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What’s Happening Inside Your Doctor’s Head and Heart (with Adam Cifu)
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Intro. [Recording date: July 29, 2024.]
Russ Roberts: Today is July 29th, 2024. My guest is physician Adam Cifu, Professor of Medicine at the University of Chicago. His blog on Substack is Sensible Medicine. This is his third appearance on the program.
He was last here in July of 2019 talking about the case for being a medical conservative. Adam, welcome back to EconTalk.
Adam Cifu: Thank you so much, Russ. It’s great to be here.
Russ Roberts: Our topic for today is the day-to-day life of being a doctor. We’re going to use some of the essays you’ve written at your blog, Sensible Medicine, that are really quite wonderful, that reveal the challenges and rewards of the career you’ve chosen. Let’s start with the Declaration of Geneva, something I had never heard of. You don’t mention how old it is. What is it?
Adam Cifu: Right. I’m afraid I don’t know. It was interesting. I wrote this essay thinking about a pledge that I assume is part of what doctors take or is part of our career, which is that we treat all of our patients equally. And, I assumed it was in the Hippocratic Oath.
And, so, I ended up taking this deep dive into the Hippocratic Oath–the original–which has become quite politically incorrect, and all the new versions of the Hippocratic Oath. And that pledge doesn’t appear anywhere in the Hippocratic Oath. And so, I finally found this Declaration of Geneva, which has been adopted by, I think, about half the medical students at medical schools as their pledge that their graduates take.
And, that declaration does, in fact, include that you will take care of your patients irrespective of wealth, creed, color, sexual orientation, anything else. And, so, I was like, ‘Okay, I found it. I’m doing an essay about this.’
Russ Roberts: And, why did you find that interesting?
Adam Cifu: Well, I found it interesting because I really do think–it’s an assumption, right? And it’s something that I think doctors pride themselves in: that we have to take care of patients who we like; we have to take care of patients we don’t like. We have to take care of patients who might talk politics in the room and we might find out that we agree with them or desperately disagree with them.
But, I think we all take pride in the fact that it doesn’t matter; and it’s, in fact, one of the wonderful things about the career is that we come to work and we talk to and we work closely with people who we might not have anything else to do with in our entire life. So, not only does it feel good to do, it actually makes, I don’t know, sort of my life more enriching, I think.
Russ Roberts: You tell the well-known story of Ronald Reagan after he was shot in Washington, D.C., being rushed to the emergency room. And, I think–was it on his way in that he said this? or was it once he got on the table? I think once he got on the table.
Adam Cifu: Right. I think it was when he got onto the table, he said to the team of doctors, ‘I hope you’re all Republicans.’ And, the surgeon, who was in fact Democrat, said, ‘President Reagan, we are all Republicans today.’ Which I thought was a wonderful response. I hope the story is true.
Russ Roberts: Yeah. It sounds apocryphal, but it’s a great story. Although I find the–Reagan was known for his sense of humor and his interest in jokes, but that to me–I recognize myself in that joke. Not that I worry that my doctors have a different political orientation from mine or ideological orientation, but that under great stress, we often turn to humor. And, I’m sure you, as a doctor, see that in some patients but not others, I assume.
Adam Cifu: Absolutely. And, I also think it speaks to the importance of the role of the patient in the doctor-patient relationship is that the patient has a lot of power to manage how those visits go. And, I think Ronald Reagan, as the great communicator, was really using it at that point. Like, ‘Here’s a way to put everybody at ease, take a little bit out of the stress of the situation, get people on my side.’ It’s kind of brilliant, actually.
Russ Roberts: Well, and of course, he was subtly reminding people of the Declaration of Geneva–that in case they were Democrats, they shouldn’t behave like them if they didn’t care for his positions on various issues.
Adam Cifu: Let me pull out the Declaration of Geneva, which I happen to carry in my breast pocket at every time.
Russ Roberts: Yeah. Now, interestingly, in that essay, you remark that many of your patients treat you poorly. I think that’s surprising to most of us, at least it is to me. I try to treat my doctors well for very self-interested reasons, but also as a form of respect to someone. Why do people treat you poorly, do you think?
Adam Cifu: Yeah. Well, I would say it’s certainly not many of my patients. It is a very, very small minority. I think–you know, people bring into the doctor’s office the way that they manage people in the rest of their lives. Most of my patients I think feel, I don’t know, entitled to good care, expect good care, expect an equal collegial relationship with me. And, that’s very easy for me. I think that’s very easy for the patients. Most of us fall in, naturally, to that.
There are also people who come to the doctor’s office feeling like they’re going to be, I don’t know, disrespected, disenfranchised, the way they are in the rest of their life. And, they sort of manage the doctor often in ways that they manage everything else.
Very often, interestingly with the doctors, that’s to be overly appreciative and overly thankful; and it comes off being very nice until you analyze where this is coming from. And, it’s kind of sad that, ‘Oh, my God, this is what this person needs to do to just get what they deserve.’
There are people who, I call them the sort of masters of the universe–the people who are used to bullying people and getting everything they expect in every part of their life–come into the doctor’s office in exactly the same way.
And then, there are people who I think just don’t recognize that there’s a benefit to a rich or at least equal or pleasant relationship with the physician, and almost look at the doctor as they would somebody else who is providing services to them in other parts of life. There’s a quote that I don’t know who it’s from: You can judge people by the way they treat bank tellers, wait staff, things like that. And, there are those people who treat those service workers terribly and they then treat their doctors terribly. And, it’s always interesting to me. So, I’m like, ‘Hmm, I’m going to do my best to take care of you like I would everybody else, but this doesn’t help you a whole lot.’
Russ Roberts: Yeah. ‘Why are you making it so hard?’
You suggest in the piece, which is quite thoughtful, that you try to treat all your patients the same, but you recognize that there are conditions and situations and interactions that make that difficult. This being one of them–an abusive patient, say. So, you mention that you actually try to–you view that as a challenge and they may even get better treatment than others.
But, you also talk about the human side of the doctor-patient relationship: that you connect to some of your patients more naturally, and then it affects your treatment of them in certain ways that was a little bit surprising to me. So, talk about that.
Adam Cifu: Right. This is a challenge, and I find this difficult. And, I think on my best days in the office when I’m mindful, I recognize this and work at it. At other times, I think I probably fall short on this. But, there are people–very often people who have similar backgrounds, similar life–who you immediately connect with and it’s very easy; and not only is there the doctor-patient relationship, but there’s something else added to it. I don’t know if this improves the care they get, but I can only imagine that it makes them more comfortable with you. This seems like a peer immediately.
And then, there are people who are from very different backgrounds, maybe backgrounds who are not–even the people from different backgrounds who I’m used to caring for, that although they’re expecting me to be a caring physician and I’m going to be that, and I expect them to be a patient I can work with and I’m going to do that, there’s still a little bit of a separation between us, right?
And, it may make them hold back, not tell me things they should. I might not understand things about their life. It may just take a little bit more work for me to understand where they’re coming from, what their social norms are, what their behaviors around medications are. And, maybe this is an argument for our continued effort to really diversify our field. But, I think most importantly, it’s just something to recognize as we care for the diversity of patients that we all do.
Russ Roberts: I have doctors in my life who I feel that peer kind of similar background and so on. None of them take care of me for money. They’re all my friends who I get free medical advice from.
The doctors that I pay or who are paid by my insurance or the state are not good at establishing that rapport; or maybe I’m not good at accepting it. I’ve never felt like a peer to a doctor, a caretaking doctor that I’m interacting with.
I have a long-standing joke on EconTalk that I got from a family friend, Paul Kerneklian[?sp.?]–he had a Ph.D. in anthropology. When people would say, ‘Are you a doctor?’ he’d say ‘Yes, but not the kind that helps people.’ So, I am a doctor, I’m a Ph.D., I am not the kind that helps people. But, that degree has never helped me establish a rapport with the doctors who’ve treated me.
In fact, many, many doctors who I’ve interacted with struggle with those kind of interpersonal skills. The friends I have, I bet they’re good at it with other people, not just me. I bet they’re good with their paying patients. So, I think it’s an art on the part of the caretaker. And, I’m curious if you think about that when you’re sitting with someone who often is partially clothed, struggling with perhaps a serious, traumatic life event: Do you have techniques or tricks or habits that help them be put at ease to share things that would be helpful to them, but otherwise they might keep to themselves?
Adam Cifu: Sure. I think those are all great points. So, I do; and, I think that it’s something that we do our best to train our young physicians/trainees in, that ability to be empathic, to meet people where they are, to put them at ease in, as you say, which is just, by definition, an uncomfortable experience.
It’s one of the few places that you go around in the world that you go to by choice–if you’re going to the doctor’s office and not the emergency room–where you’re going to be powerless, you’re not–in the end, you’re not really in control of your illness and your body. Certainly, we can all live good lives, but in the end, something’s going to get us no matter what we do. And, it’s so important to be able to support the patient during that time. Make them feel comfortable, make them be able to open up to you, feel like they have you in their corner for support.
While you were talking about it, it made me think of something that I think I struggle with most is that, although I feel like I have control of how the patient feels about the relationship in the room–I can make them feel more comfortable, I can make them feel supported–when they leave the room, what the patient brings to the relationship, in which I don’t have that much control of, does actually affect how they interact with me. Right?
The people who are maybe closer to me as peers, those people, there’s so much less of a barrier to access me. And there are so many ways to access your doctor these days, right?–whether it’s a phone call, an email, a text, the electronic medical record communication devices. Most of those people have absolutely no qualms about saying, ‘I got a question. I’m going to call my doctor about this.’
While the people who are a little bit more further afield and maybe still hold their doctors with, I don’t know, some level of respect, those people are often so hesitant to reach out, even in the ways that are completely appropriate and expected; and they’ll say, ‘Ah, I’ll wait until the next appointment.’ And often suffer for that.
Certainly, I got to take some responsibility. There’s something I haven’t done to make them feel empowered to be able to break through that. And, maybe this is one of those times that you have to think more about equity than equality, right? Those people need more help to get that adequate care that they’re supposed to have. But, boy, this is a challenge.
And, when it’s a day with 12 patients and you’re exhausted by the end of your clinic and are just sort of dying to get home, it’s just sometimes an effort that’s hard to expend.
Russ Roberts: I just want to say something on the side about this question of respect or I’d say even more. I would guess that most patients respect their doctors. They may not revere them the way they did in older, older times. And yet, despite the loss of expertise–respect for expertise–and respect for the elites that is permeating, I think, America and the West in all kinds of ways, everybody knows how hard it is to get into medical school and to survive it.
Everyone knows that you know an immense amount that I don’t know.
And then, there’s this third thing that I want to know if you feel it from patients. It’s a combination of idol worship and superstition. It’s basically–it’s almost as if there’d be a window. I wouldn’t see you. I would just slip my symptoms in the opening of the mail slot there and a response would come back, ‘You’re fine.’
And, so often we turn, I think–in those emails and texts or in sometimes personal communication, face-to-face–we want to be reassured. And, unless you’re an economist and you spend too much time listening to EconTalk or a listener to EconTalk, you’re going to accept what a doctor tells you in a way that is so different from any other service experience in your daily life.
And, I see it all the time–because I am an economist and I’ve heard every episode of EconTalk. So, when people tell me, ‘Oh, the doctor said I should do this test,’ and I’m thinking, ‘No, no, no, no, no, no, no. Don’t do that test. No, no, no. You’re not going to learn anything from it. It’s not going to change anything. Please don’t do it. There’s only downside risk.’
And, I just usually don’t say that. Because they have this almost divine respect for a doctor as somehow immortal–non-human in a godly way.
Adam Cifu: Right. Russ, there’s so much in what you just said. I think I could talk about this forever.
A few things stand out. First, the difference between reverence and respect deserves an essay in itself. I think probably a little bit of reverence is good just because that’s what the placebo effect is. Right? We use that as power, and that helps.
Though I think if you revere your doctor too much, you should probably find another doctor because you’re not going to question things.
I think respect is very different from that. Right? And, you do hope that you–I sort of hope that my patients mostly respect me, but don’t revere me, but also feel empowered enough to question me.
Your other point, which I really do love, is, sort of, the patient’s need for power in the relationship.
And, I have to say–having not listened to every episode of EconTalk, but a lot of them–your ability to–I often tell my students, when you learn to drive, my driving educator told me to aim high in steering, which always sounded like a ridiculous thing, but it was: Don’t just look very close up. Look way into the future. What am I worried about here?
And it’s so important in medical decision-making to say, ‘So, I’m choosing to take this medication. I’m choosing to have this test. What are the long-term outcomes of this? What am I going to do with the results of this test? Is it the right test? Is it worth doing it all? Do I actually want to know the results of this?’ And, that’s critical.
And then, the last thing, you’ve talked so much about artificial intelligence [AI].
And, we are quickly getting to the point where probably if a patient is able to present their symptoms, maybe even their signs–sort of physical examination signs–in a really reliable way, that maybe a computer can do as well or better than a doctor at, at least, outlining a differential diagnosis. Right? ‘Here are the three most likely things to think about and here’s the one thing that we need to really worry about.’
But, I think the vast majority of people would not be satisfied with that, because they’re not going to have maybe a little bit of that reverence for the computer that they might for a human being who they are attached to and feel like will carry a little bit more power in the discussion.
Russ Roberts: It’s such an interesting case when it’s a diagnostic issue rather than a treatment issue. They’re all interesting. But, my–I have a friend, he may be listening. He’s a doctor and I often turn to him. And, my mom turned to him once for a problem she was having, and he diagnosed it correctly. And she’s never gotten over that. She still remains in awe of his diagnostic ability.
I don’t know how special it was that he got that one right. He did.
But, I’m curious how–for your own internal, and I know you’re proud of your diagnostic ability. You write about it. It’s a combination of data and intuition, which is often data-driven, not just wild guessing. How do you feel about that? When you deliver a diagnosis, the patient doesn’t really want you to say, ‘I think this could be right.’ They want you to say, ‘It’s _blank_. The symptoms, they’re consistent with, and that’s what you got.’ Do you think about that?
Adam Cifu: I think about that a lot. Again, to talk a little bit about the arc of a career and what you gain as you get further in a career and what you lose, one of the things when I see a patient, say, in our urgent care center where I’m working with our trainees, very often we are delivering the same information. We’ve made the same diagnosis, right? But I am able to say it with such absolute confidence not only in what the diagnosis is, but in what the next steps are and how that person is going to do–I can kind of see into the future a little bit: This is what your outcome is going to be over the next three to six months.
And it’s interesting, patients–I hate saying patients because it’s really people, I’ve been in this situation–really latch onto that, because again it’s a time of uncertainty. It’s a time of powerlessness; it’s probably a time of anxiety. And, to be able to have someone who say, ‘This is what’s going on, this is what we’re going to do, and this is what’s going to happen,’ is so important.
Even if the other person standing in the room told you the exact same diagnosis, but they sort of pitch the plan and the outcome maybe a little bit more honestly, because how well do we actually know what the future holds? And, I think probably part of what your mom was responding to was ‘It’s this,’ and then you’re proven right, and ‘This person is going to be someone I’m going to trust in the future.’
Russ Roberts: That’s the Ouija board I’m going to take out again.
Adam Cifu: Right, exactly.
Russ Roberts: No, that’s just a cheap shot of humor.
Russ Roberts: Just one other aside, and then I want to ask you one last question on this topic. I have a friend who insists on addressing doctors by their first name. So, they walk in, they don’t say ‘Dr. So-and-So.’ They say, ‘Adam, good to see you,’ because often Adam says, ‘Russ, good to see you.’ So, they feel it’s important. I’m not sure why.
I don’t know if this is an ego issue or just a feeling of–I think it’s a dignity issue, a better word than ego. They want to be on that peer footing, that level field with the caregiver. Do you have patients who do that to you? What does it make you feel? Do you tell them what to call you?
Adam Cifu: I’ve thought too much about this. I generally introduce–I will say to the patient, ‘Mr. Roberts, Dr. Roberts, what would you like to be called?’ And then, I will respond in that same way.
I will not tell people what to call me. I’m perfectly happy with them calling me Dr. Cifu, Adam, whatever they like. If they say, ‘Mr. Cifu,’ I usually say, ‘You can call me anything. Call me Adam. Call me Dr. Cifu. Just don’t call me Mr. Cifu. I worked very hard for that degree. It seems weird for me.’
And so, most of the time when patients come in and say, ‘Adam, how are you?’ they’re people who I’ve already known and I’m very comfortable with. The people who address me as that right off the bat, it does seem like a little bit of a power play to me.
Russ Roberts: Yeah, that’s weird.
Adam Cifu: Yeah. And, I’m sort of fine with it, but it gives me some information about the person I’m dealing with and it makes me understand a little bit more about who they are, what they expect from the relationship, how I think they’re going to treat me. And, so, in a way, maybe as the person doing that, it’s fine. It’s a way of signaling and it probably cuts out a lot of the time of trying to work to understand who this person is.
Russ Roberts: And the same issue arises with clergy. And I think there’s another side of this we haven’t talked about and it relates to this question of worship or reverence. Some of us don’t want a first name relationship with our rabbi, imam, priest, minister. We want to look up to them, either as role models or sources of wisdom or counsel.
And, I’m not sure I want medical care from Adam. I want medical care from Dr. Cifu. And, if I could call you Your Highness, I feel even better, or Emperor Cifu. Anyway.
Adam Cifu: You would be welcome to call me any of those things. It’s funny, I’ve never sort of recognized that parallel with clergy. And, I would be wildly uncomfortable, certainly–when I meet someone, which is often for me in the office, I have to call that patient Rabbi, Father, whatever. It’s very interesting.
It probably goes to socialization as well. It’s how I was brought up, how I was taught to respect these people. And, it’s the reason that–the only reason I can call my doctors by their first name is that most of them are peers or former trainees. And, that’s how I think of them.
Russ Roberts: Well, my example of this is: when I was a grad student at the University of Chicago, all the faculty members were Mister–Mister Becker, Mister Lucas–because, of course, they all had Ph.Ds and, though they had earned them, it was unnecessary to bestow the honorific on them.
And, if you go back–if listeners go back to my, I think it’s in the first year of EconTalk, 2006, I interviewed Gary Becker, who had been my advisor. And I had spent a lifetime calling him Mister Becker–as did his secretary, Myrna Hieke, by the way, at least when she talked to us. I don’t know what she called him. And, you’ll hear me perhaps struggle to call him ‘Gary.’It was really uncomfortable.
And–there’s something kind of beautiful about it. I don’t think there’s anything shameful about it. I think it’s kind of cool.
Adam Cifu: Not at all. Not at all. Certainly, my mentors along the way, even if they have yelled at me and made them call me by their first name, I still think of them as Professor Wittner or whatever.
Russ Roberts: Yeah. Sticks in your throat.
Russ Roberts: Last question on this. You have been a patient, certainly, in your life and you’ve gone to doctors’ offices. When you’re sitting there in that beautiful robe–it’s much like a spa, really, usually when you’re at doctor’s office–when you’re sitting in that flimsy robe or in some state of undress, do you find yourself reflecting on this issue: that, the person on the other side of that relationship may not be seeing you as a peer or may be, and how that affects your ability to share your symptoms, and so on?
Adam Cifu: I do. Interestingly, from me, given my role and now advancing age, I think so much when I’m in that position about how I’m going to make sure that I’m actually being seen as a patient rather than as a doctor, and make sure that I’m, in a way, being treated like everybody else, spoken to like everybody else.
And, I probably overplay the patient role because I have seen so many–let’s call them VIPs [Very Important Persons]–treated poorly because people are so careful about how they’re going to ask questions and what kind of tests they’re going to recommend.
And, I want to stress so intensely that, like, ‘God, you got to take care of me like you would take care of anybody else.’ Maybe an opposite reaction than people would expect. But I embrace the paper gown, I guess.
Russ Roberts: Definitely a poster or a bumper sticker with an exclamation point at the end: Embrace the paper gown!
Russ Roberts: Let’s shift gears. Let’s turn to another of your essays, which are four of the things your patients have taught you. You can go through them briefly. I’ve written them down. I don’t know if you have them in front of you, but do you want to give us some highlights from that–as you’ve gotten older, the wisdom you’ve acquired?
Adam Cifu: Yeah. And, a lot of these things, when I say it, I feel a little embarrassed because maybe they’re obvious. I think the one that comes to mind most quickly from that essay is that it’s the patient who is taking the medications. And, we so often forget as doctors that we think we understand the most important reason that people should be having a surgery, taking a medication, accepting a diagnostic test, because we’re sort of obsessed with, ‘Okay, I’m doing this to get the person better and this is the obvious thing to do.’
But, it’s the person who has to live with the information that they’re getting. It’s the person who actually has to take that pill every day, maybe deal with the side effects of that medication every day. And, boy, I have just come to appreciate the fact that an educated–I wouldn’t say educated–a well-informed adult, boy, should have all the leeway in the world to accept care, to not accept care, to make what seems from the doctor’s perspective an absolutely terrible decision.
And, it seems so obvious, but it’s so difficult after you’ve been through medical training to adjust to that, to adapt to that.
Russ Roberts: You tell a great story in the essay about the older person who is–you recommend, I don’t know how old you were at the time, you were young–I think it’s a dietary recommendation. Is that right?
Russ Roberts: Is that right?
Adam Cifu: This was actually when I was an intern. I was working at the Dana-Farber Cancer Center. We had multiple people at, really the end of their lives on very complicated novel cancer therapies. And, this woman came in, even if she did perfectly last six months of her life–besides her cancer, she also had pretty severe cardiac disease.
And, I wrote her for a low-salt, low-cholesterol, cardiac diet. And the patient actually had the nurse page me to the bedside so she could berate me. And, she began her talk to me saying, ‘I’m told that you wrote me for this diet. You can only possibly be an optimist or an idiot.’ And, I was like, ‘Oh?’
And, obviously, I’m telling this story, this must have been 1993 or 1994: 30 years later and it’s stuck with me so well, and I can still picture her and she’s sort of a mentor to some extent. She taught me a lesson there, which is well remembered.
Russ Roberts: Well, we’ve finished–you’ve forgotten, I read it more recently–and she said, ‘You’re either an optimist or moron.’ And, then, she said something like, ‘I’m going to die soon, so it’s only a question of whether I’m going to be unhappy. So, can’t you at least let me eat some food that I like?’ It’s a great story.
Adam Cifu: Right. Absolutely. I changed her diet immediately. I have to. I think I might’ve brought her a cookie at some time during that admission as well. [More to come, 33:59]