11.1 - The Physician-Patient Relationship with Dr. Jay Lynch

Michael and John are joined by Dr. Jay Lynch to discuss the centrality of the physician patient relationship in the practice of medicine. Together, they explore what this relationship would look like, how it has been de-emphasized in modern medical practice, and how to balance technical expertise with human connection

39 minutes • Published Dec 30, 2025 • Download • Transcript

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[Intro music]

Hi, and welcome to the Hippocratic Society Podcast. This podcast is a project of the Hippocratic Society.

In the podcast, we aim to reflect on deeper questions in medicine, all with the aim of rediscovering the ideals that brought us to medicine in the first place in order to better serve our patients and colleagues.

Thank you for joining us and we look forward to engaging with you through this podcast.

Hi, and welcome back to the Hippocratic Society Podcast. Today we are interviewing Dr. Jay Lynch from the University of Florida. Dr. Lynch, it's really a pleasure to be with you. Thank you so much for being on the podcast today.

Pleasure to be here. Thanks for having me.

Absolutely. And could you tell us a bit just about your background and where you are now in your career? Yeah.

I'm originally from Virginia, and I went to med school at Eastern Virginia and came to University of Florida for my residency, and I worked for a year in general medicine after that, and then I went to the National Cancer Institute and did my oncology training.

And I've been back in Florida since 1991 as medical oncologist, and I'm a lymphoma specialist is kind of my area of expertise. And I spend a fair amount of time teaching medical students and fellows and also happen to be the dean of Admissions for the College of Medicine.

So that's a lot of fun.

See, you get a lot of interaction with medical students.

I have lots of interaction with the medical student. I like to say. I like to abuse medical students for a living.

And then. And your course is also titled the Physician Patient Relationship, is that right?

Yes, do have a course. In fact, I have students that are starting it Wednesday, and I was just looking at some of the readings.

Yeah, well, this is perfect because today we wanted to talk about the physician patient relationship. So your area of expertise. Exactly. Great. So, yeah, why don't. I'd love to start off just with the question,

what do we mean when we talk about the physician patient relationship and why is it so vital to medicine?

It's a good question, but it shouldn't need to be. I mean, medicine, the history of medicine, has been the idea of a physician caring for an individual human being. That kind of bond, I think, has been at the foundations of what we have called Hippocratic medicine for most of my career.

So, I mean, I can give you some stories that illustrate it if that would be helpful to you.

First, as a personal moment, I was an undergraduate. I went to student health because I was having lots of abdominal pain and dissolved nerves and I saw what turned out to be one of the nicest young physicians.

But what he did was he talked to me, reassured me, listened to me. I walked out of there and I thought, my goodness, I feel better just talking to this guy.

And I even said in my medical school interview that he was the one I wanted to emulate. And so the personal experience of what you might call the art of medicine finds its epicenter, I think, in the relationships that we have with our patients.

Patients,

yeah. I think the other thing, Jay, that is a core aspect of the patient physician relationship is something that perhaps Pellegrino would talk about, which is in his virtues of medicine.

He bases the virtues that he chooses, as he writes the book on the core foundation of the physician patient relationship. And he also talks about it in the context of the importance of clinicians to understand the patient's lived experience of illness.

And part of that is through the relationship that they develop with a patient.

Can you comment a little bit about that as well?

Sure. I mean, I think we can. We live in a world that glorifies technology,

technical expertise, and in fact, it's rewarded financially by those that can do these fancy things, the machines and all that sort of stuff. But at the end of the day,

I think that unless I know something about my patient's life and why, what I do as a lymphoma doctor, I saw three new patients this morning, for instance, and each of them has their own story.

And the details of their story actually had important implications for how I even chose their chemotherapy that I needed. And because I can know the science about a particular chemotherapy regimen for a disease and know what the survival is, what the toxicity is.

But unless I know why it matters to them and their particular situation of health, then I don't know why I'm doing it for them. And I would say I could be a great technician, but I'm not genuinely a physician.

Great. Well, yeah, going off of that, I think I heard. I think it was Oliver Sacks who said that the physicians. One of the core roles of the physician is to reform the identity of the patient and.

And find that. And aligns with Eric Cassell's definition of illness as a disintegration of the person. And so the physician reintegrating that. That's very beautiful, obviously. And the question that comes to mind is what would be the difference for a trainee or an advanced practice provider and the difference in the relationship between them and the patient,

and maybe how that would clarify the role of the physician specifically towards the patient?

So in My role as an attending physician, I get to sort of set the parameters for how I interact with my patients. I've over the years established what I think are appropriate kind of guardrails and boundaries.

But for students, I think you're in a difficult and a trainee sort of in this weird space because there's somebody,

because the patient is not actually yours, that you are caring for them on behalf of another attending physician.

And so I do think that each of us,

even as a medical student, I would develop relationships with patients. And I know John, you've probably seen this too.

The student is often the person that has the most time to spend with the patient in a busy inpatient practice and an outpatient practice as well. So I don't think there's a lot of difference between just the idea of getting to know the human being and there's story.

Half of what I've learned about the world guys actually has come from just listening to my patients tell me about what they do and what they understand.

But I do think you do have to think about the,

I don't even know if procedural maybe I don't like the word hierarchy, but there are, there are chains of command that you have to sort of live within. But I think as a medical student and as a trainee you can set your own parameters.

And if the physician that you're working with is less interested in those kind of details, that doesn't preclude you from learning them and holding on to them on behalf of the patient because there isn't a personal kind of formation going on in this I'm developing habits for how I'm going to see human beings.

Can I share another recent story that actually I think illustrates this best? It's from my mother in law, Phelan, broke her hip about eight weeks ago. She's almost 95 years old.

And for those of us that have done this, know that that's often a very, very dramatic thing. She's lived in an assisted living facility. So we were there and of course it was wonderful to have people that I know looking after her.

And the surgeon came in and did a great job. And so the day post op my wife and I were sit there in the ortho unit and I had, we had two magnificent examples of ways to think about what you do at the bedside of a patient.

A nurse comes in, a nurse teacher. Presumably she didn't introduce herself or explain who she was or what she did. She had a young man with her who was obviously some sort of trainee and we were Sitting there, my wife and I at the bed, my mother in law is awake on a little narcotics.

And so the nurse starts to hang and she just says kind of in a bly voice, I'm hanging the antibiotic now and looking at the young man and I asked,

do you mind telling me which antibiotic that is?

And the look that she gave me was one as if I'd asked for her password to her bank account. I mean it was the most bizarre kind of how dare you ask such a question.

Well, it's Kefzol. I said, okay, first generation cephalosporin.

Thank you.

And then they proceeded to ignore us and to ignore her. They talked to each other and she was, they did a service. And then my mother in law, who's not exactly the most touchy feely person in the world, she's very practical.

When, when the young man picked her up, she looked at him and said thank you.

He never responded. He just looked away and they walked out of the room. So that was exhibit A of how to think about our relationships with patients. The patient is a thing that I act upon and I get my task done and I'm gone.

Within two minutes of them leaving, the actual floor nurse came in who began, who had introduced herself, explained who she was, talked about how wonderful it was to look after mother, doing all the same tasks, the things, but doing it in a way that my mother in law felt cared for and,

and we felt seen and heard. Didn't take any more time. Okay. But it was a mindset. It's a way of thinking about how I'm supposed to relate to people. So I don't know if that gets it part of what we're all talking about here, but there's the, what you might call the industrialization of medicine.

Converting it from a relational experience to a transactional experience,

no more personal than going and buying gas with your credit card at the place I have there, I have the observation and I maybe the incorrect belief that there are folks that would be very glad for patients to just stick a card in, have something done to them leave,

and not ever have to know anything about the human beings they're taking care of, at least certain leaders and CEOs of health systems.

Yeah,

I think one of the things that as you're talking about that Jay, that I was reflecting on also is just the idea of how my relationship with the patient changed once I became an attending in the sense that it's not something that I realized it would have such a big impact because I Felt like,

oh, I'm still taking care of the same patient. I'm still, like, trying to build a relationship with them. But the thing that I found most difficult as being an attending is that there's a huge sense of responsibility that is seems like qualitatively different than when I was a trainee in the sense that a lot of the times when I was a trainee and the inpatient setting too,

even from a time perspective, like, you're with somebody for a week, maybe two weeks while you're on a rotation, and then there's a sense in which you rotate off. And so, like, that might also be the end of your responsibility from a time perspective.

But then as a neuro-oncologist, where I'm like, following patients over a period of time and even in between, when they're out of the hospital, they're my responsibility.

I'm the one that they reach out to with symptoms or progression. And even though I do this work in palliative care, where I'm oftentimes doing advanced care, planning for patients in terms of prognostic awareness, et cetera, it's interesting how that feels very different, even as a palliative care physician versus when I'm a neuro-oncologist and telling somebody about their prognosis,

as in, there seems to be a graver sense of personal responsibility that sometimes I feel is hard to balance because you care a lot about the patient and you almost feel responsible for the progression, even though clearly, intellectually that's not the case.

But there's a sense in which, like, am I really thinking about everything? You know, uncovering every stone? Like, am I really doing my all to try to figure out, like, what the next best step is?

And oftentimes, especially in my field, there's like, not great evidence for what the next line of therapy is. And so, so much of it also depends on experience.

And so this weighing of sense of responsibility,

I think is the biggest change to me in the setting of this, like, physician patient relationship. And as a seasoned oncologist, I wonder to hear your perspectives on that and how you navigated that transition from a trainee to an oncologist.

Great question. No, I do. I feel for my trainees because we talk about having relations with patients, and for the most part, when people are in the hospital or they rotate their client, they see the patient, maybe not two weeks, maybe three days, never see them again.

And it's more like a drive by shooting, if you'll forgive an unkind metaphor. But so, so, and I think it was, it was really early on in my time as an oncologist that I felt exactly what you were doing.

Oh, when they got leave the hospital, they're mine and they're going to call me. And they did that. Balance between sort of being available and yet and being vulnerable, but also maintaining my own health.

I haven't always done as well as I wish I had done. And it's been kind of a learning experience for me over the years. I think I've been more inclined to just pay a little attention to my own sort of emotional health.

And that was my motif early in life. And I think I talked about it at the meeting in Dallas, but I went through a pretty serious depression about 10 years into my time as a medical oncologist.

And it was completely invisible to me. And I'm thankful for my friends and family who were kind enough to tell me they were concerned, get me the help that I needed.

So, yeah, I have my own rules. I'm sure everybody does this. For instance, when I'm out of town, I will talk to physicians about my patients, but I very, very much try not to talk to patients when I'm on vacation.

That's just one simple thing that allows me to be available to give advice to people so they don't feel like they're hanging. But it also gives me the space that I need to kind of restore my soul, which is one of my favorite phrases, actually, because the way we practice today can be soul crushing.

I mean, it really can be. Thank you.

How do you do it, John?

Yeah,

I would say that I have also not figured it out perfectly. And in some sense, I think that this is something that a lot of people deal with in the sense that maybe it's the core issue related also to the questions of burnout and also the story that you were mentioning about that nurse,

right. Where some people, because they're not sure how to deal with it, go towards another extreme, which is like complete removal of one's own emotions from what they are doing so that they are not as affected by it.

And they see it just as a job versus somebody who then may go the other direction,

maybe not have boundaries and then get burnt out and then sometimes even, like, leave medicine because they're, like, so emotionally and intertwined in, like, what's happening with every patient. And I think that that's where this idea of the virtue theory is helpful because there is this line of prudence in the middle.

But where it is, I do think that develops over time with the growth of experience and practical Wisdom of how to navigate those things. And that even in different patients, circumstances, individual patients, I feel like the application of differs because there's also different things that different patients ask of you.

And some patients ask, like, maybe too much of you because then it also can affect the way in which you're able to care for other patients. Whereas for other patients, you're like, trying to develop a deeper relationship with them, but then they also in some sense remain distance or more guarded because of what they're going through.

And so the way that each patient kind of presents themselves is also unique and developed,

developing that physician patient relationship. And the way that I process it is like I also just on my own time with reflection, meditation,

prayer, the sense that I re evaluate the ways in which am I responding to this patient in a way in which I am like, going above and beyond,

but in a way in which it's a detriment to other patients. And in that way, like, what are places that I should place overall boundaries in terms of, okay, you know, spending more time on the phone with this patient is not necessarily helping them.

And so, like, what is the actual good of this patient in the moment and really trying to reflect on that, trying to separate out my own sense of wanting to be liked by the patient and amidst or through that, seeing, like, what is good for the patient.

Because for some patients, I think there are real problems,

real other pathologies too. So, like, patients who have certain personality disorders may actually naturally, like, pull more and more and more. And so actually giving more time to the patient isn't actually helping them.

Setting boundaries actually helps the patient in terms of being able to contain sometimes the emotions that may be coming with. With a distressing illness. Right. And at the same time, there are other patients who may not ask for as much, but there might be particular times where they need more and recognizing the difference there and also providing that for those.

Pat,

I couldn't agree more. I think here's another piece to me that I didn't realize till I was practicing is how gracious patients are and how forgiving they are.

They're amazing people.

Take out the subset that have serious personality disorders, and no matter what you do, they're not going to be happy. In one sense, those people challenge most our integrity as physicians because there isn't going to be a warm, fuzzy feeling that you have between yourself and this patient.

The tendency will always be to try to figure out how to get out of the room as quickly as possible. And that's where I have to ask myself what's medically appropriate for this person,

whether it's going to be enjoyable to do it or not. The other part of this to me is the community that I practice in. I love my colleagues, I love my students, I love my.

So when I'm struggling, did I get this right? Should I have done this better? We have conversations about it in our reflective writing sessions that we do with the third year medical students.

Everybody thinks that I go to sort of talk to them and exercise, show them the wisdom of being 66 years old, years old. But the truth is I go to it because those conversations restore my soul and help me sort through the realities.

As much as I'd like to think I can do it on my own, I can't. I also want to contradict a common misconception that I think is out there is that if you get too close to people then you're going to burn out.

And that's actually the justification for walls. I'm not saying we don't have boundaries, but I'll use the distinction between boundaries and walls. Okay,

I'm going to read a quote from Fred Griffin. Fred Griffin's a psychiatrist in Dallas who ran, I don't know if he still does an entire program for burned out doctors.

He focuses on an interesting book called the Fortunate man, which was written, if you got a few seconds, let me tell you about the book, then I'll read the quote to you, if you don't mind.

So the Fortunate man is a 1960s book where a journalist goes and spends time in Great Britain with a physician. Sassall is the doctor's name. That's not his real name, but he basically as a primary care doctor among the forest people of Great Britain and this kind of like Appalachia as far as I can tell.

So he's there and he comes in with this initial I'm going to serve the world and save these people kind of mentality.

But a series of stories happen between him and patients that kind of just blow his mind. And the whole book called the Fortunate man is the recounting of those stories and how he went from a physician who saw himself as somehow a savior to a fellow sufferer in a world of suffering who can care and learn from patients.

And this is in summary in one of these articles. I'm just going to read this to you. It is the physician's good fortune to spend their life work engaged in a profession where hand in hand with developing proficiency in helping others, they may deepen self understanding, increase their own humanity and learn how to grapple with the dilemmas they,

too, must face in life because we're all going to get sick. When physicians are willing to engage in this process, they are much more likely to find their work meaningful,

and they are less likely to become burned out by the daily impact of suffering of their patients and the emotional demands placed on them. This is only apparently a paradox,

and I love that because that describes my experience.

When I look around and see physicians who just have the wall up. And I just. I'm polite, you know, I don't yell at patients, but I don't really want to have anything to do with sort of the emotional dimension.

Most of the folks that I see becoming not just burned out, but frankly, cynical and their practice of medicine. So I'd love to hear what you guys think of that.

Yeah, I think one reflection again,

coming back to the idea of virtue theory that we often,

as a framework we're using in the Hippocratic Society is this idea that if we continue to build this habitual sense in which we're putting up walls, distancing ourselves from patients.

I mean, we're doing that for, like, eight. I mean, in medicine, really, 10 hours a day. And if we're doing that, then that is bound to affect our habitual way in which we approach relationships, whether we are as aware of it or not.

And so we gradually lose the meaningfulness of relationships overall and how we may be habituating within ourselves the approach to also those around us. Right. And so I think in that way, it is one of those things where it's not just something, again, isolated to what we're doing in the hospital,

but also plays out in the friendships, family relationships that are most meaningful to us. And then I think the. The second just reflection that I had with that is this distinction that you made between boundaries and walls, because boundaries are just kind of.

Yeah. In some sense, they're like a visual marker of something where we're coming close and we could still like, reflect on. Okay. Like, there is this boundary here at this point is a general boundary, but for this particular patient, is it important for me to cross certain of those boundaries at times in order to allow for me to address what this patient may.

May need in particular.

Right. Whereas a wall, you're just like, there's a one size fits all for all patients, and that there's, like, no kind of going beyond because it's, like, impenetrable. And I think that that's, like, the thing that I feel like even in psychiatry is, like, a way, as a Neurologist.

We also rotate it through psychiatry. And the psychiatrist would say, like, boundaries are also just like markers are kind of like flags. When you're getting close to one, you could see, like, that you're getting close to something and then be able to titrate, like, okay, like, where am I in relationship to this BO and how close am I getting?

Or how far am I? And also assessing, like, what it looks like in this particular situation.

Yeah, I like to think of boundaries. One of the most important to me is where does my responsibility end and the patient's begin?

And I would argue that that is different for each patient. You were alluding to this, that some patients need more from me than others do. I have people who say, doc, good to see you.

If I'm fine, you're doing fine. I don't need to talk much. I got something to do. And we have cordial and genuinely brief interactions. On the other hand, I have some people that I know they're going to need a lot of emotional support.

I'm grateful that vast majority of my patients are just friend. There's an old quote from about eight years ago. The older I get, the more my patients become like friends and the more of my friends become patients.

And that is just absolutely true. So, you know, I had prostate cancer two years ago. I just had my two year happy birthday psa. So all is well. After radiation and hormone therapy, I told my patients that I was going through this.

The amazing exchange of kindness and concern for one another that I never would have guessed when I was Michael, sitting where you are.

It came out of this. That's beautiful and healthy.

Has been enormously sustaining to me. I got more cards from my patients about to. Dr. Lynch, I hope you're doing okay. You're in my thoughts and prayers and these sorts of things.

And it only strengthened our relationship and the trust that we have with each other as we kind of walk forward and some of the things that are often difficult in what we do.

I think lymphoma is typically a little happier oncology than brain tumors. So my hats off to you and God bless you, John, for what you do.

Yeah, those are very beautiful reflections. I really love that.

It reminds me of advice I heard from a psychiatrist, actually, Anthony Weiss, who we've had on this podcast before. But the way he framed it when he was telling me about how difficult it is sometimes, especially with suicidal patients, to go home and leave, leave that at work and not sort of ruminate on that and overly worry about it,

which obviously it's Very distressing. But the way he framed it was saying that he has a responsibility to the patients, not a responsibility for the patients, which I think was sort of exactly what you were saying.

I see. A nice phrase. I like that. Thanks for sharing it. That gets at what I'm trying to talk about,

that. Yeah. You actually dehumanize people if you start taking responsibility for them,

not to them. Okay. I want to treat another human being as if they're an independent human being who makes decisions. And to. To somehow rob them of that, actually, I think robs them of a bit of their humanity.

So on a more practical note, what would you. What advice or what experience can you tell us about for people who maybe have. Have gone too far and maybe crossed boundaries or find themselves too invested in patients?

First of all, you will. You're going to get it wrong, okay? Period. End of discussion. We're human. We get it wrong. I think sometimes I hear my young colleagues, I've got to get it right every single time.

Get over it, okay? Learn how to tell yourself that you got it wrong and be honest with yourself. Show yourself some grace, forgive yourself, and try to get it better next time.

There are times where I have allowed myself to become so worked up and tired that I have trouble thinking, and there are times where I've just not stepped towards it, towards somebody, probably more than that, latter than the former,

and to realize, yeah,

there's no formula. We, as sort of Westerners, want a formula to stick in a computer and, oh, where's the. How close can I get to a patient computer model and stick it in and you're going to get an answer.

No, I think there is a huge amount of discernment. And this is where the community is. You talk to each other. So when you get in and you've made a mistake,

I admit it, okay? And I'm not talking about the horrific mistakes where you end up in a completely inappropriate kind of relay. I'm just talking about where you begin to feel that I'm overwhelmed.

I can't continue. And I think that's where the health system has no boundaries in this regard. The health system will let you and pay you and encourage you to do as much and as much, see as many patients as possible and do it faster and faster with no connection to your patients,

because that generates more money and efficiency and they'll even put on the mask of, oh, that's the only

way we're going to be able to

offer healthcare to everybody. As if there's some kind of virtuous motivation behind all of this.

One of your questions, I think, was how do we do this in a healthcare system that it doesn't recognize the importance of it? And I do think that's part of what I love about the Hippocratic Society.

We attend to our own sort of development as virtuous human beings. We encourage each other to remember that we are here to care for our patients, to put their interest in front of our own.

That's the simplest formulation of what the profession is about from Ed Pellegrino, and that it's fundamentally about this patient in front of me right now. What's the best thing for them?

Yeah, coming back to Pellegrino, just this idea that a lot of the.

The sacredness, one could say, of the physician patient relationship is based on some of the things that we've talked about before, which is this Hippocratic approach in the sense that the doctor is also professing to uphold certain things within the bond of this relationship that he or she will not break,

and that the patient can also trust in that. And that's why the patient can come to the physician and even in a first meeting,

say, and open up in ways that you normally wouldn't in the first time you meet a stranger.

And so there seems to be this unique aspect of the physician patient relationship that is different than other types of jobs,

that there are others, I think, that do mirror or are come close to that type of relationship, but that it is something that is fairly unique.

I would say that on the other side, though, there's this interesting tension because as we talk about this is like a moral practice or medicine as a moral practice.

And Pellegrino would also say that in a physician patient relationship, though we've been talking a lot right now of the physician's relationship to the patient, since you're a physician, Jay, that there's also, he would say, a reciprocal one,

where of course, we respect the patient's autonomy and we do not impose values on the patient.

But on the other hand,

the patient also doesn't impose values on us in the sense that it's sometimes easy to forget that the physician themselves is also a moral agent and that is deserving of respect.

And of course, in the context of a physician patient relationship, where the patient is the one who is vulnerable and suffering, then that equilibrium is not equal in terms of the patient's needs and the knowledge and the kind of power dynamic within that relationship.

But at the same time, the physician is still a human being and also has A respect for a capacity to reason,

judge, make choices that are authentically themselves. And I was wondering if you have any thoughts about that idea of kind of the patient physician relationship as well, in that direction.

Absolutely, absolutely. Yeah. I've had.

The one that's most obvious in our job is the tendency towards physician assisted suicide and wanting people to partake of that. And I can count on one hand the number of times I've had a patient and their family make such a request.

One that sticks out in my mind the most that actually helped me figure out how to speak about this as a physician to a patient was a gentleman with head and neck cancer who had had locally advanced disease.

He was in the hospital on the heme-onc service, was in an enormous amount of pain and it just didn't seem to matter what we did. I was having. We were having a hard time controlling his pain.

And while we were on rounds with about eight people, his wife said, I just wanted. I just want you to put him out of his misery.

It was kind of like out of the blue.

And so I often do things that are really dumb in those situations. But I think I got this one partly right.

I said,

that is an extremely important question and deserves time.

And I understand why you might think that. Do you mind if we come back later with just a couple of us and sit down and have a conversation about that?

So that was step A. And she went, okay. So then I came and I said, I need you to understand that as a physician, I have moral values that shape how I practice, and I simply can't violate those, no matter what the circumstances.

One of those is, I'm never going to deliberately take a human life.

I just can't do that for whatever reason. But I do want you to know we are going to work towards getting your husband better. And we did actually get his pain under better control over time.

But I did say to her, I also,

I know that it feels like that's what you think we would do, but I can't imagine you having to live the rest of your life knowing that you actually forced our hand to take the life of your husband.

I just don't think you really want that burden, do you? And she sort of thought about it and said, no. So the number of times that these things come up to me, John, are just, just relatively rare.

And I'd say 98% of my patient interactions, they knew who. That's part of the idea is you get to know each other. I'm pretty transparent about who I am.

My patients Ask about my family. They ask about how our church is going. They asked about how the study center was going. And some of these aren't even people of faith.

They're just folks that are interested in who I am. And so this mutual respect becomes organic. It isn't some artificial thing that I had to sort of impose upon relationships maybe just a handful of times and patients got mad and I could live with that.

Okay,

I'm not going to compromise my integrity to make somebody happy.

Even when the health system is trying to get you to do things that I, they wanted me to do my notes in the room with patients because they, and I just politely ignored them.

And I don't do that. I won't do that in the room with the patient. I sit down and do them afterwards. I realize I don't see as many patients, but I don't want my eyes distracted from the patient onto the computer.

Does that make sense? I mean,

I think these things are real. And, and there really is a two way relationship, at least in my experience, particularly as an oncologist. When people are terrified when they come to you, there is this enormous vulnerability that they want somebody to love and care for them.

And I'm not afraid to say that I love and care for my patients.

That does come with certain immutable boundaries about what I will or won't do.

Yeah. And I think one of the things that at least I was reflecting on as you were talking, Jay, is that,

yeah, within this idea of the patient physician relationship, and when you were talking about kind of being involved in the lives of your patients, that coming back to just a sense that the depth in which we like engage in the relationships also makes the work very meaningful to.

And that I do think that there is this common misunderstanding of like how like removing yourself is actually protecting yourself, when actually I think it's the opposite of engaging in the relationships that make it most meaningful.

I was also reflecting just on the fact of,

even though in the Hippocratic Society we talk about the individual moral development,

but in reality we also,

speaking of the physician patient relationship,

cannot ignore the fact that there are systematic things that sometimes get in the way of physician patient relationships. And I think that these are some of those things. When things like profit or when things like efficiency from a system is trying to be maximized,

rather than the physician patient relationship being the thing that should be maximized. That's when there are also things that are getting in the way between that relationship and that. That's when people on both sides become unsatisfied because the end goal is like not that development of the bond, but rather some other end goal that is actually often not intrinsic to the care of the patient itself.

And how to try to create systems where we try to not have those things get in the way,

I think is really important for maintaining the sense of trust in the system. I'm reading this book right now. Now it's very interesting. It's called, it's a New York Times bestseller by this physician who talks about like the kind of seven or eight major mistakes that medicine has made over the past couple decades.

And the theme behind a lot of those mistakes are not actually mistakes that were unintentional.

They were actually mistakes because they were based on research that was faulty, but that was presented intentionally in a faulty two way in order to gain a lot of fame for that physician.

And there's a lot of this, you know, and he talks about this in the setting of like what happened with peanut allergies and increasing peanut allergies and how it's based on that kind of really not great evidence, but really it was like something that just caught on as well as this idea of hormone replacement therapy for postmenopausal women and how that was actually based on evidence where the result wasn't even statistically significant.

But the kind of authors kind of perpetuated this idea that it was actually what the study showed, when actually if you go into the study wasn't what it showed,

but that resulted in a lot of things like promotion and fame and et cetera that got in the way. And so that's why there's system level things. But actually a lot of these things are also based on then the individual moral formation of the physician to make sure that there aren't things that are getting in the way between the physician and the patient and getting in the way of that relationship where something else may be influencing

what is core to that relationship.

Yes,

I agree with you. I think that here's a little story that will actually,

I think make it even more clear how dangerous this is. So in the 1990s,

you may recall,

there was an attempt, you guys probably aren't old enough to remember the 1990s, but when President Clinton was the president, they tried to institute healthcare reform and it was using capitation was the rate.

And so there was a survey done of gastroenterologists and radiologists. And the gastroenterologists and radiologists were asked if somebody has a Hemoccult-positive stool, what's the best way to evaluate it?

You'll see what I'm getting at in a second.

So prior to this, when it was fee for service,

all the gastroenterologists, 85% said endoscopy and colonoscopy is the best way to do it. And 2/3 of radiologists said upper GI and a barium enema were the two ways best to do this.

Each sided literature to support it after capitation, when suddenly the payment model means you get a certain amount of money and every time you do a procedure you actually lose money.

They resurveyed the same Doctors and now 2/3 of the gastroenterologists think that barium enema and upper GI and dusk and upper GI is the better way to do it and vice versa with the radiologist.

And each of them cited the literature from the other side as the reason why they had this opinion.

And in my own world in oncology, I know there are physicians that have calculated how much money they make for each particular regimen. And I've had them tell me, I use this one because the margin that I make from it is much larger than the margin I make from others.

And then they go and oh, look, it actually works in trials. So I think the capacity of we human beings for self deception is profound and requires the community where we will be honest with each other.

And I routinely say to my friends and students, you have somebody in your life that you give them permission to tell you when they think you're making the wrong move, that you are not well and that something is wrong.

And that's not something that's easy to do in our kind of individualistic culture. But I think without that we're all going to be.

I am the best justifier of my behavior of anybody in the world. I could convince all of you that everything I did was for all the good reasons. And the truth is I'm lying to myself and I'm lying to you.

And it's one of the examples is I believe this is really true and it just happens to get me promoted.

So yeah, I think the realities of being human are infused in the realities of being a physician.

Yeah, I think that's. I know we're running low on time, but I think that's a perfect note to end on for an argument for the Hippocratic Society and why we need virtue.

I just want to say how much I appreciate the work you're doing.

It is. If I can be personal here for a minute,

I've tried to sort of. We've had our little world here at UF but I had always longed for and even prayed for a national organization that would try to do something like this.

So I'm really, really thankful to be part of your work.

Yeah. Well, it's it's an honor to have you as part of it, and we're really grateful for all that you've done and. And the amazing community you're starting at uf.

All right. We'll look forward to having you here.

Thank you so much.

Jay,

thank you very much for joining and reflecting with us today.

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