47 Comments

Spot on!

For your insomnia besides; you did stop all caffeine right!?!

Try L-theanine! This is not an advertising.

I’m just a nurse for whom it’s worked perfectly!

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From a 85+ year old………..you try……..want to do the right thing………and self aware………I’m sure most in health care are like you……..I’m learning more that you have skin in the game & that you “care” Don’t feel guilty….

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Adam, glad to hear there's another minimalist primary internist out there! I appreciate your boldness and transparency in writing this one. Sounds like a personal memoir of my own. In your defense (not that you need it), I would say TA was a "good riddance" situation. If she couldn't understand it takes a while to make a diagnosis sometimes AND she was a "cry wolf" type gal, it was only a matter of time until her first-world expectations were not met. I don't believe there's a physician in the world who could meet those expectations...not unless that physician gave an unjustifiable amount of attention to her frequent complaints. Just reality...not saying it's a perfect take...just that, well, it is what it is. Dems da breaks...

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I wish you lived near me and could be my doctor!

I recently switched PCP after 35 years with one, whom also had treated my late husband, and two teens/young adults. I felt that over the course of these 35 years, I had changed in terms of what kind of relationship I wanted w this doctor. In short, when I started with him at age 34, I was OK with his "paternalistic" style I'll call it (we're about the same age). Now, at age 71, I am a much more informed medical consumer and wanted more of a partnership with him. As I expressed this, he pushed back. This was not his style or comfort level.

I talked and thought about leaving him for 3 years or so, and finally did so. I composed several letters to him, all of which focused on the good parts of our relationship, but by the time I left I was too angry and frustrated and never mailed it. The moral of this story for me is clear but factors such as inertia on my part as well as the power imbalance (was I making a mistake?) contributed to my staying too long,

If I'd read a piece like this one, Dr.Ciful, it would have given me a better perspective. Thank you for sharing your side of things. I think I'll send that letter to him. He took good care of me and my family for years, in the best way he knew how.. And it was time to move on.

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Great article. Very thoughtful.

As a retired family physician, I’ve had very similar experiences. In general, I came to the conclusion that when patients left my practice, it was for the best; either I wasn’t selling what they wanted or in other cases they had lost confidence in me, for whatever reason (sometimes I really had screwed up, other times it was their mistaken impression that I had screwed up). I couldn’t sell everything to everybody, and on the occasions when I wasn’t true to my own beliefs and values, it always seemed to come back to bite me in the end (as for your patient who expected more when you offered less, where you would inevitably end up treating things you knew little about with drugs you weren’t familiar with in doses you weren’t comfortable with).

As I was nearing retirement, I went back to my old group practice to do a locum. I met many patients that I had known and treated over the years. Some had started out as my patients then quietly transitioned themselves over to one of my associates (just as there were many who switched to me from one of my colleagues). With some, I would think back and wonder why they had left me for someone else. Usually, after a few minutes, I would recall what I had known in the past, namely that I wasn’t the right doctor for them. I tended to be less directive, some wanted a doctor who was more directive. I was more inclined to watchful waiting, some wanted a doctor who would aggressively investigate everything up front. Fortunately, we had a range of practice styles in the group, and the patients sorted themselves out. However, that tends to be self reinforcing. The patients I see like the way I practice, so it must be the right way to practice. I don’t end up seeing the patients who don’t like my style. However, this must be true in every business. I go to the restaurants I like, which are full of the people who like eating there. Other restaurants serve different crowds.

And, like your patient with RA, one of my partners had an anxious patient with dozens of symptoms. He trod the fine line between watchful waiting and active investigation for years, trying to keep her anxiety under control without missing anything. One day, a test turned up a “missed ectopic” (ie it had never ruptured, just scarred the fallopian tube sometime in the past, who knows when). Having had that to “explain” one of her many complaints, she rolled into the office with a list of every one of her previous complaint, expecting him to reconsider each and every one!

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author

Wonderful perspective. Thanks.

Adam

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Dec 15, 2023Liked by Adam Cifu, MD

You only hear from the people who love you and the people who hate you. Most patients are in the middle. Today was a good day. I had patients say they were happy with me. Over the years, I have learned to hold on to the praise for when people say they are not happy with me. Also, I have learned not to let the praise go to my head as tomorrow someone will have ten unreasonable complaints about me. Developing a thick skin is a prerequisite of working with the public, both to defend against those wishing to tear us down and against those who build us up to the point of becoming overconfident and arrogant.

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author

Very wise words. Thanks.

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I've always been somewhat unclear about what "sleep hygiene" is. I understand what general hygiene is, but not when it comes to sleep.

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Common sense stuff, bearing in mind that common sense isn’t common.

Don’t jump straight into bed after doing something overstimulating, expecting to fall asleep immediately.

Try to maintain a bedtime routine, don’t mix up the bedtime from day to day.

Avoid stimulants like caffeine in the hours leading up to sleep.

Think about what things in your bed room make it easier or harder to sleep, like tv’s, cell phones, temperature setting, noises, excess light, etc.

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It's a misnomer that any one person can satisfy another person's needs whether be a doctor or lawyer or individual. As you said you have learned over time maybe how to not "do it better" but "do it differently. I don't think that remember your "failures" only happens to doctors either. Since we only get to live in that moment once you do the best you can at that moment. That's life!

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Interesting that we as providers can really remember our “failures” so saliently. They are first to come to mind most of the time. Of note - self reflection revealed the toxic side of people pleasing which I continually work at to be somewhat balanced. The desire to be the best in my field initially made it hard to do the right thing for some patients; as you point out, time helps those rookie mistakes. Sometimes the best treatment is a referral and that was a good lesson to learn. I always appreciate your own self reflection as it helps enhance my own to deal with patients today in my pro bono work.

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Dec 15, 2023Liked by Adam Cifu, MD

One of the most valuable things my nursing instructors told me was, "You will not be the best nurse for every patient you encounter." It was very rare but it happened, and I was able to recognize it early in the process & request a change of assignment. I've always been grateful for that perspective.

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Dec 15, 2023·edited Dec 15, 2023Liked by Adam Cifu, MD

Regarding the guy who was religious - I think there is a lot to this that he simply didn't explain, and you shouldn't feel bad.

As a Catholic who uses NFP to follow my cycle/ovulation, I've always wanted an OBGYN who will respect this choice rather than blowing me off. I've been lucky that midwives are often well-versed in NFP because they're helping women get pregnant, but I still get "well if you ever feel like it, we can prescribe you BC". I'd much rather have had an offer for help when charting in menopause gets tricky.

As someone is approaching end-of-life care, it's really important to find someone who will help you walk the spiritual walk even if it makes the physical walk harder. Someone who isn't going to get frustrated if you refuse a medication grown on aborted fetal cell lines, and someone who isn't going to offer you euthanasia when you're at your weakest moments. My guess is that this guy had already had an issue with a previous doctor and was looking for someone who he could trust to support him in his spiritual and physical journeys together. I've already been chewed out by an NP over this kind of thing, and it definitely makes you very guarded about what you say to medical personnel so I totally sympathize. It's not your fault that you aren't on the same walk, and I'm sorry it made you feel bad but it really was what he needed, and it's good that you two figured that out sooner rather than later.

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Dec 15, 2023Liked by Adam Cifu, MD

I think that finding someone that shares your beliefs, whatever they be, makes people feel more comfortable because they (feel) they can understand the entire situation better.

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Dec 15, 2023Liked by Adam Cifu, MD

Excellent post Adam! 👏 Really like the way you "normalize" patients' comings and goings. So much human chemistry. In my career I was helpful to many people, less than helpful to many, and then there was the one patient who informed me angrily that "You provided me with NOTHING of value!" Blew my hair back! I took a deep breath, expressed my regret (but did NOT apologize), and refunded her payments (I smelled a lawsuit coming). Never a dull moment.

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Dec 15, 2023Liked by Adam Cifu, MD

The level of self-awareness and humility you demonstrate in these stories makes me wish I could have you for my doctor!

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author

🙏

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Dec 15, 2023Liked by Adam Cifu, MD

Sometimes you get lucky and get it right. Sometimes you get lucky when the patient leaves.

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Dec 15, 2023Liked by Adam Cifu, MD

I look forward to the Friday edition of Sensible Medicine because I know it will likely be written by you, Adam Cifu. Enjoyed this one very much. If I moved to Chicago I would seek you out as my GP. Thank you again.

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Dec 15, 2023Liked by Adam Cifu, MD

Thanks for this courageous reflection.

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