51 Comments

Excellent piece, though I'm not sure I fully understand VRC as you describe it. I'd love to learn more, not because I love new terms (I think we're all agreed they're best avoided!) but because I think you're exploring something extremely important and, as you noted, the discord rather than the concord is often what comes to light. Some of what I study are "contested illnesses" - what one anthropologist described as "illnesses you had to fight to get" - like ME/CFS, fibromyalgia, chronic Lyme, etc. I notice that there is often discord between evidence-based physicians and patients who identify as having one of these illnesses, and it often comes down to what I see as a discord on thresholds in the face of uncertainty. Ross Douthat describes this in his recent book describing his experience with what he believes is chronic Lyme disease, noting that there has to be some middle ground between "first do no harm" and quacks out there trying to sell snake oil. Where is the place that suffering patients can go to try different therapies because the evidence, as currently described, isn't helping them. Evidence-based physicians are often strictly in the "first do no harm" camp, and for good reason (I'd generally put myself there too), but we all have our thresholds - we prescribe NSAIDS (or don't dissuade our patients from taking them) even though we know they increase cardiac risk. We know patients might derive some benefit from things like vitamins or probiotics, even if that benefit is pure placebo. I've wondered if threshold concordance on this continuum is what sometimes makes for a rewarding doctor-patient relationship. I'm getting the sense that what you describe is similar to this but also different and I'd love to think through the implications. Thanks again for the great piece!

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I miss you Dr Cifu! I found you on Twitter a free years ago and we’ve conversed but I couldn’t take the Twitterverse and what it’s become especially for Medicine so I’m not going back there. You and Dr Prasad were often my anchors during the pandemic. Wonderful article.

Might I suggest Value Realization Fusion and Value Realization Fracture?

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Sep 5, 2022·edited Sep 5, 2022

I'm a Generalist, too. However, in my case, I come from a long line of Specialists, and my point is I know a little about medicine. Why do I have to go thru my PCP to get to the Specialist I know I need? My PCP, and I, have known each other for over a decade, but I do not see the need for having him, other than for SUPPORT.

My community is building a strong PCP presence for the future...and I can't help but worry, because I feel they assume I'm stupid. Covid has been a disaster in terms of emphasizing the real deal: either you do as I say, or I will, along with everyone else in this community ostracize you, instead of going slow, and respectfully LISTENING TO ME, working with me, a true partnership. It's a new model, but reluctantly adopted.

Thank you, very much, for responding.

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Sep 3, 2022Liked by Adam Cifu, MD

Well stated. Most of the time in our daily care we get just a small glimpse into our patient's lives. We see them in the artificial environment of our office for a specified interval managing a host of required tasks. We try hard to slow the process down, greet, sit, smile, make eye contact, be fully present, ask open ended questions, examine, conclude, attend to the EMR and this usually works ok, or at least it's functionally ok, care is provided, problems addressed.

Then there are those moments when the door opens wider and we see at least some of what we've missed, perhaps through visiting patients in their homes, receiving a call or visit from a loved one or concerned friend or when your patient, in the quiet moments of an office visit, reveals something that reframes the entire picture, revealing the forest.

Humility is essential for physicians, not least so we acknowledge our limitations and those of our practice environment, but so we are attentive to a greater understanding of our patients' wishes, needs and their daily lives.

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Sep 3, 2022Liked by Adam Cifu, MD

Thanks for this article which caused me some self-reflection. It brought up some questions.

What would I want said at my funeral? Has anyone benefited from my efforts for them?

How can I communicate more effectively with my doctor?

I come across as a know it all and asshole a lot of the time. I am very direct and don't sugar coat criticism. Does this hinder my ability to help people, considering that people tend to trust people that they like?

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Sep 3, 2022Liked by Adam Cifu, MD

I love this piece. It really codifies feelings of the physician.

But please don’t use the term physician extender if you’re referring to advanced practice providers. They’re additional providers in their own right and not an extension of the physician.

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Sep 3, 2022Liked by Adam Cifu, MD

value-realization-concordance. You’re on to something here. In business school we called buyer’s remorse “post-purchase” dissonance. There is a possible academic research project hidden in those concepts. Loved the subtle dig at hospital marketing brochures. I’m a patient, never been a medical provider.

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Sep 3, 2022Liked by Adam Cifu, MD

This Is wonderful! Thank you. As an RN who worked at a large SF Bay Area teaching hospital for many years (then hospice nursing for a few), I can relate. I know that If I'd met you as a resident you would have stood out. One of my favorites was a surgical resident whom I had to call for a severely agitated patient at 0200. His intervention? He sat down at the bedside, held the patient's hand and spoke soothingly to her for nearly an hour. (It worked.) I know he was aware he would not get any more sleep, as it was a busy surgical day--and yet he chose to do this, when he could have ordered a benzodiazepine and gone back to his call room. I wouldn't have faulted him if he had, of course. I really don't know how you all survive residency...it seemed profoundly inhumane to me; more of an endurance contest (or hazing!) than an education. I guess it's a case of "that which does not kill you makes you stronger"...? Looking forward to more of your experiences and thoughts!

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author

Thanks so much for reading! Adam

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Way too much detail. Who has the time to revel in the detailed ruminations of your mind. I suppose it’s mansplaining at its finest. Idk, I guess I’m a bottom line person.

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author

These frou frou reflections are definitely not everyone’s cup of tea. Not sure you can accuse me of mansplaining though, when you chose to read it. I could equally accuse you of masochism. 😉

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Better stay in the forest as much as you can.

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Sep 2, 2022Liked by Adam Cifu, MD

>> It is narcissism to believe that longevity is anything more than luck – genetic, societal, fated.

I'm sure this comment was well-intended, but I have a lifetime of observing substance abusers and people with poor diets die young and with their bodies broken- and now enjoy the backing of a social-justice ideology dominating our media assuring them that their behavioral outcomes had nothing to do with it.

To me this was a blight on an otherwise very nice post.

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author

Thanks for reading. I hear you loud and clear. Yes, there’s a lot of genetics at work but people do make bad decisions too.

I was thinking of it in the other direction. Those that pat themselves on the back for their good health, when it was mostly luck, and look down on those with poor health related to bad luck.

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Sep 2, 2022Liked by Adam Cifu, MD

Fair point.

I definitely won't argue the strong role of genetics in many- if not all- preconditions of human health. I think ignoring genes is a willful blindness in its own right.

But disavowing people's agency in their health and fitness has been a very bad road our culture has gone down. The human genome has not changed so dramatically in a handful of generations that we can point to an obesity and addiction epidemic and say voluntary behavior played no role- and it's very destructive to evidence-based medicine when that idea is promoted in the name of political correctness.

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Well said.

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Sep 2, 2022·edited Sep 2, 2022

That is lovely. My doc is young and handsome. He's a bit of a pill pusher, but not extreme. I suspect he mostly sees the numbers. But what numbers does he chose to see and what numbers does he chose to not see, that is the issue. As a biologist who can read medical papers, to a degree, at the statistical end at least.

We've known for decades that psychiatry Rx are nothing more than placebo, that there's no evidence for chemical imbalances in the brain, so no evidence-based justification for SSRIs. Sure, when SSRIs are compared to placebo, there's a 10% difference. Allow me to not feel excited for that. Yet, my numbers obsessed doctor wants to push chronic Rx onto me. I refuse. I want LIFE Rx, not pharma Rx, and that's where my doctor needs tons of coaxing.

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Sep 2, 2022Liked by Adam Cifu, MD

Tasty food for thought. Thank you. As a practicing out of network dentist, I don’t face a lot of the externally imposed pressures you do. Nonetheless, many times I’m in situations in which my encounters with patients could be more valuable to them and satisfying for me if I had the time to take a breath, ask some versions of the questions you list, and have a useful conversation.

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Sep 2, 2022Liked by Adam Cifu, MD

Interesting perspective, but I'm not fond of coining new terms in health care. Already we have too many acronyms, syndromes named after people long forgotten, and misleading/dangerous jargon. "Value-realization discordance" is opaque. It seems you were referring to "understanding", "discernment", "perception" ... ? Tom Perry, general internist, Vancouver, Canada.

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Agreed about new terms!

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author

I'm with you on the new terms!

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Sep 2, 2022Liked by Adam Cifu, MD

satisfaction

feminine noun

1.

Act by which one grants to someone what he asks for.

To have, to obtain satisfaction.

2.

Feeling of well-being, pleasure that results from the accomplishment of what one considers desirable.

Feeling of satisfaction.

The doctor's satisfaction comes from the feeling of having been competent to give the right care, of having made the right diagnosis, of having helped his patient to treat him, Or for simply helping him feel better. (self-satisfaction)

and it is even better when the patient expresses his gratitude. (acknowledgement)

Patient satisfaction comes from the feeling of having been listened to and understood (physician empathy) and from the impression that they have received the best care.

Proposition :

reciprocal satisfaction. RS

unilateral satisfaction of the doctor. USD

unilateral patient satisfaction.UPS

the feeling of reciprocal satisfaction is thus obtained by the fact of giving and receiving and this is done reciprocally

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author

Love it.

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