Interviewed by Ethan Clement and Krishna Vellanki
Riley Lipschitz is an Assistant Professor in the Division of General Internal Medicine, Department of Internal Medicine. She received her medical degree from UAMS in 2014. She later completed a residency in Internal Medicine-Primary Care at the Hospital of the University of Pennsylvania in Philadelphia.
Can you tell us about your journey into medicine?
I never thought I would go into medicine. Both of my parents are physicians, so medicine was a part of my life as a kid. I never thought I would be a doctor. I went to a liberal arts college. I majored in International Relations as an undergraduate. I spoke Chinese and thought one day I would work for the State Department.
When I got out of college, trying to find my path, I ended up creating a business with my dad where we did healthcare consulting and education. I learned about how to educate people about their health, how to empower people about their health, and how to help them navigate the health system. I became increasingly interested in patient education. I wasn’t yet sure I wanted to be a doctor.
Still, I thought, people listen to doctors. Furthermore, while I was doing health care consulting, it was painfully clear that navigating the health system was incredibly difficult. The thing that really pushed me to do medicine was that if you were wealthy and well educated, it was hard to be an empowered consumer of health care. If you were poor and uneducated, it was impossible to be an empowered consumer of health care.
Over time, I developed an interest in vulnerable patients. It became clear to me that how to work with folks on the margins of society was a problem someone had to address. I thought it had to be addressed from the physician’s side, from within the system, not from the outside.
So, I decided to go back to school. I went back and did all basic science prerequisites: biology, chemistry, and physics. Eight months later, I was in medical school. I wanted to do primary care because our health system was so royally dysfunctional. By investing in primary care, I could help address some of those gaps.
I was a fourth-year medical student when the Affordable Care Act—the ACA—came out. I went from seeing people who did not have insurance being prematurely discharged home to suddenly having access to public insurance. It was clear that the ACA was going to change how care was delivered. I started working with Dr. Joe Thompson at the Arkansas Center for Health Improvement in order to figure out what this meant for future physicians and how they would practice medicine. I started to learn about payment reform, health system design, and primary care innovation. After graduating from the UAMS College of Medicine, I ended up going to a primary care internal medicine residency at the University of Pennsylvania in Philadelphia, keeping all that in the back of my mind, thinking that I someday wanted to get back to health policy.
Towards the end of my residency, I began picking my head out of the sand from just learning to be a doctor. That is when I started to hone in on population health and complex care management. Specifically, I wondered who had the highest needs within our health care system? Whose health care costs the most? I came back to Arkansas because I knew UAMS was a place where you can make things happen. I was sure this would be a good place for me to be innovative.
Is there a particular patient or encounter that shaped how you practice medicine?
Fresh out of residency, I was working in the general medicine clinic. There was this one patient; I remember him so vividly. I’ll call him David. His wife pushed him in a wheelchair into the clinic room. He had this huge beard, was morbidly obese, and just looked bad. He was working hard to breathe. Because of that, he couldn’t tell me very much about his history. I looked back at all his clinical encounters, seeing that he had had three admissions at UAMS in the past several months plus a couple of admissions at Baptist Hospital.
David’s health story was not straightforward. Everybody was fighting about how to take care of his heart failure, chronic kidney disease, and diabetes. Everyone wondered whether his heart disease was leading to his renal failure, or whether his renal failure was leading to his volume overload. Some clinicians would give him diuretics, and his renal failure would get worse. Others would liberalize fluids, and his heart would decompensate. He was one hot mess of a patient. There was no way in 25 or even 40 minutes I could wrap my mind around all the things that had happened to him. Yet, there he was, volume overloaded, suffering, and in need of intervention.
David was the catalyst for me to say that UAMS needed a clinic dedicated to high risk, high-need patients, those who cycle through the health and social service system without getting any better. I knew he needed a multidisciplinary approach to help him manage his health. He needed someone to think about medicine, but he also needed a pharmacist to talk about his medications. He needed the psychologist because he was profoundly depressed from coping with illness. He needed a social worker because he had socioeconomic instability. He needed a care manager to check in with him all the time.
Because of David, I ended up creating an ambulatory ICU, the High Impact Health Clinic. To help one patient.
David did great. After nine months we graduated him from the High Impact Health Clinic. He ended up doing a video promotion for the Clinic. He went into the hospital once, about a year after we discharged him from the clinic, and he told everybody how he was the guy on the video I showed at Grand Rounds. He had just learned so much. He learned how to manage his diabetes. He learned how to manage his heart failure. He was truly empowered to care for himself, and he had a lot of hope for the future. What he showed in the video was that he had a lot of hope for his life and he wanted out of it.
The most poignant part of the video was when he was asked what the High Impact Health Clinic did for him. He looked at me, and said, “You know? Y’all saved my life.”
He was awesome. He gave me hope.
What eventually happened to David?
The pandemic hit David hard. He struggled with being isolated. He gained weight. He did not eat well. He was not as active as he would have liked to be. He was not coming to the clinic.
During this time, I went on maternity leave. I heard he had been admitted, but I did not get a chance to see him. I reached out to the Clinic’s nurse and suggested we get him back in soon because his condition sounded so gnarly. He was scheduled to see me within a week.
Then, I got a note from his wife saying he had died.
I assumed that he had had a heart attack. I called his wife to give my condolences and asked what happened. “He killed himself,” she said.
Shocked, I asked what happened. What she said broke my heart. “He couldn’t tolerate dialysis. He just couldn’t handle it.” It turned out that during his last hospital stay, his renal failure had just gotten too bad, and the inpatient team started him on dialysis. She told me that he hated spending three hours in a dialysis chair. He was uncomfortable, in pain, and the cramping was too much to bear. He lost the sense of control we worked so hard to build. It just killed me—I felt like I failed him. I could have told anybody that David would not have wanted dialysis. But I wasn’t there to advocate for him in his most vulnerable moment.
I can imagine exactly what happened during his hospital stay. A well-meaning physician probably said, “Dialysis will save your life.” With that “live or die” proposition, most people will say, “Okay, do it. I don’t want to die yet.” However, very few clinicians have the time or skill set to sit with someone and fully evaluate the reality of a new chapter in life. Dialysis without hope of transplant is a terminal experience with a five-year life expectancy of 10%. Many patients do not know that. But more than the reality of life on dialysis, it is hard to be truly patient-centered in that decision. The discussion tends to be very medicine-centric—dialysis or not, live or die.
I like to think that David could have made a different decision. He could have been home with his garden, eating the tomatoes he loved to grow. He could have chosen hospice at the end of life. Instead, he killed himself. He felt that suicide was his only way out.
In my “doctor savior” mind, I think had I been there I would have talked about the nuances of end-stage renal failure. I would have presented him options and helped him arrive at a decision that would have worked given the realities of his life. And should he have chosen to pursue dialysis, I would have been there for him when the experience failed to meet his expectations, or when he felt he had enough. While I know I’m no “savior,” I still feel a bit like a failure. His renal failure couldn’t be avoided, but I believe his suicide was preventable. He did not deserve to die alone, in desperation. I was not there to be his advocate when he most needed it.
What lessons can we all learn from David’s death?
There are a lot of lessons in David’s story, as there are with all patients who have complex health and social needs. David was a complicated person with many things contributing to his health and well-being, renal failure being only one. When he felt a sense of control over his health, he thrived. When that control was lost, so was his will to live. David’s story is not about dialysis, it is about the culture of our health system.
First, physicians are still trained to fix people’s problems, and we assume that our medical fix is the right one. We all come from that framework, we all entertain that perspective. While many enter medicine to help folks, we can fail to remember that the medical system accounts for only 10 to 20 percent of patients’ health outcomes. The remaining 80 to 90 percent is from the social determinants of health, including health-related behaviors as well as socioeconomic and environmental factors. Keeping that 10 to 20 percent in mind can remove a little pressure when helping a patient make a purely “medical” decision. For patients with complex health and social needs, it is incredibly important to maintain this perspective.
Second, we have simplified the breadth of “patient-centered care” into a simpler approach of “shared decision making.” In the push away from paternalism, we now give patients a pu pu platter of options: “Here are all the things that we can do. You choose what sounds best.” Now that might be the right approach for me, were I a patient. I am somebody who is educated, well-informed, and able to evaluate the nuances of a medical decision. For our most vulnerable patients, that is not the way to do it. The key is to align our goals with theirs.
In David’s case, being truly “patient-centered” would have required his team to have stopped before going down a road of urgency with him. We could have tried to determine whether David really understood his options. We could have given him a little breathing room to make the decision he needed to make. And, then, we would have recommended a medical path most in line with his personal goals, one that would give him the most control at the end of life.
In the hospital culture, this type of breathing room to be fully patient-centered is nearly impossible. Everything is, “We gotta get you going. We gotta fix your problem. We gotta get you out of here. Let us do it now.” David was a casualty of that kind of thinking. Everything aligned for David to spiral downward once he left the hospital. The fact that he took his own life in such an isolated and brutal way, we failed him.
Lastly, physicians—myself included!—need to shift our perspective away from being “saviors” to being facilitators. We help facilitate decision-making by understanding what is important to our patients. The better we understand our patients, the more successful we will be. The less we understand them, the more failures we are going to have. We cannot continue to assume that just because we have the right answers from a medical perspective, we have the right answer for any particular person.
Do you have any final thoughts you would care to share?
David’s death has redoubled my commitment to put patients’ goals first in the decisions we help them make. Sometimes these decisions are not linear. Sometimes they don’t make sense through our physician lens. But, that’s okay. We must support patients throughout their entire journeys and give them room to find their own best way to health.
Editors’ note: If your patient has suicidal thoughts, explore the issue deeply together, discuss a safety plan, including calling 911, and provide emergency suicide prevention phone numbers (1-800-273-8255) and/or text “HOME” to 741741. If indicated, escort the patient yourself to the Emergency Room for psychiatric care.