally present for this person, and whether I know what to do or not, it's going to be fine. We're going to work that out. So there's a little bit of internal patience in terms of the information and knowledge task, which doesn't mean I am not insecure; we'll come back to that, but definitely, that's one part of the... And I guess when you're... When the frame changes to, okay, we're going to connect and get the story of what's going on here, I think of it truly as a consultation. It's a little bit like a lawyer seeing somebody that they're going to get, let's get the story, let's get it out on the table, and then... Excuse me, my nose is running. I think there's part of me that's just genuinely, okay, I wonder how I'm going to establish some sort of relationship here. I see people who are often expecting a certain mindset from their doctor. And I'm very aware that they're expecting somebody who, my friend Saul calls the efficient task completer, who's going to be, you know, doing things fast. And I am, too. Like, I'm still typing, but part of my goal is to disabuse them of the notion that I will be that. And that I want to be able to create the sense that no, I'm really here like an actual human.
[00:04:44] Dr. Cifu: Yeah.
[00:04:45] Dr. Kertesz: And we'll work this out, even though yes, I have to interact with this computer over to the side.
[00:04:49] Dr. Cifu: Yeah.
[00:04:49] Dr. Kertesz: Those are some of the changes.
[00:04:52] Dr. Cifu: So do you take a different role when, you know, because people want different things out of their doctors, right? People... There are some people who are very happy to have that relationship with someone who is going to be collegial. Think of them, you know, as a person. Get to know them. There are other people who truly want that efficient task completer, right? This is how all of the professionals I interact with should interact, and I'm here for my blood tests and my mammogram, damn it. Do you make those shifts?
[00:05:25] Dr. Kertesz: Oh, well, first of all, I don't have as many of those people as you do. I work in the VA hospital. I'm not speaking for VA, in case somebody out there is listening, but I work in a VA hospital with mostly formally homeless people, although I also work in another clinic with residents, and that can be just sort of an efficient thing. That's not a problem. That feels all right to me. I think I can shift with people's needs for something that's relatively quick and simple. It's just that I don't see as many of those patients as you do.
[00:05:49] Dr. Cifu: Right, right. I may be reading too much into what you said, but you know, I think I've been through a similar evolution that, you know, recognizing that I don't need to know everything. And the people who I imagine in my past knew everything, I'm sure they didn't actually know anything either. I also have come to recognize that I don't need to do everything, right? That, like, this relationship can evolve over a long period of time. Right? That it can take three years for me to get things done, and that'll just be fine.
I worry a little bit that part of what is behind that in me is that I've come to understand that many of the things we do, especially in primary care, have little likelihood of helping the individual in front of me, right? And so I feel a little bit less stressed to, you know, check that A1c on the first visit, or, you know, schedule a colonoscopy the first time I see this person because, you know, for, I don't know, you know, 99 out of 100 people, if I never do that, it's not going to have a consequence.
[00:06:58] Dr. Kertesz: So are you worried that you might be failing somebody 'cause they could be the one? Or are you worried that you just come up with a... You wrote an entire book called Ending Medical Reversal, like, is that a one giant excuse for being lazy?
[00:07:10] Dr. Cifu: No, I am not trying to make my inertia okay.
[00:07:13] Dr. Kertesz: But are you worried that you're trying to make your inertia okay? Are you self-criticizing?
[00:07:17] Dr. Cifu: A. This is my podcast. I get to ask the questions.
[00:07:20] Dr. Kertesz: Oh, okay. Sorry.
[00:07:23] Dr. Cifu: No. So, when you... Sounds like you take more time in your practice now than you used to, and feel like you're under less pressure.
[00:07:31] Dr. Kertesz: I feel less internal pressure, less internal pressure.
[00:07:33] Dr. Cifu: Right. And where does that come from? Does that just reflect that, you know, I can figure this stuff out over time, or does that have something to do with your understanding of medicine?
[00:07:43] Dr. Kertesz: I think the first thing is that the priority is to establish a relationship, and that first step does have to address whatever the reason is the person walked in. Like, you can't.... If you don't do that, you're probably going to fail in establishing the relationship. The priority is to establish the relationship, and usually, the types of folks I see have had some history with healthcare and healthcare institutions that was terrible. And that involved being looked down on, or that involved a stigma, involved being seen as a problem.
And I'm going to have to put a lot of energy into acting like a normal human being who's actually interested in them, which isn't... Seems strange, like, you don't need to act especially nice. You need to act really present for that person. I'd say, "Okay, so what's life like? What are you doing? Where are you? What branch of the service were you in? Tell me, what went well and badly the last time?" I think that your question, just to restate your question, your question was why have I changed? I think that I'm really... I mean, deeply where the lot of the people I see expect the relationship to not be one that they feel comfortable in.
[00:08:48] Dr. Cifu: Right.
[00:08:49] Dr. Kertesz: I'm also... This is another thing that's changed. I am much more genuinely curious about the stories people bring. And I think it's kind of a... I mean, I'm the thousandth person to say this, it's a privilege, but it's really fun to learn about where people live, what they do. I might travel in a certain circle, I see people by choice everywhere else, or because we work together at a university, but here I get to hear people's stories from realms that are vastly different from mine. And I think that's really enjoyable. And my enjoyment and my curiosity is one of the tokens I bring into building a sense that, well, we're here together, and if necessary... The other thing that's changed is I will share things about myself.
[00:09:33] Dr. Cifu: Right.
[00:09:34] Dr. Kertesz: And I don't share it, to be very careful, I don't share things about myself because I need the patient to like me. It's not the patient's job. I might even ask permission to share something about myself and sort of make sure the patient's all right with that. But if it seems like there's something in my experience or something that I've observed in myself or in a parent that really speaks to the health concern that a patient has, I'll say, "You know, I've seen something similar in my parents. Can I share it with you? Would that be all right?" And if they say yes, I'll say, "Look, you know, this is the thing I've seen." And again, it's trying to establish that we're really in this together.
[00:10:10] Dr. Cifu: Yeah.
[00:10:10] Dr. Kertesz: And that is a change from the first 10 years, where it's not that I... I cared about the patients, I liked the patients, actually, or liked a lot of patients and I didn't like others. We should get back to that, but more of the pressure was on proving my competence.
[00:10:24] Dr. Cifu: I love your comment about, I also feel it that, you know, part of what makes this job amazing is just the breadth of humanity, you know, you get to spend time with, and as you said, it's an overwrought statement, but what a privilege that is, but I like the way you turn it around, that actually not only is that a benefit for you, but that's changed you and it's made you, you know, better for your patients.
[00:10:53] Dr. Kertesz: And we're going to talk about that. There's a talk I'll give tomorrow, and that'll come up again.
[00:10:57] Dr. Cifu: So many people this season on the podcast have talked about that as they've gone on in their career, they've actually been more comfortable about sharing things about themselves. It's interesting, I think most of us are trained to, you know, keep a little bit of a wall up, you know? You're not here to talk about you. And that often, as you kind of get to understand your relationships with people, that breaks down some, and you realize how you can use that therapeutically, I guess.
[00:11:25] Dr. Kertesz: Yeah. The issue is the reason for the sharing. That's the sensitive issue. If one is sharing... In broad strokes, okay. You could be happy that day for whatever reason you want, but if one is sharing information because one needs gratification, or certification, or validation from this patient, that's imposing on the patient something that's not their job. That's not why they're there. The purpose of the relationship is healing. But if the sharing could be in the service of the healing, then it's potentially okay as long as the patient doesn't feel intruded upon, which actually, that's why I ask.
[00:11:57] Dr. Cifu: So, I always say one of the great things about medicine is that it keeps you humble, right? You never really master this.
[00:12:02] Dr. Kertesz: Oh my gosh.
[00:12:03] Dr. Cifu: Every time you think like, I'm good at this, you know, the other shoe drops or, you know, name your metaphor. What specifically, you know, about the patient-doctor relationship still challenges you? What do you feel like, "God, you know, I'm still working on this and I still get burnt by this every now and then."
[00:12:22] Dr. Kertesz: Well, there's a few things. First of all, to be fair, and you alluded to this, one of it is just that I don't know off the top of my head the latest way to prescribe and give a medication. Whether or not I should switch diabetes medicines at this point in the game, I still have to go check that up. And so part of me is painfully aware that as a person who does 20% clinical, 80% research, this patient could be seeing somebody else who knows that right off the top of their head.
And so that's not really a relationship issue except that I feel a little embarrassed sometimes, but I just say, "We got to check this up. We gotta make sure we do this right." The second thing that can happen is that I still use the wrong words sometimes. I'm trying to think of a good example.
[00:13:03] Dr. Cifu: Wrong word...
[00:13:04] Dr. Kertesz: Oh, wrong word meaning that, let's say I'm talking to someone with addiction and we've talked about drug use before. And in the moment, I want to inquire about recent use, and I'll say, "Did you mess up?" And you know, I'll think, "Oh goodness. You just threw in your whole model of what is recovery, and what is addiction, and what this human being is, and implies judgmentalism."
So there's sometimes just the wrong word. And my patients, they're different people. Some of them are highly attuned to me using the wrong word, and I'll see a reaction right there in the room, and I'll think, "Oh shit, I just bungled the last minute, and I'm going to have to untangle this for the next four minutes." So that can be frustrating, and it happens. The only difference now is that I see it instantly, and I realize, okay, I have some homework now that I've just added to our own visit. The other thing that I think is a little bit frustrating, and yet I want to say it's also a change for me, is I think I have gotten used to the idea that I can almost make a good start, a friendly start with anybody, no matter how grumpy. And occasionally when that doesn't happen, there's a little part of me that just growls at me. There's a part of me that says, "Damn it, I thought I was good at this. What the hell's going on?" And I feel a sudden sinking in my chest. Like, now I feel disturbed. Usually, I have to like, stop myself but this... that can happen. And it's frustrating in the moment, but the change since 15 or 20 years ago is that part of me says, "This is interesting. You know, the fact that your normal song and dance is not resonant for this human being is information. And it's interesting also, Stefan, that you need someone to confirm your feelings of being able to engage with people, like, it's not their job." And then, oh, maybe this will tell me something. I just need to explore it and let it happen over time. And if this person never likes me, that's okay. But there's that moment of frustration. It's just that I recover from it a little faster because I realize it's information, too.
[00:15:18] Dr. Cifu: I often say that our default kind, empathic bedside manner probably works with 90% of people, and there are 10% of people that you really have to, you know, use your personality as a tool and like pull other things out of your quiver or whatever to like, how am I going to get this to work with this individual. And one other thing I just wanted to point out. I love what you said about, you know, recognizing when you say something the wrong way, right? You used 'messed up,' because I think that shows such sort of, you know, presence and mindfulness in the office to pick up on that. Right? Which is, you know, I expect one other thing that's evolved over your career, being able to do that, that like, not only are we having a conversation with this patient, but I'm sort of a third person in the room seeing how the patient's reacting to me and what's said. I feel like that's a difficult thing to do. I feel like it's feedback that we as physicians almost never get, because how would you do that? You would need standardized patients to be evaluating you. But there have been situations for me where I've been a patient and a doctor said something, you know, a perfectly reasonable thing to say, but that I heard wrong. And I'm like, "Ah, I'd love to give this person feedback about this, but I'm not going to give the person feedback because he or she is doing a wonderful job with me. And that's not my role as their patient, but I always think about, could we do a better job training ourselves when we don't have that mindfulness or insight, which we don't always have.
[00:16:54] Dr. Kertesz: Yeah. I mean, there's a lot of ways to go with this. So one thing is, the core of this is boundaries. I actually have always been highly attuned to the emotional reaction of the person in front of me. The problem was that I cared about it too much or that I thought it involved my validation as a person. That's just how I'm wired. Another person's wired differently. So there's some people we need to teach to pay attention. There's other people we need to teach, hey, you're very tightly attuned to people's reactions because you think it impacts your self-worth. Now, we've got to talk about the difference between the way you gain a sense of self-worth and a love relationship with an intimate partner versus the work you need to do with the patient. And those have to be so different that when you're attuned, you don't necessarily respond to the signal instantly when you feel that things went wrong. The other thing, when you told your story about you sometimes felt disappointed, you know, I'm now thinking right as we talk, I should be able to ask the patient, "You know, there's something about the way I said that, that might not have been the right way to say that." Like, why not just ask the human being? And then let them say, "Yeah, doc, that seemed kind of crappy the way you just said that." And I'll say, "Yeah, I was kind of wondering." I mean, they're adults. I mean, I'm not seeing kids. It would be a different thing, but even with kids, I have to tell you, I've worked with kids at a summer camp. By eight or nine, they also have reactions where you can ask them, "Am I saying this right, in a way that works for you?" And they'll tell you.
[00:18:19] Dr. Cifu: Right. And I'm sure, I mean to use your example again, right? There are people with addictions who, if you say, you know, "Have you messed up?" That's exactly the way they would express it, and they'd be completely fine with it. And then there'd be another group who's like, "Oh, that's not how I think about this." Right? And it's one of the things that makes the job wonderful, but makes the job nearly impossible because, you know, you can do the same thing every day, and as the people change, it may be totally right one day and totally wrong the next day.
[00:18:55] Dr. Kertesz: Right. The key is to roll with it and then to... You can sort of redeem these situations usually by just getting to know the person. People want to be known.
[00:19:04] Dr. Cifu: Right. And the more you know people, the more they'll excuse missteps because you know, most of us are generous enough to recognize that we all make a thousand missteps every day.
So, you know, you've been very honest and reflective about, you know...
[00:19:23] Dr. Kertesz: I intended to lie today. That's kind of strange that this happened.
[00:19:25] Dr. Cifu: I'm sorry... About like, sort of where you fall short as we all do, but at this point in your career, what are the things about your role in the patient-doctor relationship that you appreciate? And I mean that either that gives you kind of great satisfaction in your job and your career, or things that you're honestly just proud of, that you're like, "I do this well and I am happy that I've gotten to this point in my work."
[00:19:53] Dr. Kertesz: There's a couple things. One is going to sound kind of odd because I should be talking about what I do, but one of the things I think I'm good at is enlisting the expertise of the other people who are on the team, whether it's inpatient or outpatient. So if I'm not in the right state to pursue a certain conversation, or if I think that the words come better from the lips of a senior resident or of a nurse, I quickly, like, "Hey, do you want to do that conversation? And I'll be here, but I'd love to watch you do it because I don't think I'm going to say it right for this person." So quickly understanding when somebody else could bring skills to the fore that would allow the patient to hear what they need to hear in the right way. I'm happy to yield, and I think yielding that terrain is really enjoyable because then I learn from the person about how to do things better. They also recognize that I don't need to feel... I'm not running things, we're a team. So that's one thing that's changed. The other thing I would say for me at least, is usually I can quickly - this particularly happens on inpatient wards - I can quickly establish some common ground when we walk into a room. And it's because the first thing in my head, and this is helpful if you're an extrovert, it's a little harder if you're an introvert, but the first thing in my head is, "Oh, a new person! What might we learn? What story could they tell?" And it'll just start with, "Hey, where do you live? What do you do? What branch of the service are you in? Cool." You know, our senior residents here, they really run the show. That's basically the master sergeant, and I'm the captain, but they're running it. And I can usually... I feel good about the fact that most patients kind of smile and sort of react and say, "Okay. This person is here for me." And I'm a little faster at that 'cause I'm not as anxious about the medical stuff. I trust we'll figure it out. So that's an improvement.
[00:21:48] Dr. Cifu: I've enjoyed, you know, so far in the conversations I've had this season to hear these things, and where I always go is, what can we do to make, you know, trainees, younger physicians sort of get to these places earlier. And it just may be something at the end of this. We take all of these, and we say, okay, you know, some of these are actually not that difficult, right? To figure out how to do. What you just spoke about, you know, would be easy to model. The first thing you spoke about would be very difficult, right?
[00:22:27] Dr. Kertesz: Like model asking for help?
[00:22:28] Dr. Cifu: Um, I think asking for help is more difficult, right? When you are, say, a young attending physician, being able to step back and say, "I'm going to let someone else have this conversation," is a really hard thing to do. While placing yourself in a role for a patient and coming up with you, you know, what's truly meant well, but is a little bit of a spiel that, you know, you give to everybody...
[00:22:55] Dr. Kertesz: I have a bit of a spiel. Yes.
[00:22:56] Dr. Cifu: Right. That's a positive thing. And that's something that, you know, we can probably instruct people to do that better, faster, and, you know, advance faster in their career in their doctor-patient relationship.
[00:23:08] Dr. Kertesz: One of the things that I've learned, and this is from my friend Saul Wiener, who wrote a book called On Becoming A Healer, is this way of thinking about the relationships as you can only engage with people for real if you have boundaries. And if you... The normal stance of doctors is we're actually not taught to think about those boundaries very much. So we just remain at a slight distance. And that means we may or may not be cool, but we're not engaged with that actual person in front of us. So when there's someone who's already by happenstance, by tendency, a little bit remote from the patient, I wonder if we can just say, "Look, this is another person. In some ways, they're just like you." I mean, not the same, but why don't we find out a little bit about what life is like for this human being? Why don't we... And then try to understand how what they want to do with their life could be super relevant to the medical decision we're going to make because if they want to get on a tractor at the end of this visit and they can't get on a tractor at the end of this visit, you need to know that so you can explain it in the right way.
It's not just that you're trying to get to know them, but because it could alter the care that we do. And there's this other category of person, which is what I was much more, and I saw this recently on the wards, where people expect that every patient will be pleased with them, and they're disturbed when the patient doesn't want to talk to them and is unpleased with them. And with those folks, I've used this little diagram that Saul has in his book, which shows these two circles. One is the doctor, one is the patient. The goal is for the two circles to meet, but not to overlap. And if they overlap, that's intrusion. That means that you're expecting certain kinds of emotional rewards from the patient. Obviously, in the extreme case, it'd be a tremendous violation, like sex with a patient or something, but the goal is to have enough of a boundary that you don't expect them to fulfill you or to please you. And I think for the people who are already super attuned to people-pleasing, the goal is in a way to say, you should distrust that people-pleasing instinct a little bit. Just seek the information and allow that somebody might be very displeased with you and see where that leads without worrying as to whether you're a failure or a success. That was an issue with your parents. It's not an issue with your patient. You just need to use what you gain toward their benefit over time. I think we could talk about it, and when I talked about this on teaching rounds with residents, they seemed genuinely pleased to see the little diagram on the whiteboard in the workroom and like, "Oh, that's a new way of thinking about what I'm doing here." So, it's not impossible, but I'm still just beginning to do that.
[00:25:41] Dr. Cifu: They really want the differential diagnosis of microcytic anemia, though, on the whiteboard.
[00:25:46] Dr. Kertesz: Absolutely. Are you saying that as a joke or for real?
[00:25:48] Dr. Cifu: That was a joke.
[00:25:49] Dr. Kertesz: I really want that differential diagnosis and when I don't have it, I feel bad. So that's interesting.
[00:25:54] Dr. Cifu: So instead, you draw little circles about the doctor-patient relationship.
[00:25:57] Dr. Kertesz: I do that, but no, there has to be a balance. People actually, if I do a discussion of, you know, a differential or delta delta acid/base, people still like that a lot.
[00:26:08] Dr. Cifu: Stefan, thank you very much for joining us for the second time on The Clinical Excellence Podcast. This has been wonderful.
[00:26:14] Dr. Kertesz: I'm both thankful and I'm very honored by the Bucksbaum-Siegler Institute and the people who made it possible for me to come here.
[00:26:20] Dr. Cifu: Thanks for joining us for this episode of The Clinical Excellence Podcast. We're 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 Bucksbaum Institute webpage. That is bucksbauminstitute.uchicago.edu. The music for The Clinical Excellence Podcast is courtesy of Dr. Maylyn Martinez.