Thanks for the beautiful post, Adam, and a timely reminder of what is at stake for physicians. i obviously loved this: "Someone once said that as we get older, more of our patients become friends and more of our friends become patients." As someone who has spent substantial time on both sides of the story, I see this to be such an insightful comment. Keep on inspiring!
I also have a Me File Too. 28 years in the ED with a locker full. One day in retirement I plan to look at it all. I have received far more blessings than I deserve. ❤️
My career was forged in the blast furnace of AIDS when it was actually called GRIDS.
I cared for numerous patients who initially walked into my office appearing healthy and concerned knowing that their CD4 of 26 meant that, in 18-24 months they would be dead, or wishing they were.
I also was told it was unethical to accept gifts but couldn’t turn them down because although I knew they could represent a psychological bargain for them, they really were showing their appreciation, and my worth to them. I still have 4x6 embroidered mural of Calabria given to me by a paisano.
42 years ago at the very start of my practice, when I actually had an office and a desk, I began a Me File too. It swelled to about 8 inches thick but I never looked in it until one grey cold Saturday afternoon 4 years or so after I retired from clinical IM/ID/Critical Care practice. Reading through it I could recall the people and the faces. It was a very moving experience.
When young people ask me why I went into Medicine I say truthfully it was an idea I had when I was very young and I just stuck with it.
No Resident, Fellow or Attending ever told me that the most satisfying and profound part of my practice would not be in the diagnoses, and successful therapies but, instead would be seeing patients as human beings who provided me the honor and privilege of being part of their lives.
Dr. Cifu, You and I are about the same age. I have been in residency education for 30 years, now as a Program Director in Family Medicine for the last 5 years in a semi-rural location in the SE US. Culturally, we are a far cry from Boston, but people are the same everywhere. Everything you wrote resonated with me as I have had the same experiences over these many years.
Despite being told not to accept the gifts of patients, I frequently wear a bracelet made for me by a patient who I have cared for with our residents since moving to this new location. Twenty years ago, an elderly lady whom I diagnosed with hyperthyroidism as the cause of her atrial fibrillation, which had disabled her knitting ability, brought me a hand-made blanket for my new home. She had asked me once ( I had not remembered) about the colors of my decor, creating a beautiful masterpiece which took her a year to complete. She and her daughter came to the clinic to present it to me near the end of her life (she died a few months later). I accepted it through tears and heartfelt thanks that any patient had cared enough for me to be so meticulous and thoughtful. Can anyone imagine turning down such a gift? Never. I would rather have gone to jail than perpetuate such an uncaring act.
We have far too many stupid and thoughtless "rules" to follow in medicine which have, in many ways, destroyed the doctor-patient relationship. I find myself frequently telling my residents to consider Direct Primary Care as a mechanism to take back control of patient care and those relationships rather than bow to insurance and other external forces that care little about outcomes other than profit margin.
Thank you for such a thoughtful piece of writing and exceptional advice.
Thank you for sharing this (again)! I've had so many bad experiences with doctors; what drew me to Sensible Medicine in the first place-and keeps me reading-was my search for some light in the dark. Pieces like this go in *my* sunshine folder.
What a beautiful essay. I am a psychologist, and in my class yesterday I reviewed an article about things that people who had lost a loved one find helpful or harmful. Your post reinforces the idea that being caring and thoughtful and skilled is an essential skill in medicine and in other helping professions. Well done.
Thank you, Adam — your words are heartfelt and spot on. As I sit in my sunny office this morning, your piece inspired me to reach for my own “sunshine folder” — a random collection of letters, photos, memorial programs, and mementos from patients I’ve shared life with over the years. It's not meticulously curated, but it’s deeply meaningful.
One piece in there always stops me: an ink portrait of me drawn by a patient who passed away 30 years ago from polyarteritis. (I had much longer hair back then!) I often wish I had recorded more details about these remarkable individuals and the moments we shared.
I’ve shown this folder — which has grown quite thick over time — to my daughter, who now works alongside me. She’s begun her own tiny version, and I know it will grow too, filled with her own stories and connections.
Thank you for the reminder to honor and cherish these memories. It’s sage advice — and beautifully said.
All of the above applies equally well to professors in other fields, where the stakes are usually much lower. All one needs to do is replace "patient" with "student." Unfortunately, these skills/habits are rarely taught in graduate programs.
Thank you for this wonderful piece, Dr. Cifu. As I read it and tried to put myself in your shoes, all I could think about was the blaring red flags on epic for EJs “care gaps” and quality metrics that I would not have met. I feel that I have lots of patients like EJ, who are pleasant and kind but always have a ton of problems which make it next to impossible to ever close out the care gaps while addressing their acute concerns in 10 minutes…
Usually, when I see these patients names come up on my schedule I end up getting immediate anxiety as I can anticipate the fact that I won’t address anything epic is telling me to, and will have to explain that to my preceptors. Any advice on how you kept this anxiety in check when you approached patients such as EJ? It feels to me that it is detracting from my ability to bond with patients as you did.
Primary care has boxed itself into a corner of preventives, screenings and assorted forms of bureaucracy. I will take an acute problem to anyone but primary care now. Hell my *dentist* probably understands my health history better than my GP. Chiropractors. The oil change guy at Mobil1. Anyone.
Talking to patients is like touching grass. It grounds you in everything you do and it feels good.
Interestingly it also helps close some ‘care gaps’ that otherwise might not occur down the road (even with a practiced pitch). Do it as often as possible. At least 50% of primary care visit should be spent chit chatting / connecting with the patient.
If your plan sounds ‘incomplete’ to your attending because of a gap, first ask yourself if they practice primary care. If they do, tell them you spent the time investing in the relationship and it was time well spent. You have a plan to discuss the gap at a follow up spot in *** months - a visit the patient will be thrilled to follow through on because you invest in relationships. If you have an attending that doesn’t practice primary care, my advice is to politely suggest they were overwhelmed in the encounter, you’re running behind, and you promised the patient another doc might be coming in to address anything that could be important that you missed ;)
You’re right, managing your attending is the hardest part about training in primary care, particularly when care is pressurized by ‘care gaps’ ;)
Thanks for the beautiful post, Adam, and a timely reminder of what is at stake for physicians. i obviously loved this: "Someone once said that as we get older, more of our patients become friends and more of our friends become patients." As someone who has spent substantial time on both sides of the story, I see this to be such an insightful comment. Keep on inspiring!
That therapeutic alliance you mention, so much there and so much goes into it. Thank you for the inspiring thoughts.
I also have a Me File Too. 28 years in the ED with a locker full. One day in retirement I plan to look at it all. I have received far more blessings than I deserve. ❤️
These thoughts are just as valuable to those of us in physical sciences. Thank you, Adam.
Well done.
My career was forged in the blast furnace of AIDS when it was actually called GRIDS.
I cared for numerous patients who initially walked into my office appearing healthy and concerned knowing that their CD4 of 26 meant that, in 18-24 months they would be dead, or wishing they were.
I also was told it was unethical to accept gifts but couldn’t turn them down because although I knew they could represent a psychological bargain for them, they really were showing their appreciation, and my worth to them. I still have 4x6 embroidered mural of Calabria given to me by a paisano.
42 years ago at the very start of my practice, when I actually had an office and a desk, I began a Me File too. It swelled to about 8 inches thick but I never looked in it until one grey cold Saturday afternoon 4 years or so after I retired from clinical IM/ID/Critical Care practice. Reading through it I could recall the people and the faces. It was a very moving experience.
When young people ask me why I went into Medicine I say truthfully it was an idea I had when I was very young and I just stuck with it.
No Resident, Fellow or Attending ever told me that the most satisfying and profound part of my practice would not be in the diagnoses, and successful therapies but, instead would be seeing patients as human beings who provided me the honor and privilege of being part of their lives.
Thanks so much.
Love this post and especially advice #1. From the patient's perspective, there is true healing power in a physician showing they care.
As to number 3, I had an elderly colleague who used to say that the smiting shall continue, so take what solace you can when you can. Sound advice.
Dr. Cifu, You and I are about the same age. I have been in residency education for 30 years, now as a Program Director in Family Medicine for the last 5 years in a semi-rural location in the SE US. Culturally, we are a far cry from Boston, but people are the same everywhere. Everything you wrote resonated with me as I have had the same experiences over these many years.
Despite being told not to accept the gifts of patients, I frequently wear a bracelet made for me by a patient who I have cared for with our residents since moving to this new location. Twenty years ago, an elderly lady whom I diagnosed with hyperthyroidism as the cause of her atrial fibrillation, which had disabled her knitting ability, brought me a hand-made blanket for my new home. She had asked me once ( I had not remembered) about the colors of my decor, creating a beautiful masterpiece which took her a year to complete. She and her daughter came to the clinic to present it to me near the end of her life (she died a few months later). I accepted it through tears and heartfelt thanks that any patient had cared enough for me to be so meticulous and thoughtful. Can anyone imagine turning down such a gift? Never. I would rather have gone to jail than perpetuate such an uncaring act.
We have far too many stupid and thoughtless "rules" to follow in medicine which have, in many ways, destroyed the doctor-patient relationship. I find myself frequently telling my residents to consider Direct Primary Care as a mechanism to take back control of patient care and those relationships rather than bow to insurance and other external forces that care little about outcomes other than profit margin.
Thank you for such a thoughtful piece of writing and exceptional advice.
M. Shawn Morehead MD
Thank you so much for the note and for all you do.
Adam
Thank you for sharing this (again)! I've had so many bad experiences with doctors; what drew me to Sensible Medicine in the first place-and keeps me reading-was my search for some light in the dark. Pieces like this go in *my* sunshine folder.
What a beautiful essay. I am a psychologist, and in my class yesterday I reviewed an article about things that people who had lost a loved one find helpful or harmful. Your post reinforces the idea that being caring and thoughtful and skilled is an essential skill in medicine and in other helping professions. Well done.
Here is the article in case you or others are interested. https://www.researchgate.net/profile/Holly-Prigerson/publication/15397323_Complicated_grief_and_bereavement-related_depression_as_distinct_disorders_Preliminary_empirical_validation_in_elderly_bereaved_spouses/links/582cb9bd08ae102f072a134c/Complicated-grief-and-bereavement-related-depression-as-distinct-disorders-Preliminary-empirical-validation-in-elderly-bereaved-spouses.pdf
Thanks so much.
Adam
Thank you, Adam — your words are heartfelt and spot on. As I sit in my sunny office this morning, your piece inspired me to reach for my own “sunshine folder” — a random collection of letters, photos, memorial programs, and mementos from patients I’ve shared life with over the years. It's not meticulously curated, but it’s deeply meaningful.
One piece in there always stops me: an ink portrait of me drawn by a patient who passed away 30 years ago from polyarteritis. (I had much longer hair back then!) I often wish I had recorded more details about these remarkable individuals and the moments we shared.
I’ve shown this folder — which has grown quite thick over time — to my daughter, who now works alongside me. She’s begun her own tiny version, and I know it will grow too, filled with her own stories and connections.
Thank you for the reminder to honor and cherish these memories. It’s sage advice — and beautifully said.
So great to hear!
I hope you're well.
Adam
All of the above applies equally well to professors in other fields, where the stakes are usually much lower. All one needs to do is replace "patient" with "student." Unfortunately, these skills/habits are rarely taught in graduate programs.
Love this! I share similar advice with my med students:
https://substack.com/@dfloramd/note/c-136485500?r=11bw2f&utm_medium=ios&utm_source=notes-share-action
Thanks for sharing!
I’m stealing this. Thank you!
Thank you for this wonderful piece, Dr. Cifu. As I read it and tried to put myself in your shoes, all I could think about was the blaring red flags on epic for EJs “care gaps” and quality metrics that I would not have met. I feel that I have lots of patients like EJ, who are pleasant and kind but always have a ton of problems which make it next to impossible to ever close out the care gaps while addressing their acute concerns in 10 minutes…
Usually, when I see these patients names come up on my schedule I end up getting immediate anxiety as I can anticipate the fact that I won’t address anything epic is telling me to, and will have to explain that to my preceptors. Any advice on how you kept this anxiety in check when you approached patients such as EJ? It feels to me that it is detracting from my ability to bond with patients as you did.
Primary care has boxed itself into a corner of preventives, screenings and assorted forms of bureaucracy. I will take an acute problem to anyone but primary care now. Hell my *dentist* probably understands my health history better than my GP. Chiropractors. The oil change guy at Mobil1. Anyone.
It’s such a struggle, right? I still have to constantly remind myself that it is the patient’s appointment, not mine.
That’s a fantastic perspective, I’ll have to repeat that in the mirror every day!
Talking to patients is like touching grass. It grounds you in everything you do and it feels good.
Interestingly it also helps close some ‘care gaps’ that otherwise might not occur down the road (even with a practiced pitch). Do it as often as possible. At least 50% of primary care visit should be spent chit chatting / connecting with the patient.
If your plan sounds ‘incomplete’ to your attending because of a gap, first ask yourself if they practice primary care. If they do, tell them you spent the time investing in the relationship and it was time well spent. You have a plan to discuss the gap at a follow up spot in *** months - a visit the patient will be thrilled to follow through on because you invest in relationships. If you have an attending that doesn’t practice primary care, my advice is to politely suggest they were overwhelmed in the encounter, you’re running behind, and you promised the patient another doc might be coming in to address anything that could be important that you missed ;)
You’re right, managing your attending is the hardest part about training in primary care, particularly when care is pressurized by ‘care gaps’ ;)
Thanks for the advice and encouragement. I hadn’t really thought about the relationship as the care before, but you’re totally right — it is.