What's Happening Inside Your Doctor's Head and Heart (with Adam Cifu)

Aug 19 2024

Physician Adam Cifu keeps a binder of every patient of his who has passed away. Every once in a while, he opens it and remembers the lives of his past patients. Morbid? Maybe a little. But it's just one of the ways Cifu tries to make his practice of medicine more mindful. In this conversation with EconTalk's Russ Roberts, Cifu explores the human side of medicine and the challenges of being a good doctor.

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Time	Podcast Episode Highlights
0:37	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.
1:02	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.
5:27	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.
10:42	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.
15:20	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.
20:32	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.
23:26	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.
28:16	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!
30:07	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? Adam Cifu: Yes. 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. Russ Roberts: Yeah, salted caramel, I'm sure. What else? We've got--a very interesting wording. You say "Diagnostic tests give you more than just a diagnosis." What does that mean? Adam Cifu: Yeah. So, when we do a diagnostic test, we are looking to say, 'Do you have coronary disease? Do you have a urinary tract infection?' But, what's interesting is that very often those diagnostic tests, one, change people's lives. We're very fond of saying that they take people and turn them into patients. Sometimes that's necessary. Sometimes, especially in the case of screening tests, that's not necessary. Maybe you're turning people into a patient in a way that's not going to benefit them at all. The other thing is that doing a diagnostic test, especially with 21st-century medicine, generally unleashes an entire string of decisions and possibilities and interventions. And, you just have to be so careful at the very beginning of that string: Do you want to go down this path? And, I think most of us think that, 'Oh, what's wrong with a little bit of information? Knowledge is power.' But sometimes in retrospect, you, me as the doctor, my patient feels like, 'Ah, maybe if we'd never known this, instead of living for two years, 18 months of those two years knowing that I had cancer, would I have been better off living for two years but only knowing I had cancer for the last six months of it?' And, I'm not sure--well, I should say I know I don't have the right answer most of the time, but very often I just like to pause before placing that order. Have the conversation with the patient and say, 'Look, these are next steps. These are possible outcomes. Do you want to really start this?'
36:13	Russ Roberts: Yeah. And I'm going to say something now I don't--I want listeners to be careful. I think it's a risky advice--or it's not advice: it's just a risky observation and somewhat dangerous. I've written that, oftentimes, we delay decisions because we just don't want to make a decision, and we claim that we're waiting to get more information, and when in fact we just don't want to make a decision. There's actually no information forthcoming that would make the decision any better. It's just: I'd rather postpone it. And it seems to me sometimes in medical care, this issue you're talking about, of--once you get on this conveyor belt, you're going to be put through a series of further tests, further diagnostics, and interventions--that sometimes it's worth waiting to see if that situation is stable or not. What's the speed of growth? And, of course, often we're just so horrified that we have something that we don't want to wait. That's also very wise and very human. But I just know times in my life, whether it's fear of the diagnosis or an awareness that not all diagnostics are free, even if they're financially nothing out of pocket, that there are times that it's better to wait. Do you think about that? It seems to me it's an interesting challenge for us--certainly as potential patients. It can kill you. Adam Cifu: Right. It can kill us. Russ Roberts: That's why I say it with some trepidation. I'm not suggesting that you should always wait. That would be really not smart. But, sometimes it is better to keep something under observation and learn something about it--sometimes. Adam Cifu: I think it is worth asking the question because, as you say, sometimes a diagnosis can be life or death. And, it's worth asking the question: How necessary is it that I need to make a decision now? How long would you feel comfortable waiting? As soon as you started talking about it, although I very much identify, as a medical conservative, with: Boy, a lot of the things we take care of just get better on their own and probably waiting is the best medicine. There are so many people who I've taken care of over the years who postpone decisions for so long; and I can hear myself at so many visits saying, 'You have made the decision not to embark on this workup. You've made that decision by postponing the decision.' And, for me as someone with limited time with patients, I mostly have to tell them, 'I'm considering this decision made. Because you've postponed making a decision for six months, I assume you're never going to do anything about this. Please bring this up to me again if you change your mind.' Because at some point as a doctor, I'm like, 'I can't wait any longer for this person.' Russ Roberts: But, I think that's really important advice. To make someone aware that they've implicitly made that choice and forcing them to confront it is, I think, incredibly helpful. Most doctors just say, 'Go get this tested. Go get this test.' And, it's not their test. They send you somewhere else. And, there are many of those I never did. And I've been lucky. Maybe I'm stupid. I don't know. It was foolish, but reminding me that that's in my nature is a good thing, because that's dangerous. Adam Cifu: Well, I think your point is--also, and it's probably something I'm now coming out of this recording, both with a new essay topic but also with a new tool to use with patients--is that I think that delaying a test until you have more information is an intelligent thing to do. And, that 'more-information' may be that I'm doing more research, I'm waiting for some study to be completed, or I'm waiting to see how my symptoms progress over the next three months. If you are delaying a test for more information which will not be coming, then you've made a decision not to have that test and that probably just needs to be articulated.
40:41	Russ Roberts: Yeah. The other lessons you talk about, anything you want to say there about there are two ways to care for patients with ambiguous illnesses goes poorly and one way it goes well. What's that about? Adam Cifu: So, ambiguous illnesses are something which has gone by a lot of names over the years--symptoms of unknown origin is another one which I love--are patients who are clearly suffering from something but that we in medicine haven't been able to reduce it to our sort of 21st-century pathophysiologic rubrics. And so, not only do we not understand them well, we generally do not have good treatments for them. And, I think probably what we're talking about most now is long COVID: that even the people who study this the most don't understand it that well and even have trouble defining it. And, seeing patients who have these ambiguous illnesses can be very frustrating, both for doctor and patient. And, what I tried to articulate in this essay was that I have seen these visits go well or these relationships around an illness go well, and that's usually when a doctor can be honest and say, 'We don't understand this, but I am committed to working with you on this. I am happy to entertain suggestions for you. I'm happy for you to seek care that I feel like is safe and not something which will steal your money outside of traditional medicine.' And, where a patient is willing to almost buy into that uncertainty, accept that uncertainty, work with the physician to try to get better. Often those relationships go very poorly, either because the doctor just gives up--is so frustrated that, 'I can't take care of this the way I can take care of hypertension or diabetes or breast cancer,' and feels like they have nothing to offer the patient. And, even if they don't say, 'I have nothing to offer you,' the patient understands very quickly that this doctor has given up on me. Sometimes--although we hate to say this--sometimes it's the patient's fault, because the doctor has sort of done what's right and says, 'We don't understand this. No further evaluation is going to lead us to a diagnosis. I am not going to be able to prescribe a silver bullet for you. But I will work with you.' And, that's honest. That person is committed to helping the symptoms. But the patient at that point in time is kind of unwilling to accept that and will continue to change doctors, will constantly shop for that diagnosis which will be the answer, even if all evidence says that that won't exist. And, those people often put themselves at great risk. Because there's nothing we're better at medicine than spending lots and lots of money doing lots and lots of tests; and many of those are invasive, many of those are dangerous, and some of those turn up information that leads to treatments of other problems which aren't important. Russ Roberts: That comes back partly to what we said earlier, too. We have such respect, I think, for modern medicine. You're in the kitchen. I had a friend who worked in the pharmaceutical business who said he never took medicine. I said, 'What do you mean?' He said, 'I worked for a pharmaceutical company.' And, he was serious. I don't think he literally meant he'd never take medicine; but he had an inherent skepticism of the reliability of certain treatment. But for most of us, that's just not an entertainable hypothesis and we expect you to--used this image on the program before: you lift up the hood of the car and there's a switch that should be on On and it's off. 'Oh, I found the problem.' That is what we expect of our doctors. We often get it. And it's wonderful. So, when it can't be done or isn't easily done, the cognitive dissonance there is very disturbing. Adam Cifu: Yeah. There are a lot of downstream risks to our successes in the 21st century. Certainly true.
45:24	Russ Roberts: I want to go to my favorite essay of the ones I read recently that you shared with me when we were prepping for this, which is called--it's about your memory binder. What is your memory binder? Adam Cifu: So, my memory binder is truly a binder--I have it behind me in my office here--which has the face sheet, the snapshot as we call it, for every patient who I've ever taken care of who has died. Not people I've known for three days in the hospital, but people who I've cared for in my outpatient practice who have passed away. I certainly did not plan to keep this. I began keeping it because my very first patient who died when I was an attending physician, I was pretty broken up. It was a very difficult--and for a very young woman. And, as I sort of pulled her face sheet out of my file, it was, like, 'What am I supposed to do with this?' And, the idea of just throwing it in the garbage was literally painful. So, I stuck it in a drawer. And, that became a habit for me of what I would do with those. And then, when my office got moved a few years into my practice and I opened up this drawer, and I was like, 'What do I do with these?' And, so, I just put holes in them and put them in a binder and I've continued that. And it's turned into this sort of amazing thing for me, because it reminds me of people who I was close to, even if it was for a brief amount of time, often very intense periods--certainly in their life, but often in mine. The diseases that are represented in there have evolved over time. My patient panel has evolved so much over time: where at the beginning, these were patients who I knew very briefly and there's usually just a sheet. As time has gone on, very often families send me remembrances, or I take things from their funerals, which I attach on there. Now, given where I work and what my patient panel looks like, I have three-page obituaries which go along with those, which I staple on. And, I can't say--it would be very morbid for me to say, 'Oh, I look at this every week.' But, there are occasional times when someone passes and I put their sheet in there that I take towards, kind of thumbing through it. And, interestingly, the memories are usually good rather than painful because what's lost is sort of the disease state; and what remains is kind of an image of just these people, these patients of mine, which is kind of wonderful to be reminded of them. Russ Roberts: And, to be clear, these are not people who died because of your mistakes--although there are such people who collect those. These are just people who, in the course of life, either at the end of an illness, that was not curable or just from [?] other causes unrelated to medical treatment just didn't--are no longer with us. You also mention that some people keep binders, if they're OB-GYNs [obstetrician-gynecologists], of babies they've delivered. And so, you write about yours, Within the binder is a single page for every one of my patients who has died. The collection is not a place of bitterness and regret, nor is each entry associated with the joy of a new life. Instead, it is a place I visit to pay my respects, to learn, to reminisce, and to trace the arc of my career. So, I think that's very beautiful. I want to go back to that first page, though, because it just struck me as very interesting. There are people who are hoarders, who have trouble throwing things out. I don't know if you're one of those, but this strikes me--the face sheet, the keeping, the finding yourself, having a very somewhat sterile summary of a human being, holding it in your hand after that person has passed away, and feeling uncomfortable throwing it out, is really a beautiful thing. It reminds me of--in the Jewish tradition, if you have a holy document, whether it's a piece of a Torah scroll or anything that was used for ritual purposes, often you're not allowed, according to Jewish law, to throw it away. And in fact you have to bury it the way you would a human being, because there is something divine about that writing. Which is a very--I think--powerful idea. On the surface, it might strike some people as kind of silly, but it forces you, over time, to revere--to come back to a word we used before--language. And holy language in particular; and things used in ritual, and so on. And, it's obvious to me that you saw that somewhat sterile piece of paper to have some transcendence to it and that it would be unseemly to treat it the way you would a receipt or an invoice that was inside a package, which is what we usually do when we throw a piece of paper away. And, it didn't belong with those kinds of pieces of paper. So, that's really extraordinary. Adam Cifu: Yeah. That is true. It is wonderfully stated. It probably gives more thoughtfulness to the action at the time. I think as you talked about it, and I think of the individual patient, this was someone at the very start of my career. And, reflecting on it now, her outcome would have been the same no matter what I had done, but I certainly would have taken care of her differently now 30 years in than I would have at the time. And I think I recognize that I wasn't perfect in the way I cared for her. And, because there was a little bit of, let's call it guilt at the time, that was another reason that I couldn't just toss this away. I wanted to be reminded of it. Russ Roberts: Roughly how many entries are in that binder? How many people? Adam Cifu: Yeah. So, it's hard to ask a doctor to admit this, right? I graduated from medical school in 1993. I've had my own practice here since 1997, so 27 years as a general internist. When I picked up my practice, most people were in their 50s and 60s and by the wonders of math, those people are mostly in their 80s and 90s now. So, we're talking a few hundred patients at this point. I went back and added the one man who I took care of as a resident in my resident practice who died. Just sort of wrote his name on a piece of paper and stuck it in the back because I felt like he was an important person to me as the first person I lost.
53:00	Russ Roberts: Why do you think you do this? I understand why you might've been uneasy throwing that away, but obviously this is more than just respect for a memento. There's something else going on there. Adam Cifu: Yeah. I think there are two things, one is personal and one is professional. I do think, to some extent, it is medically interesting. I can look back through this and I can see why people died. And, it really is amazingly interesting that, at the beginning of my career, there was a lot of chronic obstructive pulmonary disease, HIV [Human immunodeficiency virus], heart disease, cancers. As my practice has progressed and as medicine has progressed, more and more people just die of old age, die after falls, because medicine has gotten so much better that a lot of those things that people used to die , people don't die of anymore if they're receiving good regular medical care. And, that's important. The other thing is as physicians, and I think patients often don't realize this, I become quite attached to a lot of my patients. They're not my friends, but I am very interested in them, I am very fond of them. And, when I'm not seeing them anymore, when all of a sudden they disappear from my schedule, whether it be every couple of weeks, often at the end of somebody's life, or every few months while they're old and sick, or maybe every year or two when they're young and healthy, they sort of leave a hole. And, when a family member dies, we can memorialize that person, whether it's going to a graveyard or whether it's just sitting around at a family dinner and telling stories about someone. That person lives on. For doctors with patients, that doesn't happen. Those people just truly disappear. And, this is really a way for me to memorialize people who, often I was fond of. Even the people who I'm not fond of--maybe to go back to the beginning of this conversation--they played a big part in my life. Often in the last weeks of people's lives, especially when you're caring for them in hospice, or they're very sick and you're trying desperately to keep that person around for a little longer, I'll wake up at four o'clock in the morning thinking about, like, 'Ah, we should do this. This is a good idea.' And, it seems like there should be a way to think about that as you go forward. Russ Roberts: I never thought about it. I have friends here at work, I have friends from my community activity, whether it's religious or hobbies or other things. I have my family. You don't spend so much time with your colleagues. I mean, you do. They're colleagues you interact with daily. But most of your daily interactions are patients. So, at least a third of your life, maybe more, are these people; and it would be unseemly to take a picture of them before they passed away--or any other patients generally. But, for our friends and family who we love, whether they're alive or not, we often look at pictures of them as a way of remembering how they played a role in our life, that time in our life. And, obviously, this is a way that you can do it. Do you know of any other doctors who do this? Adam Cifu: There are a couple of my colleagues who do this--I'll say do this now because of me talking to them about them. But, as you say, there are people in medicine who carry other lists. Many obstetricians keep a list of every child they've delivered over the years. I also have a list, fortunately--a much smaller little journal of errors that I've made--that I keep track of that I do go back somewhat frequently to. And, Henry Marsh wrote an amazing book a few years ago called Do No Harm, where he really spent an entire book--each chapter going in quite detail to patients who he feels like he harmed during his career--always setting out to do the best, but where the outcomes were poor. And, the honesty of that book, which is essentially a list turned into a nonfiction memoir, is spectacular and really resonates with me. Russ Roberts: You're right that you worry that your colleagues might find it morbid. I think it is morbid. Do most of them know about it? Do any of them ever--you say a couple have copied you. Do any of them look at you askance for doing this? Adam Cifu: I'm sure they do, but they don't tell me. I think having written about this, I think they all know. To circle back to what you said about colleagues, I think it's interesting. Of the colleagues who we work with, you think of the conversations you have with your colleagues, and 95% of them, they are very much, 'How are the kids? What'd you do over the weekend? Do you have any travel planned?' And, you think of the conversations you have with your patients, which are so much deeper than they are with people who you've worked with for decades. Russ Roberts: Interesting. Yeah.
58:55	Russ Roberts: You're a pretty sensitive person. You might be faking it. Your essays reveal a certain sensitivity to my ear and eye. And, you just mentioned something in passing that you keep a book of your mistakes and review it from time to time. Many people--I don't know about most doctors--but many people prefer not to think about those. They're not interested in learning from them. They'd rather repress those memories. I'm curious what made you who you are to the extent that you have a feeling for it. Is it something you think you have from your parents, books you read, role models you found? It's a slightly awkward question. I apologize for it. But, I think it's--your essays reflect a level of care that I think all of us would want to receive from a doctor and don't always feel that we do. So, I salute you for that. And, I'm curious if you know the source of your devotion to your craft. Adam Cifu: I appreciate that. They're very kind words. I could say that I didn't come on EconTalk to be psychoanalyzed, so I'm going to refuse to answer the question. Russ Roberts: Fair enough. We can cut it, too, if you want. Adam Cifu: No, no, no. I'm not sure. Interestingly, my father was an adolescent psychoanalyst, a job which I think you could only do in 1980s Manhattan. And, I always said to some extent, it was impossible because as a teenager, he always knew what I was thinking more than I was thinking, which just sort of pissed me off. But, on the other hand, he was always a step ahead about thinking about things and I think pushed me to do it. And so, I think I do owe a lot to him. I also, although I'm not going to say I'm a fraud, it's always a little bit hard having these conversations because these kind of things are always a small part of ourselves. And, I don't want it to make it seem like I'm always walking around sort of navel-gazing, thinking about my practice in great depth. But, I do think that medicine is such a rich field as far as the human interaction part of it, that I do find myself having to think about that almost as part of doing a good job and keeping myself sane. And, I like to figure out a way of processing that. Some of it is conversations with family and colleagues and friends, and some of it for me are these written reflections. Because as anybody who does any writing knows, you have these ideas, which when you're walking to work, you think, 'Wow, that's profound.' And then, you write it down and 90% of the time, you're like, 'This is the stupidest thing I've ever written.' And, sometimes you're like, 'Huh, there's something to this.' And, it's helpful to work it out on a piece of paper and figure out what actually works and what doesn't. Russ Roberts: My guest today has been Adam Cifu. Adam, thanks for being part of EconTalk. Adam Cifu: Thank you so much, Russ.

Time

Podcast Episode Highlights

0:37

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.

1:02

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.

5:27

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.

10:42

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.

15:20

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.

20:32

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.

23:26

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.

28:16

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!

30:07

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?

Adam Cifu: Yes.

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.

Russ Roberts: Yeah, salted caramel, I'm sure.

What else? We've got--a very interesting wording. You say "Diagnostic tests give you more than just a diagnosis." What does that mean?

Adam Cifu: Yeah. So, when we do a diagnostic test, we are looking to say, 'Do you have coronary disease? Do you have a urinary tract infection?' But, what's interesting is that very often those diagnostic tests, one, change people's lives. We're very fond of saying that they take people and turn them into patients. Sometimes that's necessary.

Sometimes, especially in the case of screening tests, that's not necessary. Maybe you're turning people into a patient in a way that's not going to benefit them at all.

The other thing is that doing a diagnostic test, especially with 21st-century medicine, generally unleashes an entire string of decisions and possibilities and interventions. And, you just have to be so careful at the very beginning of that string: Do you want to go down this path?

And, I think most of us think that, 'Oh, what's wrong with a little bit of information? Knowledge is power.' But sometimes in retrospect, you, me as the doctor, my patient feels like, 'Ah, maybe if we'd never known this, instead of living for two years, 18 months of those two years knowing that I had cancer, would I have been better off living for two years but only knowing I had cancer for the last six months of it?'

And, I'm not sure--well, I should say I know I don't have the right answer most of the time, but very often I just like to pause before placing that order. Have the conversation with the patient and say, 'Look, these are next steps. These are possible outcomes. Do you want to really start this?'

36:13

Russ Roberts: Yeah. And I'm going to say something now I don't--I want listeners to be careful. I think it's a risky advice--or it's not advice: it's just a risky observation and somewhat dangerous. I've written that, oftentimes, we delay decisions because we just don't want to make a decision, and we claim that we're waiting to get more information, and when in fact we just don't want to make a decision.

There's actually no information forthcoming that would make the decision any better. It's just: I'd rather postpone it.

And it seems to me sometimes in medical care, this issue you're talking about, of--once you get on this conveyor belt, you're going to be put through a series of further tests, further diagnostics, and interventions--that sometimes it's worth waiting to see if that situation is stable or not. What's the speed of growth?

And, of course, often we're just so horrified that we have something that we don't want to wait. That's also very wise and very human.

But I just know times in my life, whether it's fear of the diagnosis or an awareness that not all diagnostics are free, even if they're financially nothing out of pocket, that there are times that it's better to wait.

Do you think about that? It seems to me it's an interesting challenge for us--certainly as potential patients. It can kill you.

Adam Cifu: Right. It can kill us.

Russ Roberts: That's why I say it with some trepidation. I'm not suggesting that you should always wait. That would be really not smart. But, sometimes it is better to keep something under observation and learn something about it--sometimes.

Adam Cifu: I think it is worth asking the question because, as you say, sometimes a diagnosis can be life or death. And, it's worth asking the question: How necessary is it that I need to make a decision now? How long would you feel comfortable waiting? As soon as you started talking about it, although I very much identify, as a medical conservative, with: Boy, a lot of the things we take care of just get better on their own and probably waiting is the best medicine.

There are so many people who I've taken care of over the years who postpone decisions for so long; and I can hear myself at so many visits saying, 'You have made the decision not to embark on this workup. You've made that decision by postponing the decision.' And, for me as someone with limited time with patients, I mostly have to tell them, 'I'm considering this decision made. Because you've postponed making a decision for six months, I assume you're never going to do anything about this. Please bring this up to me again if you change your mind.' Because at some point as a doctor, I'm like, 'I can't wait any longer for this person.'

Russ Roberts: But, I think that's really important advice. To make someone aware that they've implicitly made that choice and forcing them to confront it is, I think, incredibly helpful. Most doctors just say, 'Go get this tested. Go get this test.' And, it's not their test. They send you somewhere else. And, there are many of those I never did. And I've been lucky. Maybe I'm stupid. I don't know. It was foolish, but reminding me that that's in my nature is a good thing, because that's dangerous.

Adam Cifu: Well, I think your point is--also, and it's probably something I'm now coming out of this recording, both with a new essay topic but also with a new tool to use with patients--is that I think that delaying a test until you have more information is an intelligent thing to do. And, that 'more-information' may be that I'm doing more research, I'm waiting for some study to be completed, or I'm waiting to see how my symptoms progress over the next three months.

If you are delaying a test for more information which will not be coming, then you've made a decision not to have that test and that probably just needs to be articulated.

40:41

Russ Roberts: Yeah. The other lessons you talk about, anything you want to say there about there are two ways to care for patients with ambiguous illnesses goes poorly and one way it goes well. What's that about?

Adam Cifu: So, ambiguous illnesses are something which has gone by a lot of names over the years--symptoms of unknown origin is another one which I love--are patients who are clearly suffering from something but that we in medicine haven't been able to reduce it to our sort of 21st-century pathophysiologic rubrics.

And so, not only do we not understand them well, we generally do not have good treatments for them.

And, I think probably what we're talking about most now is long COVID: that even the people who study this the most don't understand it that well and even have trouble defining it.

And, seeing patients who have these ambiguous illnesses can be very frustrating, both for doctor and patient.

And, what I tried to articulate in this essay was that I have seen these visits go well or these relationships around an illness go well, and that's usually when a doctor can be honest and say, 'We don't understand this, but I am committed to working with you on this. I am happy to entertain suggestions for you. I'm happy for you to seek care that I feel like is safe and not something which will steal your money outside of traditional medicine.' And, where a patient is willing to almost buy into that uncertainty, accept that uncertainty, work with the physician to try to get better.

Often those relationships go very poorly, either because the doctor just gives up--is so frustrated that, 'I can't take care of this the way I can take care of hypertension or diabetes or breast cancer,' and feels like they have nothing to offer the patient. And, even if they don't say, 'I have nothing to offer you,' the patient understands very quickly that this doctor has given up on me.

Sometimes--although we hate to say this--sometimes it's the patient's fault, because the doctor has sort of done what's right and says, 'We don't understand this. No further evaluation is going to lead us to a diagnosis. I am not going to be able to prescribe a silver bullet for you. But I will work with you.' And, that's honest. That person is committed to helping the symptoms. But the patient at that point in time is kind of unwilling to accept that and will continue to change doctors, will constantly shop for that diagnosis which will be the answer, even if all evidence says that that won't exist.

And, those people often put themselves at great risk. Because there's nothing we're better at medicine than spending lots and lots of money doing lots and lots of tests; and many of those are invasive, many of those are dangerous, and some of those turn up information that leads to treatments of other problems which aren't important.

Russ Roberts: That comes back partly to what we said earlier, too. We have such respect, I think, for modern medicine. You're in the kitchen. I had a friend who worked in the pharmaceutical business who said he never took medicine. I said, 'What do you mean?' He said, 'I worked for a pharmaceutical company.'

And, he was serious. I don't think he literally meant he'd never take medicine; but he had an inherent skepticism of the reliability of certain treatment.

But for most of us, that's just not an entertainable hypothesis and we expect you to--used this image on the program before: you lift up the hood of the car and there's a switch that should be on On and it's off. 'Oh, I found the problem.'

That is what we expect of our doctors. We often get it. And it's wonderful. So, when it can't be done or isn't easily done, the cognitive dissonance there is very disturbing.

Adam Cifu: Yeah. There are a lot of downstream risks to our successes in the 21st century. Certainly true.

45:24

Russ Roberts: I want to go to my favorite essay of the ones I read recently that you shared with me when we were prepping for this, which is called--it's about your memory binder. What is your memory binder?

Adam Cifu: So, my memory binder is truly a binder--I have it behind me in my office here--which has the face sheet, the snapshot as we call it, for every patient who I've ever taken care of who has died. Not people I've known for three days in the hospital, but people who I've cared for in my outpatient practice who have passed away.

I certainly did not plan to keep this. I began keeping it because my very first patient who died when I was an attending physician, I was pretty broken up. It was a very difficult--and for a very young woman. And, as I sort of pulled her face sheet out of my file, it was, like, 'What am I supposed to do with this?' And, the idea of just throwing it in the garbage was literally painful. So, I stuck it in a drawer. And, that became a habit for me of what I would do with those.

And then, when my office got moved a few years into my practice and I opened up this drawer, and I was like, 'What do I do with these?' And, so, I just put holes in them and put them in a binder and I've continued that. And it's turned into this sort of amazing thing for me, because it reminds me of people who I was close to, even if it was for a brief amount of time, often very intense periods--certainly in their life, but often in mine.

The diseases that are represented in there have evolved over time. My patient panel has evolved so much over time: where at the beginning, these were patients who I knew very briefly and there's usually just a sheet. As time has gone on, very often families send me remembrances, or I take things from their funerals, which I attach on there. Now, given where I work and what my patient panel looks like, I have three-page obituaries which go along with those, which I staple on.

And, I can't say--it would be very morbid for me to say, 'Oh, I look at this every week.' But, there are occasional times when someone passes and I put their sheet in there that I take towards, kind of thumbing through it.

And, interestingly, the memories are usually good rather than painful because what's lost is sort of the disease state; and what remains is kind of an image of just these people, these patients of mine, which is kind of wonderful to be reminded of them.

Russ Roberts: And, to be clear, these are not people who died because of your mistakes--although there are such people who collect those. These are just people who, in the course of life, either at the end of an illness, that was not curable or just from [?] other causes unrelated to medical treatment just didn't--are no longer with us. You also mention that some people keep binders, if they're OB-GYNs [obstetrician-gynecologists], of babies they've delivered.

And so, you write about yours,

Within the binder is a single page for every one of my patients who has died. The collection is not a place of bitterness and regret, nor is each entry associated with the joy of a new life. Instead, it is a place I visit to pay my respects, to learn, to reminisce, and to trace the arc of my career.

So, I think that's very beautiful.

I want to go back to that first page, though, because it just struck me as very interesting. There are people who are hoarders, who have trouble throwing things out. I don't know if you're one of those, but this strikes me--the face sheet, the keeping, the finding yourself, having a very somewhat sterile summary of a human being, holding it in your hand after that person has passed away, and feeling uncomfortable throwing it out, is really a beautiful thing.

It reminds me of--in the Jewish tradition, if you have a holy document, whether it's a piece of a Torah scroll or anything that was used for ritual purposes, often you're not allowed, according to Jewish law, to throw it away. And in fact you have to bury it the way you would a human being, because there is something divine about that writing.

Which is a very--I think--powerful idea. On the surface, it might strike some people as kind of silly, but it forces you, over time, to revere--to come back to a word we used before--language. And holy language in particular; and things used in ritual, and so on.

And, it's obvious to me that you saw that somewhat sterile piece of paper to have some transcendence to it and that it would be unseemly to treat it the way you would a receipt or an invoice that was inside a package, which is what we usually do when we throw a piece of paper away. And, it didn't belong with those kinds of pieces of paper. So, that's really extraordinary.

Adam Cifu: Yeah. That is true. It is wonderfully stated. It probably gives more thoughtfulness to the action at the time.

I think as you talked about it, and I think of the individual patient, this was someone at the very start of my career. And, reflecting on it now, her outcome would have been the same no matter what I had done, but I certainly would have taken care of her differently now 30 years in than I would have at the time.

And I think I recognize that I wasn't perfect in the way I cared for her. And, because there was a little bit of, let's call it guilt at the time, that was another reason that I couldn't just toss this away. I wanted to be reminded of it.

Russ Roberts: Roughly how many entries are in that binder? How many people?

Adam Cifu: Yeah. So, it's hard to ask a doctor to admit this, right? I graduated from medical school in 1993. I've had my own practice here since 1997, so 27 years as a general internist. When I picked up my practice, most people were in their 50s and 60s and by the wonders of math, those people are mostly in their 80s and 90s now.

So, we're talking a few hundred patients at this point.

I went back and added the one man who I took care of as a resident in my resident practice who died. Just sort of wrote his name on a piece of paper and stuck it in the back because I felt like he was an important person to me as the first person I lost.

53:00

Russ Roberts: Why do you think you do this? I understand why you might've been uneasy throwing that away, but obviously this is more than just respect for a memento. There's something else going on there.

Adam Cifu: Yeah. I think there are two things, one is personal and one is professional. I do think, to some extent, it is medically interesting. I can look back through this and I can see why people died. And, it really is amazingly interesting that, at the beginning of my career, there was a lot of chronic obstructive pulmonary disease, HIV [Human immunodeficiency virus], heart disease, cancers.

As my practice has progressed and as medicine has progressed, more and more people just die of old age, die after falls, because medicine has gotten so much better that a lot of those things that people used to die , people don't die of anymore if they're receiving good regular medical care. And, that's important.

The other thing is as physicians, and I think patients often don't realize this, I become quite attached to a lot of my patients. They're not my friends, but I am very interested in them, I am very fond of them. And, when I'm not seeing them anymore, when all of a sudden they disappear from my schedule, whether it be every couple of weeks, often at the end of somebody's life, or every few months while they're old and sick, or maybe every year or two when they're young and healthy, they sort of leave a hole.

And, when a family member dies, we can memorialize that person, whether it's going to a graveyard or whether it's just sitting around at a family dinner and telling stories about someone. That person lives on. For doctors with patients, that doesn't happen. Those people just truly disappear. And, this is really a way for me to memorialize people who, often I was fond of.

Even the people who I'm not fond of--maybe to go back to the beginning of this conversation--they played a big part in my life. Often in the last weeks of people's lives, especially when you're caring for them in hospice, or they're very sick and you're trying desperately to keep that person around for a little longer, I'll wake up at four o'clock in the morning thinking about, like, 'Ah, we should do this. This is a good idea.'

And, it seems like there should be a way to think about that as you go forward.

Russ Roberts: I never thought about it. I have friends here at work, I have friends from my community activity, whether it's religious or hobbies or other things. I have my family. You don't spend so much time with your colleagues. I mean, you do. They're colleagues you interact with daily. But most of your daily interactions are patients.

So, at least a third of your life, maybe more, are these people; and it would be unseemly to take a picture of them before they passed away--or any other patients generally. But, for our friends and family who we love, whether they're alive or not, we often look at pictures of them as a way of remembering how they played a role in our life, that time in our life.

And, obviously, this is a way that you can do it. Do you know of any other doctors who do this?

Adam Cifu: There are a couple of my colleagues who do this--I'll say do this now because of me talking to them about them. But, as you say, there are people in medicine who carry other lists. Many obstetricians keep a list of every child they've delivered over the years. I also have a list, fortunately--a much smaller little journal of errors that I've made--that I keep track of that I do go back somewhat frequently to.

And, Henry Marsh wrote an amazing book a few years ago called Do No Harm, where he really spent an entire book--each chapter going in quite detail to patients who he feels like he harmed during his career--always setting out to do the best, but where the outcomes were poor. And, the honesty of that book, which is essentially a list turned into a nonfiction memoir, is spectacular and really resonates with me.

Russ Roberts: You're right that you worry that your colleagues might find it morbid. I think it is morbid. Do most of them know about it? Do any of them ever--you say a couple have copied you. Do any of them look at you askance for doing this?

Adam Cifu: I'm sure they do, but they don't tell me. I think having written about this, I think they all know.

To circle back to what you said about colleagues, I think it's interesting. Of the colleagues who we work with, you think of the conversations you have with your colleagues, and 95% of them, they are very much, 'How are the kids? What'd you do over the weekend? Do you have any travel planned?'

And, you think of the conversations you have with your patients, which are so much deeper than they are with people who you've worked with for decades.

Russ Roberts: Interesting. Yeah.

58:55

Russ Roberts: You're a pretty sensitive person. You might be faking it. Your essays reveal a certain sensitivity to my ear and eye. And, you just mentioned something in passing that you keep a book of your mistakes and review it from time to time. Many people--I don't know about most doctors--but many people prefer not to think about those. They're not interested in learning from them. They'd rather repress those memories.

I'm curious what made you who you are to the extent that you have a feeling for it. Is it something you think you have from your parents, books you read, role models you found? It's a slightly awkward question. I apologize for it. But, I think it's--your essays reflect a level of care that I think all of us would want to receive from a doctor and don't always feel that we do.

So, I salute you for that. And, I'm curious if you know the source of your devotion to your craft.

Adam Cifu: I appreciate that. They're very kind words. I could say that I didn't come on EconTalk to be psychoanalyzed, so I'm going to refuse to answer the question.

Russ Roberts: Fair enough. We can cut it, too, if you want.

Adam Cifu: No, no, no. I'm not sure. Interestingly, my father was an adolescent psychoanalyst, a job which I think you could only do in 1980s Manhattan. And, I always said to some extent, it was impossible because as a teenager, he always knew what I was thinking more than I was thinking, which just sort of pissed me off. But, on the other hand, he was always a step ahead about thinking about things and I think pushed me to do it. And so, I think I do owe a lot to him.

I also, although I'm not going to say I'm a fraud, it's always a little bit hard having these conversations because these kind of things are always a small part of ourselves. And, I don't want it to make it seem like I'm always walking around sort of navel-gazing, thinking about my practice in great depth.

But, I do think that medicine is such a rich field as far as the human interaction part of it, that I do find myself having to think about that almost as part of doing a good job and keeping myself sane. And, I like to figure out a way of processing that. Some of it is conversations with family and colleagues and friends, and some of it for me are these written reflections.

Because as anybody who does any writing knows, you have these ideas, which when you're walking to work, you think, 'Wow, that's profound.' And then, you write it down and 90% of the time, you're like, 'This is the stupidest thing I've ever written.' And, sometimes you're like, 'Huh, there's something to this.' And, it's helpful to work it out on a piece of paper and figure out what actually works and what doesn't.

Russ Roberts: My guest today has been Adam Cifu. Adam, thanks for being part of EconTalk.

Adam Cifu: Thank you so much, Russ.

What's Happening Inside Your Doctor's Head and Heart (with Adam Cifu)

Anupam Bapu Jena on Random Acts of Medicine

Becky Liddicoat Yamarik on Palliative Care and End-of-Life Medical Issues

READER COMMENTS

Shalom Freedman

Aug 19 2024 at 10:15am

Adam Cifu

Sep 18 2024 at 4:42pm

Zach

Aug 19 2024 at 2:53pm

David Gossett

Aug 20 2024 at 1:53pm

Luke J

Aug 21 2024 at 6:45pm

Gerald M Casey MD

Aug 24 2024 at 2:38am

What's Happening Inside Your Doctor's Head and Heart (with Adam Cifu)

Anupam Bapu Jena on Random Acts of Medicine

Becky Liddicoat Yamarik on Palliative Care and End-of-Life Medical Issues

READER COMMENTS

Shalom Freedman

Aug 19 2024 at 10:15am

Adam Cifu

Sep 18 2024 at 4:42pm

Zach

Aug 19 2024 at 2:53pm

David Gossett

Aug 20 2024 at 1:53pm

Luke J

Aug 21 2024 at 6:45pm

Gerald M Casey MD

Aug 24 2024 at 2:38am

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