Patients are not universally impressed by the seasoned physician. A new patient referred by her friend to “my marvelous physician” is often disappointed when I turn out to be as human and fallible as her last physician.
Wonderful reflection, thank you for sharing this. The resident who caught me when I was born went on to become my family doctor, and then my son’s. It’s impossible to even measure the value of a familiar and trusted doctor, something I learned the hard way when I moved to a different country. As an aside, your footnotes are the best!
I enjoyed this article. My own health took me out of the twilight of my career, which in reflection has been a wonderful gift. I can take care of those who want what I offer pro bono, on my time - and bc each patient is an N=1 I can help them customize their plan so they can fire me (chronic non cancer pain and addiction).
Nobody teaches us how to slow down and enjoy life after an intense career in healthcare. My body did it for me. What I have learned is that it’s doubtful that anybody said, “I wish I had worked more” on their deathbeds. I know I won’t. We need more Dr. Cifu’s as well as good descendants of his methods!
As a senior year resident who certainly has nowhere near the amount of training Dr. Cifu is talking about, his description of the level of uncertainty upon starting independent practice is not reassuring!
Lovely reflection, Dr Cifu. Thanks for letting your professional 'armor' down a bit, with your candor. Would also note the ongoing joys (beyond the early mentorship period) of working in an academic group practice, with the constant cross-pollination of ideas, attitudes, and thought-provoking cases from trainees and specialist colleagues.
Mar 3, 2023·edited Mar 3, 2023Liked by Adam Cifu, MD
This is a beautiful recollection of your practice history. I grieve as I read because my own PCP with whom I bonded for decades collapsed under the ever growing demands of his field. EMR. Coding. Nights on-call. Cash flow. He ended up working with another MD to help share the load (so to speak). That was helpful for only a short while. Finally has ended up in a "concierge" type system. Where I was once Linda, I became #_____, DOB____. But I fondly remember the years I was treated as an entire entity because he knew my family, my history, the joys and heartaches I dealt with. Thank you for being who you are.
wow this sums up my practice also...what a beautiful reflection...we are lucky to be able to reflect on years of primary care practice in an environment that allows us to practice our way. i so admire you and your writing and anyway.. any friend of vinay's is a friend of mine!!
My career path sounds very similar to you. I also did a primary care internal medicine residency at Northwestern. I do believe it gave us an advantage in managing our patients when we started our careers. I feel as though many of my patients who have remained with me for 35 years, are truly friends. Incidentally, my Internist is retiring, could you be my doctor?
Your career is more illustrious than mine. I haven’t done as much teaching. When I taught residents and medical students in the past, they didn’t believe me when I told them that we didn’t used to get CAT scans when we thought we had somebody with appendicitis. We simply called the surgeon who would get the OR ready and examine the patient just to see that they agreed with us. My students were incredulous.
Like wine (and some physicians--Dr. Cifu being one, thank goodness), most art museums age spectacularcularly well. Here's an opinion piece about one that may not have: shttps://www.city-journal.org/metropolitan-museum-of-art-has-redefined-itself-as-an-antiracist-agent-of-change
Started seeing my physician in early '79, when I was 28, and a new mother. At the time, he must have been barely out of his residency, as he was only (by the date of his college diploma) about 3-4 years older than I. He retired ~ 4-5 years ago. Nothing like the consistent care of an interested-in-you doctor. He knew my husband, he knew all my children whom he had cared for from birth; he knew the 'vibe' of the family. When we started to get slipped "down" to the younger members of his practice, things were not so good. My 18 yr-old was conned--by a young, female physician who did not know the girl--into taking Gardasil. I ask you, does a virgin need that?
If the patient is not a virgin, then it's too late. So yes.
One of my first patients as a medical student came in bleeding all over the floor with stage IV invasive cervical cancer. It is not pretty. Gardasil is not some experimental mRNA of uncertain effect, the evidence is quite well established (defer to my colleague here). I don't know in what sense this individual is being "conned".
Strong evidence suggests 80-90% reduction in invasive cervical cancer if parents support HPV vaccination BEFORE girls are sexually active (age 11-12 is the standard timing advised). Even if there's only 1 lifetime partner for your daughter, if that man has had prior sex, he can transmit it. There are 13,000 new cases, and 4000 deaths from it each year in the US. Recent NEJM paper below.
The efficacy and effectiveness of the quadrivalent human papillomavirus (HPV) vaccine in preventing high-grade cervical lesions have been shown. However, data to inform the relationship between quadrivalent HPV vaccination and the subsequent risk of invasive cervical cancer are lacking.
Methods We used nationwide Swedish demographic and health registers to follow an open population of 1,672,983 girls and women who were 10 to 30 years of age from 2006 through 2017. We assessed the association between HPV vaccination and the risk of invasive cervical cancer, controlling for age at follow-up, calendar year, county of residence, and parental characteristics, including education, household income, mother’s country of birth, and maternal disease history.
Results During the study period, we evaluated girls and women for cervical cancer until their 31st birthday. Cervical cancer was diagnosed in 19 women who had received the quadrivalent HPV vaccine and in 538 women who had not received the vaccine. The cumulative incidence of cervical cancer was 47 cases per 100,000 persons among women who had been vaccinated and 94 cases per 100,000 persons among those who had not been vaccinated. After adjustment for age at follow-up, the incidence rate ratio for the comparison of the vaccinated population with the unvaccinated population was 0.51 (95% confidence interval [CI], 0.32 to 0.82). After additional adjustment for other covariates, the incidence rate ratio was 0.37 (95% CI, 0.21 to 0.57). After adjustment for all covariates, the incidence rate ratio was 0.12 (95% CI, 0.00 to 0.34) among women who had been vaccinated before the age of 17 years and 0.47 (95% CI, 0.27 to 0.75) among women who had been vaccinated at the age of 17 to 30 years.
Conclusions Among Swedish girls and women 10 to 30 years old, quadrivalent HPV vaccination was associated with a substantially reduced risk of invasive cervical cancer at the population level. https://www.nejm.org/doi/full/10.1056/NEJMoa1917338
My young female MD was pushing Gardasil on my 11 year old!! When she mentioned it was for when she would be sexually active in the future I mentioned that HPV screening is standard with pap smears now, so as long as she was going for routine checkups in later years they would surely catch the disease before it risked cervical cancer. I had taken her in for a tetnus booster mind you so I wasn't anti-vax but she treated me as such. She then proceeded to tell me that here in South Carolina gynos won't do pap smears on women under 25. I was floored. I think that was lie meant to coerce me to give her the Gardasil shot.
She also insisted that both my 11 year old and my 8 year old get Covid vaccines, even though I mentioned they had already had the illness (mild symptoms) and had natural immunity.
Recommending COVID shots for those children is wildly inappropriate, illegal in some more sensible countries, and of course Dr. Prasad and other have explicated this very well. Gardasil is not the same thing at all.
Part of the situation we're in now is that accurate information is mixed with propaganda and lies, and unfortunately many physicians seem disinterested in making any distinction between what's true and what isn't.
Well, you by your actions, cut her income! Shame on you! I cringed, closer to ten years ago, than five, listening in the faculty room to an aide talking about getting this for her daughter--she clearly expected her daughter to be going to be what I would call 'promiscuous'.
A gem of an essay- thank you. I have an 18 yo cardiology-EP practice. Not the same, but I have come to appreciate the rewards of a long-standing patient relationship.
I too spent my childhood at the met with my mom, what wonderful memories this essay stirred up.
Wonder if we ever crossed paths?!?
More likely at dalton.
What a perfect description of our work. Beautiful piece, Adam.
Thanks Amy!
Beautiful piece. A great lesson on the importance of continuity of care.
Wonderful reflection, thank you for sharing this. The resident who caught me when I was born went on to become my family doctor, and then my son’s. It’s impossible to even measure the value of a familiar and trusted doctor, something I learned the hard way when I moved to a different country. As an aside, your footnotes are the best!
An amazing story. Thanks for sharing.
I enjoyed this article. My own health took me out of the twilight of my career, which in reflection has been a wonderful gift. I can take care of those who want what I offer pro bono, on my time - and bc each patient is an N=1 I can help them customize their plan so they can fire me (chronic non cancer pain and addiction).
Nobody teaches us how to slow down and enjoy life after an intense career in healthcare. My body did it for me. What I have learned is that it’s doubtful that anybody said, “I wish I had worked more” on their deathbeds. I know I won’t. We need more Dr. Cifu’s as well as good descendants of his methods!
As a senior year resident who certainly has nowhere near the amount of training Dr. Cifu is talking about, his description of the level of uncertainty upon starting independent practice is not reassuring!
(Fortunately I'm going into fellowship).
Lovely reflection, Dr Cifu. Thanks for letting your professional 'armor' down a bit, with your candor. Would also note the ongoing joys (beyond the early mentorship period) of working in an academic group practice, with the constant cross-pollination of ideas, attitudes, and thought-provoking cases from trainees and specialist colleagues.
Amen.
This is a beautiful recollection of your practice history. I grieve as I read because my own PCP with whom I bonded for decades collapsed under the ever growing demands of his field. EMR. Coding. Nights on-call. Cash flow. He ended up working with another MD to help share the load (so to speak). That was helpful for only a short while. Finally has ended up in a "concierge" type system. Where I was once Linda, I became #_____, DOB____. But I fondly remember the years I was treated as an entire entity because he knew my family, my history, the joys and heartaches I dealt with. Thank you for being who you are.
I always enjoy your Friday reflections.
Thanks.
No patient is a routine
wow this sums up my practice also...what a beautiful reflection...we are lucky to be able to reflect on years of primary care practice in an environment that allows us to practice our way. i so admire you and your writing and anyway.. any friend of vinay's is a friend of mine!!
Thanks so much Nancy, and thanks for your work.
You seem a vintage mix of sensitivity and humor. Wish i could find a “you” close by!
Thanks for serving well.
My career path sounds very similar to you. I also did a primary care internal medicine residency at Northwestern. I do believe it gave us an advantage in managing our patients when we started our careers. I feel as though many of my patients who have remained with me for 35 years, are truly friends. Incidentally, my Internist is retiring, could you be my doctor?
Thanks Robert, it does sound like I have followed close behind you!
Your career is more illustrious than mine. I haven’t done as much teaching. When I taught residents and medical students in the past, they didn’t believe me when I told them that we didn’t used to get CAT scans when we thought we had somebody with appendicitis. We simply called the surgeon who would get the OR ready and examine the patient just to see that they agreed with us. My students were incredulous.
Like wine (and some physicians--Dr. Cifu being one, thank goodness), most art museums age spectacularcularly well. Here's an opinion piece about one that may not have: shttps://www.city-journal.org/metropolitan-museum-of-art-has-redefined-itself-as-an-antiracist-agent-of-change
Started seeing my physician in early '79, when I was 28, and a new mother. At the time, he must have been barely out of his residency, as he was only (by the date of his college diploma) about 3-4 years older than I. He retired ~ 4-5 years ago. Nothing like the consistent care of an interested-in-you doctor. He knew my husband, he knew all my children whom he had cared for from birth; he knew the 'vibe' of the family. When we started to get slipped "down" to the younger members of his practice, things were not so good. My 18 yr-old was conned--by a young, female physician who did not know the girl--into taking Gardasil. I ask you, does a virgin need that?
If the patient is not a virgin, then it's too late. So yes.
One of my first patients as a medical student came in bleeding all over the floor with stage IV invasive cervical cancer. It is not pretty. Gardasil is not some experimental mRNA of uncertain effect, the evidence is quite well established (defer to my colleague here). I don't know in what sense this individual is being "conned".
Strong evidence suggests 80-90% reduction in invasive cervical cancer if parents support HPV vaccination BEFORE girls are sexually active (age 11-12 is the standard timing advised). Even if there's only 1 lifetime partner for your daughter, if that man has had prior sex, he can transmit it. There are 13,000 new cases, and 4000 deaths from it each year in the US. Recent NEJM paper below.
The efficacy and effectiveness of the quadrivalent human papillomavirus (HPV) vaccine in preventing high-grade cervical lesions have been shown. However, data to inform the relationship between quadrivalent HPV vaccination and the subsequent risk of invasive cervical cancer are lacking.
Methods We used nationwide Swedish demographic and health registers to follow an open population of 1,672,983 girls and women who were 10 to 30 years of age from 2006 through 2017. We assessed the association between HPV vaccination and the risk of invasive cervical cancer, controlling for age at follow-up, calendar year, county of residence, and parental characteristics, including education, household income, mother’s country of birth, and maternal disease history.
Results During the study period, we evaluated girls and women for cervical cancer until their 31st birthday. Cervical cancer was diagnosed in 19 women who had received the quadrivalent HPV vaccine and in 538 women who had not received the vaccine. The cumulative incidence of cervical cancer was 47 cases per 100,000 persons among women who had been vaccinated and 94 cases per 100,000 persons among those who had not been vaccinated. After adjustment for age at follow-up, the incidence rate ratio for the comparison of the vaccinated population with the unvaccinated population was 0.51 (95% confidence interval [CI], 0.32 to 0.82). After additional adjustment for other covariates, the incidence rate ratio was 0.37 (95% CI, 0.21 to 0.57). After adjustment for all covariates, the incidence rate ratio was 0.12 (95% CI, 0.00 to 0.34) among women who had been vaccinated before the age of 17 years and 0.47 (95% CI, 0.27 to 0.75) among women who had been vaccinated at the age of 17 to 30 years.
Conclusions Among Swedish girls and women 10 to 30 years old, quadrivalent HPV vaccination was associated with a substantially reduced risk of invasive cervical cancer at the population level. https://www.nejm.org/doi/full/10.1056/NEJMoa1917338
My young female MD was pushing Gardasil on my 11 year old!! When she mentioned it was for when she would be sexually active in the future I mentioned that HPV screening is standard with pap smears now, so as long as she was going for routine checkups in later years they would surely catch the disease before it risked cervical cancer. I had taken her in for a tetnus booster mind you so I wasn't anti-vax but she treated me as such. She then proceeded to tell me that here in South Carolina gynos won't do pap smears on women under 25. I was floored. I think that was lie meant to coerce me to give her the Gardasil shot.
She also insisted that both my 11 year old and my 8 year old get Covid vaccines, even though I mentioned they had already had the illness (mild symptoms) and had natural immunity.
We are not going back.
Recommending COVID shots for those children is wildly inappropriate, illegal in some more sensible countries, and of course Dr. Prasad and other have explicated this very well. Gardasil is not the same thing at all.
Part of the situation we're in now is that accurate information is mixed with propaganda and lies, and unfortunately many physicians seem disinterested in making any distinction between what's true and what isn't.
Well, you by your actions, cut her income! Shame on you! I cringed, closer to ten years ago, than five, listening in the faculty room to an aide talking about getting this for her daughter--she clearly expected her daughter to be going to be what I would call 'promiscuous'.
A gem of an essay- thank you. I have an 18 yo cardiology-EP practice. Not the same, but I have come to appreciate the rewards of a long-standing patient relationship.
Thanks.