Models and Mentors
In Conversation with Clarence Braddock, MD, MPH
Dr. Braddock is the Associate Chief for the Division of General Internal Medicine, a member of the Stanford Center for Biomedical Ethics and the course director of Practice of Medicine at Stanford School of Medicine. He earned his MD at the Pritzker School of Medicine at the University of Chicago in 1981 and his MPH at the University of Washington in 1995. In addition to his work in medical ethics education, Dr. Braddock is recognized as a national expert on informed decision making and doctor-patient communication, having given numerous invited lectures on informed decision making, as well as workshops at national meetings, and is frequently interviewed for the print, radio, and television media.
What has inspired your work in medical ethics, particularly the doctor-patient relationship and cultural competency?
It really all started with my own experiences, my own training, and years of practice; just coming to realize the power and importance of the personal interaction between the patient and the physician. I always remember, for instance, this one particular encounter I had as a resident involving a patient with cancer. My attending was an oncologist and one day, he came by the work room and said, “I’m going to talk to this patient about their diagnosis and treatment . . . why don’t you come with me.” So, I went along and just watched him talk to the patient and was struck by how well he was able to communicate a lot of information to the patient in a very sensitive way, all the while listening and being much attuned to the patient’s feelings – just masterful! I was struck by how important that interaction was, but also, how that interaction was truly a goal to aspire to.
After residency, I worked in Intensive Care Medicine, and through those years, constantly encountered critically ill patients and their families and friends. Having to talk to patients and family members about how to proceed in their care engrained in me the importance of physician-patient and physician-family communication.
Coming to understand that the observation I’ve always kept with me - that the thing that sometimes for us, as physicians, is just another moment in the day, is for patients and their families something they will remember for the rest of their lives - is kind of humbling and also makes you pause or slow down for a minute, inspired in me the need to pass on that, as physicians, we must try, at least to the greatest extent we can, even when we are incredibly busy, to be there and be present, fully, for the patient and their family.
The final thing that solidified the interest for me was realizing the potential pathway ethics could be as a career. Naturally, I then started getting involved on ethics committees and ethics consultations. I also started teaching about ethics and ethical problem solving with students and residents. One thing led to another and I soon began doing more of this kind of work as a scholar - studying it, writing about it - and eventually, developed curriculum to train the next generation of physician.
That was going to be my next question! How did your work as a scholar, researcher, and eventually, expert in this particular field, start for you?
I believe it was just the idea of mentorship of others - helping them to navigate the more subtle parts of becoming a physician – that really sparked my academic interest. I had the opportunity to come to Stanford as part of a month-long mini fellowship at the faculty development center and that was what really opened my eyes to many things, in particular, different ways of teaching.
Specifically, learning more of the science of teaching and how you can be rigorous when working under a studied framework. While the experience took me away from my day-job as a clinician, it allowed me to become immersed in learning again. I liked having the opportunity to be a student because it felt even more possible, to me, the idea of taking a step out of my career path to delve into ethics and patient-physician communication. It was at that time when I decided to do a fellowship, and ultimately, get and MPH - all to expand my scholarly potential and contribute, in some way, to the thinking on how we practice medicine.
You already touched on this, but how did your public health training, and your own definition of public health, impact your career?
Basically, I think about public health as recognizing that the dyad of the doctor-patient relationship occurs in a broad context – from the patient’s life experience, to the health care system, the public, and politics. All these different things are not isolated, but in fact, are connected. My public health training taught me, first-hand, the value of service-learning experiences, where you actually get out and work in an area you otherwise might not have access to. I learned how, while it is challenging to do health policy, if you stick with it and understand the rules of engagement, you can get things done that can be very positive and meaningful.
Some of the courses I took in biostatistics came in useful for research work. However, the thing that expanded my thinking, besides the courses that were part of the distribution requirement that any field of study has, was a course on health systems, systems thinking and organizational theory, which I took because it sounded interesting. Little did I know that it would expose me to a whole other realm of thinking about the practice of medicine!
Again, as a medical student and resident, you are trained to think, “well, there is a doctor and a patient”, but not so much to think about the context, such as other health care providers they have been working with, other hospitals, other clinics, the public health system, society, access to health care, etc., and so, the course got me thinking more about that bigger context and enabled me to be exposed to literature in that area.
Another course I took in health policy, which was about some factual stuff like how health care was financed, had, as a requirement, a service learning project as part of the course. The service learning project that I did involved working with a group of ethicists who had been asked by the state Health Services Commission to help write regulations for health care reform in the state of Washington. What happened was that in the early 1990’s, Washington State passed a law that was going to basically become the precursor to the Clinton health plan. It was the idea of working with employer-based insurance and uniform benefits packages to expand access for the poor and uninsured. Once the law passed, someone had the bright idea to have ethicists help with the ethical issues.
For example, when you say that you have access to basic medical care, what does that mean or what does that translate into? So, I got to work with a bunch of state senators and staff and actually, after I finished my MPH, I continued to work with them for several years. So, yet again, it was an introduction to another totally different world of medicine.
You are obviously an accomplished clinician, researcher, teacher . . . but you also are an advocate, quoted in newspapers, journals, radio, etc. What are some valuable lessons you’ve learned regarding advocacy that you could pass on to medical students?
One is that when you come to medical school, you come from all different backgrounds - from biology to art history, the Peace Corps, to industry - and it is easy to lose sight of things you were passionate about just because you are hit with this barrage of things you have to learn. You also probably think that there isn’t a place in medicine for you to do “fill in the blank”. But realize that if there is something you are passionate about that has anything to do with people or their health - even remotely, like land irrigation in another country - all those things ultimately affect people’s health and if you’re passionate about it, you can probably find a way to build it into your career.
Also, if you can find a way to view what you’re learning through the lens of what you are passionate about, you will better serve your patients. I feel like I only came to realize that, when I went back to do my MPH because that was the chance to do more of what I was passionate about than when I was a medical student. Because, I too, as a medical student, got caught up in, “When’s the next test? What’s the next thing I have to learn?” So, one piece of advice is to hold on to those things that you are passionate about, that led you to medicine, even when you think there is no way you are going to be able to return to that passion in the future. Just don’t give up on that thing!
Another piece of advice is to think small because advocacy spans a whole range of activities. I just read the book about Paul Farmer, “Mountains Beyond Mountains”, and you read a book like that and think, “oh my gosh this man is amazing,” and “I could never do anything like that - fly to Haiti then to D.C. to speak to powerful congress people and tell them off,” and certainly there are those rare people who can be that kind of advocate, but most of us start small.
The thing that you can affect and embrace is the fact that advocacy, with perhaps a little “a”, is something that every physician should do. If there is a PTA meeting about vending machines at school or school lunches, you might go as an interested parent or you could go as a physician concerned about not only your child’s health, but other kid’s health . . . and people will listen to that. Or, you could go into the classroom as a role model. I remember a neurosurgeon who brought into my kid’s classroom zip-locked bags holding brains and the kids just loved it. And to think, there is some kid in there who is going to get charged up about medicine.
So, advocacy/mentorship opportunities are around all over the place, and while they might seem small, they can in fact be really powerful.
What about your career are you most excited or passionate about at this point?
I would say the thing I’m most excited about is the work in cultural competence training that we’ve started to build on here at Stanford, and on the national level through a collaborative on the subject. Also, I’m just excited about thinking of cultural competence in different ways, but in a more general sense, actually change the way we think about medical education. For a long time, medical education has been very fact-based, where you have to learn all these facts, and a little about the art of medicine, with the hopeful acquisition of communication skills, cultural competency skills, etc.
But the other piece that we haven’t spent much time on, that I am really excited about, is how to affect the mind set and perspective and self-perspective physicians have as they go through medical school, residency and their life-long practice. A classic example is creating the time and space, framework, and the life-long habit of being reflective about what you do. Take the time to think about things that have gone well and also things that haven’t gone well, to be aware of your own biases you bring to your work – we all have them – and so, that is the next challenge.
I think that some of the work I’ve had the opportunity to do with the curriculum here at Stanford, this nation-wide group, and the faculty development center have really given me the chance to start tapping into what I think about, in essence, how to teach people how to teach themselves. In other words, you’re teaching people certain skills and you hope that those skills can help them to perform better, all the while teaching them how to be life-long learners through self-reflection. I think that is something we’ll hear a lot more about and so it is exciting to be doing this kind of work.
-- Interview by Tiffany Castillo
Posted: 04/13/06
