Danielle Ofri, MD on sharing stories and the emotional epidemiology of disease [PODCAST]

Listen and followApple PodcastsSpotifyYouTubeMore apps · Browse all episodes

This episode is sponsored by Athelas, the number one provider of remote patient monitoring.

“This last mile of the COVID pandemic—Omicron or not—is a painstaking one-on-one endeavor. As is most of primary care. Sadly, we now have to deal with political epidemiology as much as emotional and clinical epidemiology.

We’ll sit with each of our patients, listening as much as possible, attempting to understand and address their concerns. With some, the bloc of silence may be impenetrable. This is heartbreaking, especially for those of us who’ve penned more condolence cards this past year than we have in a lifetime of clinical practice. But such is the reality of our society’s self-inflicted wounds.”

Danielle Ofri is an internal medicine physician and editor-in-chief, Bellevue Literary Review. She can be reached at her self-titled site, Danielle Ofri.

She shares her story and discusses her KevinMD article, “Emotional epidemiology of disease is as critical as clinical epidemiology.”

Reflect and earn 1.0 AMA PRA Category 1 CME for this episode.

This episode is sponsored by Athelas, the number one provider of remote patient monitoring.

Did you know more than 65 percent of doctors are actively investing in remote patient monitoring?

That’s because RPM is the fastest-growing segment in health care today. And for good reason:

RPM boosts patient outcomes through preventative care. In fact, a recent study by the VA showed that implementing RPM at a practice can reduce hospital readmission rates by as much as 25 percent, saving more than $20,000 per patient in medical costs.

If you’re not investing in RPM, you’re missing out. Luckily, Athelas can help you roll out RPM end-to-end. They provide devices to your patients, handle 100 percent of billing, and even provide a team of nurses to monitor patient vitals for you. All at zero net cost to your practice.

Try out RPM for your practice by going to KevinMD.com/tryrpm.

Did you enjoy today’s episode?

Rate and review the show so more audiences can find The Podcast by KevinMD.

Subscribe on your favorite podcast app to get notified when a new episode comes out.

Do you know someone who might enjoy this episode? Share this episode with anyone who wants to hear health care stories filled with information, insight, and inspiration.

Hosted by Kevin Pho, MD, The Podcast by KevinMD shares the stories of the many who intersect with our health care system but are rarely heard from.

Transcript

Kevin Pho: Hi, welcome to the show, where we share the stories of the many who intersect with our health care system but are rarely heard from. My name is Kevin Pho, founder and editor of KevinMD. Today on the show we have Danielle Ofri. She’s an internal medicine physician, and she’s the editor-in-chief of the Bellevue Literary Review. She’s also the author of the book When We Do Harm: A Doctor Confronts Medical Error. She wrote the KevinMD article “Emotional epidemiology of disease is as critical as clinical epidemiology.” Danielle, welcome to the show.

Danielle Ofri: Thanks, Kevin. It’s so great to be here.

Kevin Pho: So we’ll get into your article in a little bit, but first off, can you share your story and journey to where you are today?

Danielle Ofri: You know, I’ve spent my life mostly at NYU and Bellevue. I trained in internal medicine. I was an MD-PhD, thinking I would end up in a lab, but then I ended up really just falling in love with the stories of my patients in general medicine. I took off a year and a half to travel after residency. I trained during the AIDS epidemic, so it was a pretty intense time, somewhat similar to the COVID time, and I remember just feeling all of these stories that had piled up from those years, that I knew were singular. And so I just started writing them down, not with any plan for a book, but just because you need a place to put them so you can go forward.

When I came back to Bellevue, because I really loved working at Bellevue, I began to publish these stories in literary journals, and they finally came together as a book, Singular Intimacies: Becoming a Doctor at Bellevue. And then around the same time, we started the Bellevue Literary Review to publish fiction, poetry, and nonfiction about health and healing. So for me, I’ve kind of gone on this sort of journey from being sort of straight science and wanting to be a lab researcher, to ending up in primary care, and then being a writer and an editor on the side.

Kevin Pho: So, primary care internal medicine, we could say. I’m also primary care internal medicine, and some would say we’re the last of a dying breed. Now, tell me what keeps you going in primary care.

Danielle Ofri: I would say it’s still the stories, the patients and their stories. It’s endlessly fascinating. And I have to say, for anyone who’s married to an accountant or, I don’t know, a government worker, I try to sort of compare the stories we come home with. There’s never a day, no matter how frustrating the days are, and there are many, as you know, there’s always an interesting story. I mean, just yesterday I had so many different patients, and I was regaling my husband with all of these stories. It never gets dull.

And I think the other thing is that in so many jobs we just have frustration, and we have frustration here too, but we get the opportunity to move the needle for our patients, sometimes even just one degree. You shift the dosing of the Lasix so the patient can go out and not have to find a bathroom in the New York City streets. It seems like nothing to us, but it can be life-changing for the patient. There’s nothing more gratifying than to have a patient feel better after they’ve been with you than before.

Kevin Pho: Now, as you mentioned, you are the editor-in-chief of the Bellevue Literary Review. Tell us how important it is for us in health care to really share not only patient stories, but stories about medicine in general, and how healing that can be.

Danielle Ofri: You know, I think the pandemic really brought this out. We were awash in writing about science and medicine, and you could see that it only goes so far. Of course we need our randomized controlled trials. We live on them. But we also need to grapple with the existential issues that health and illness and disease bring up, both for patients and for caregivers, and of course we are all patients as well. Certainly many of us became patients during the COVID pandemic. Often we need other mechanisms. We need poetry, metaphor, and fiction, the great lie that tells the truth, which can often get into some of the deeper issues that our top 10 tips for asthma care don’t really get to.

Kevin Pho: I’m going to put you on the spot here. Can you think of a particularly poignant story from your experience that has moved the needle, whether it’s from a patient’s standpoint or from a clinician’s standpoint?

Danielle Ofri: Well, there are many, so I’ll share one about a patient of mine who was, for the classic doctors, like the train wreck patient. He’s got CHF, CAD, diabetes, AFib, asthma, obesity, gout, renal failure, everything. He’s on 18, 20 medications. So this is the kind of patient who’s just a disaster waiting to happen. He needed to get an implantable defibrillator. He didn’t want to make the decision. He was at risk for having an arrhythmia, and so he put it on me and said, “You make the decision, Dr. Ofri.” That was really hard, because it’s primary prevention. But we went back and forth, and finally I said, “I think the benefits outweigh the harms.” He did the procedure, and it was a disaster. Everything that could go wrong went wrong, to the point that they had to turn the defibrillator off. It was that bad.

I felt terrible that I advised this patient to do something that turned out terribly. But we spoke about it, and I told him how I felt, and he told me how he felt. It was the chance to sort of be really honest about this. We’ve been together now since I was an intern, and I won’t tell you how long that is, but he’s my longest-term patient. And I think because we had the chance to really talk over a difficult issue like that, it feels like family now, that we could sort of acknowledge our shortcomings. He eventually got a repeat one, and he did well, and he’s doing well to this day. Even though his creatinine is getting close to three, he’s still doing well, and he’s still so happy to see me, and I am so happy to see him.

And so I think that moving the needle has lots of different definitions. Of course there are instances where a patient’s pain is less, or we’ve helped them through a difficult diagnosis or through death. But just being able to solidify a relationship, to me, was moving the needle for both of us. It changed, I think, how he viewed the medical system, and for me, it changed how I reacted to difficult situations when things don’t go as well as they should.

Kevin Pho: Wonderful. Thank you so much for sharing that. Now, let’s talk about your most recent KevinMD article. It’s titled “Emotional epidemiology of disease is as critical as clinical epidemiology.” Now, for those who didn’t get a chance to read that article, can you just walk my audience through it and share the story of why you decided to write it?

Danielle Ofri: Sure. So at this point in the pandemic, we’ve been through three waves. Obviously the first wave, we were hit really hard in New York, and it was just the nightmare you all remember, and it was just trying to catch our breath. And then the vaccine finally came during the middle of the Delta wave, and we thought, “This is it. All the sacrifice, we’ve done it.” And then a year in, I still have patients who don’t want the vaccine, and they’re almost always my highest-risk patients, and it’s been such a painful experience.

And so I was grappling with some of my patients’ responses. Some will say, “This is crazy, I don’t want it,” or “You’re talking crazy,” or “I think there’s more harm. I’ve heard about patients who die from the vaccine.” And no matter what I do or say, even when I say, “Hey, listen, I don’t want to lose you.” I mean, I’ve sent more condolence cards in the last year and a half, two years, than I have in my entire career, and I’ve been to a lot of Zoom funerals, and I don’t want to lose my next patient. And it still doesn’t move them. And so even though we have such compelling data about the epidemiology of disease and vaccination, that is not convincing for our patients. It’s not about logic. It is about this emotional epidemiology.

And it made me think back, if you guys can remember the swine flu, when all of our patients were clamoring for the vaccine. When we finally got it, oh, nobody wanted it. And why? It’s the same disease. But the sense that we should have solved this already, the sense of urgency, was gone. All these things, we as doctors think they don’t matter, but for our patients they matter. And so I didn’t come away with a great pearl or solution, if you’re looking for that, but with the idea that we have to think about the facts, but we really have to think about the emotions that go into people’s decisions to trust a medical intervention.

Kevin Pho: No, I think that what you say is so resonant, because I say this all the time, and my talk is that we only can go so far with things like data and statistics and numbers, and really it’s the emotion that guides decision-making among patients, and I always encourage stories. So over your many encounters with patients who may be a little bit hesitant and resistant to vaccines, is there anything that you’ve learned in order to better connect with patients emotionally, in hopes of swaying them?

Danielle Ofri: Well, I always start by saying, “I’m never going to force anyone to do anything. This is your decision. I want to tell you what I know. I also want to tell you how much I don’t want to lose you, but this is my personal wish. You’re my patient, I’m your doctor, I don’t want to lose you, and here’s why I’m willing to go out on a limb on this.” And then I want to ask them, “What have you heard? Tell me about that. Where’d you hear that from?” And I think about putting risk in perspective. A patient may hear one story of someone who died from a vaccine, and that’s much more resonant than 800,000 people dying of COVID in the country. So asking questions and being curious.

I think a lot about my older attendings back in the day, and one of the things they exhibited was clinical curiosity. They always were interested in patients. Even these old-fashioned, bow-tied, button-up, white-coat older white guys, which most of them were, asked a lot of questions. They wanted to know about the patient, about the disease. And with that approach, both clinically and also in this kind of scenario, it was helpful to ask the patient, “Tell me what you’ve heard,” and to say “Wow” instead of saying, “Oh, that’s ridiculous.” “That is so interesting. I’ve never heard that. Tell me about that. Where are you learning this? I want to know.” It can help. A few patients will get swayed, and many won’t, but often we keep the conversation going.

I have one patient who, on religious grounds, will not do it, or her family. Anytime we talk about it, she’s so appreciative that I still talk about it. She’s not resentful. I think she sees it as caring, and we kind of can joke about it and laugh a little bit, like, “It’s my job to try and convince you,” and about how important it is: “It’s more important than the iron pill you’re taking. It’s more important than the cholesterol pill you’re taking.” And to keep at it, not to give up. A few patients have since, after the Delta wave, some were more likely, or after the Omicron wave that was so prevalent. Sometimes they’ll say, “I just need to hear from you. You’re my doctor. If you think it’s really good.” And I say, “I can’t guarantee perfection, but I think it’s better than what we have, which is not having the vaccine.”

So keeping at it, and not being too dogmatic, being personable, being willing to show what we don’t know. And it’s true, we don’t. It was fast, it was very fast, thank goodness. I try to explain to my patients that the overnight success was also based on 20 years of research. It didn’t pop out of a hat. Often they don’t know that mRNA vaccines have been studied for quite a long time. So giving some perspective can help too.

Kevin Pho: Now, you’ve clearly articulated the importance of sitting down with patients and sharing their stories and listening to their stories. But as you know, in primary care there are so many pressures that are forced upon us and that limit our time, so many checkboxes that we have to click in an EMR, and we have to see patients every 15 minutes. So in that context, where we have a shorter and shorter amount of time with patients yet still want to connect with them emotionally and hear their stories, how do you still connect with patients in the face of the increasing pressures that we face as primary care physicians?

Danielle Ofri: I like to acknowledge that we have these limitations. So I may say, “Hey, listen, we only have 15 minutes. I want to make sure we get to the important stuff. What are the two most important things you want to get to? And here are the two most important things I want to get to. So let’s make sure we get those. You may have 20 things you want to get to, but if we do them all, we’ll guarantee being superficial, and I don’t want to do that. And one of the most important things for me today is to talk about the COVID vaccine. It’s as important as your diabetes.” So I try to do that.

I try to do my first minute of full-frontal listening, eyes on the patient, off the computer, or not typing while you’re on a video visit. And then I say, “Hey, listen, I don’t want to miss what you’re saying. Do you mind if I take notes while we speak?” Because we’ve got to document while we talk. So if I acknowledge that, as opposed to just turning away and seeming to be completely focused on the computer, that is helpful too. I think patients recognize that. And then I say, “Hey, if we miss something, let me know by message, or if it’s a lot of things, we’ll schedule follow-up time.” And I just recognize, “I’m sorry we couldn’t get to them all today. I don’t want to keep anyone else waiting or keep you waiting.” But it’s not easy.

And then I file patient safety complaints to our system when I think there are structural things that endanger patients, and sometimes it is a time thing. Here a patient’s got 18 active medical issues, and I’ve got to convince him to get COVID vaccinated, and you’ve given me 15 minutes. It’s actually dangerous, because I’m not going to be able to read through every medication. And so I’m literally filing complaints, because I think that they don’t know. I had a patient read her COVID result in the chart, and the first column is actually the reference value, which is “not detected.” That’s all she saw, and she went off to work and didn’t see the “detected,” which is off the screen. And I file a patient safety complaint.

So be liberal, folks, when you think that structural things are endangering patients. They’re not so interested in our mental health, but at least they are when we say patient safety, and some of that is time. Don’t be shy about letting your administration know and clogging up their queue with your observations of how some of these things endanger patients’ health.

Kevin Pho: And has filing these patient safety complaints made a difference?

Danielle Ofri: Well, the issue, for example, of the COVID test: They didn’t know about that. Now, I don’t know how long it takes to change this, but it wasn’t on their radar before, that patients were mistakenly reading their COVID test. You think it’s not that hard, but you’d be surprised. And so they’ll never know if we don’t make our voices heard. And I think the two frameworks through which the administration can see things are patient safety and patient satisfaction, because those things they really care about.

And so when your patient gets frustrated, you say, “I am frustrated too that you’ve had to wait an hour to come in here,” and I encourage them to file a complaint, and I’ll mention that too: This patient was so unhappy because they had to wait, and they had to wait because the system was not working, and the last patient took too long because they had an acute issue. I don’t know if it’s helping, but it certainly won’t go anywhere if we don’t make our voices heard, because who else knows so intimately what the risks and problems are?

Kevin Pho: We’re talking to Danielle Ofri. She’s an internal medicine physician. She’s the author of the book When We Do Harm: A Doctor Confronts Medical Error. She’s also the author of the KevinMD article “Emotional epidemiology of disease is as critical as clinical epidemiology.” Danielle, I just want to ask a quick question about your latest book, When We Do Harm. What are some of the main takeaway messages that you want readers to come away with?

Danielle Ofri: Well, to recognize that medical error is many things, and I think that we need to distinguish things that people do sort of intentionally wrong or negligently wrong from systems that make us make errors. It may be that we’re the one who grabbed the wrong medication, but there are always factors that make that more likely to happen, as I’ve alluded to before, and we need to address both. Obviously if we make a mistake, we want to correct that and acknowledge that, and if someone’s negligent, you get them out of the field, but that’s rarely the case. I think the bigger thing is recognizing what makes errors more likely, and there are so many that it would take us 10 hours to talk about them, to bring those out.

And then I think the third message is that there is an emotional component to errors, and that when we make mistakes, intentionally or not, we are devastated. We feel shame, we feel guilt, and we often don’t want to speak about them, which of course is a bad thing for overall patient safety, because we have to know what kind of errors are happening and where they’re happening, to research them and study them and rectify them. And so if we don’t address the emotional component that health care professionals feel when they make an error, we’ll never be able to sort of solve the medical error epidemic.

Kevin Pho: We’re going to have to have you come back on the show so we can talk more about your book in depth. Now, for my final question, what are some of your take-home messages that you want to leave with the KevinMD audience?

Danielle Ofri: I think we’re so privileged to be in medicine. I mean, I can’t imagine a better place to be, even despite how hard it can be, despite how hard the pandemic was. And I think a lot about how during the pandemic many people sort of had kind of quarantine boredom and a feeling of uselessness. We didn’t have that. How lucky we are to have had a purpose and have a skill that we can use, and to use that to our best for educating our patients, educating the students and colleagues around us, and to never lose sight of what a privilege it is to be practicing medicine or nursing. Listen, the alternatives: You could be in a windowless office, just on a spreadsheet moving widgets around. But instead we get to be with patients in the thick of things and be with them at their most vulnerable moments.

Kevin Pho: Danielle, thank you so much for sharing your stories, time, and insight, and thanks again for being on the show.

Danielle Ofri: Thanks, Kevin.

Listen and followApple PodcastsSpotifyYouTubeMore apps · Browse all episodes