Month: July 2019

Cardiac arrest for pathologists to podiatrists with EM Physician, Dr. Jeff Jarvis

Dr. Jeff Jarvis, the EMS Medical Director for Williamson County EMS and Marble Falls Area EMS in Central Texas, teaches us about cardiac arrest for every physician, from pathologists to podiatrists.  We learn how to identify and manage a cardiac arrest if we happen to be the medical professional on the scene.  We cover multiple circumstances from the woods to the mall to a plane.  After this talk, you will feel better equipped to know what you can and can’t, should and shouldn’t do in those situations.

Dr. Jarvis maintains his clinical practice at Baylor Scott & White Hospital in Round Rock, Texas. He is board certified in both Emergency Medicine and Emergency Medical Services. He began his career in EMS over 30 years ago, has worked in three states as a paramedic, and retains his active paramedic license today. He teaches extensively and has authored multiple articles on EMS issues in both peer-reviewed and industry journals. His research interests include airway management and clinical performance measures. He discusses EMS research on his podcast “EMS Lighthouse Project Podcast”.

Find this and all episodes on your favorite podcast platform at PhysiciansGuidetoDoctoring.com

Please be sure to leave a five star review, a nice comment and SHARE!!!

Cardiac arrest for pathologists to podiatrists with EM Physician, Dr. Jeff Jarvis

Dr. Jeff Jarvis, the EMS Medical Director for Williamson County EMS and Marble Falls Area EMS in Central Texas, teaches us about cardiac arrest for every physician, from pathologists to podiatrists.  We learn how to identify and manage a cardiac arrest if we happen to be the medical professional on the scene.  We cover multiple circumstances from the woods to the mall to a plane.  After this talk, you will feel better equipped to know what you can and can’t, should and shouldn’t do in those situations.

Dr. Jarvis maintains his clinical practice at Baylor Scott & White Hospital in Round Rock, Texas. He is board certified in both Emergency Medicine and Emergency Medical Services. He began his career in EMS over 30 years ago, has worked in three states as a paramedic, and retains his active paramedic license today. He teaches extensively and has authored multiple articles on EMS issues in both peer-reviewed and industry journals. His research interests include airway management and clinical performance measures. He discusses EMS research on his podcast “EMS Lighthouse Project Podcast”.

Find this and all episodes on your favorite podcast platform at PhysiciansGuidetoDoctoring.com

Please be sure to leave a five star review, a nice comment and SHARE!!!

EPISODE TRANSCRIPT

Disclaimer: This is the transcript to the episode. This transcript was created by a talk to text application and the function of having this here is to improve the page search engine optimization. This transcript has not been proofread, so please listen to the episode and don’t read this. The information contained herein will inevitably contain inaccuracies that affect that quality of the information conveyed and the creator of this content will not be held liable for consequences of the use of the information herein.

On today’s episode of the physicians guide to doctoring, we speak to Dr. Jeff Jarvis, the MS Medical Director for Williamson County, MS and Marble Falls area ms in Central Texas. We discuss cardiac arrest for every physician from pathologists to podiatrist. He teaches us how to identify and manage a cardiac arrest. If we happen to be the medical professional on the scene. We cover multiple circumstances, from the woods to the mall to a plane. And after this talk, you’ll feel better equipped to know what to do and what you can’t do in those circumstances. Dr. Jarvis maintains his clinical practice at Baylor Scott and white Hospital in Round Rock, Texas. He’s board certified in both emergency medicine and emergency medical services. He began his career in CMS over 30 years ago, he has worked in three states as a paramedic retains his active paramedic license today. He teaches extensively and is offered multiple articles on the MS issues in both peer reviewed and industry journals. His research interests include airway management, Clinical performance measures. He discusses ms research on his podcast, EMF lighthouse project podcast and I strongly recommend you check it out.
Welcome to the physicians guide to doctoring A Practical Guide for practicing physicians. Dr. Bradley Block interviews experts in and out of medicine to find out everything we should have been learning while we were memorizing kreb cycle. The ideas expressed on this podcast are those of the interviewer and interviewee and do not represent those of their respective employers.
And now, here’s Dr. Bradley Block.
Dr. Jeff Jarvis, thanks so much for being on the podcast today.
Absolutely. I’m happy to be here. Thanks for having me.
So we’re going to talk about cardiac arrest for the non specialist right for doctors who don’t typically see it but might find themselves in a situation outside the clinical arena where they’re going to be looked at because they’re the only doctor around. So for the pathologist that doesn’t have his microscope for the ante that doesn’t have his otoscope. Right, what what do we do so we’re going to give a couple of scenarios. We’re going to go from the the arena where you have the least accoutrement at your disposal to more. So we’re going to start with your a pathologist, you’re 15 years out from residency, you’re on a camping trip with some of your friends, and one of them clutches his chest and collapses. You’re the only doctor. So everyone looks at you knowing full well that you don’t have your HIV stain, you don’t have your microscope. So what do you do? Let’s start with the physical exam. What am I What am I examining this person for?
Absolutely. So I think the the key thing, the scenario that we’re given is that we sort of know the answer, right? It’s all like an m&m. We don’t discuss an m&m Fl things went well. So we know this is gonna end up in cardiac arrest, but the poor pathologist is out hunting with his friends doesn’t know that he just knows he collapsed. So he has an undifferentiated patient. And what he needs to determine is whether he’s actually in cardiac arrest or not. And the way we do that what we traditionally taught is that you do the shaking, shout, you assess breathing for, like 30 minutes, and then you assess for a pulse for another 30 minutes. I exaggerate slightly, but there were these long periods of time where you would try to feel for breathing in a pulse and what a fair amount of research has been done in telecommunicator CPR. So the non one responder who is or the 911 dispatcher who’s trying to determine whether the patient on the other side of the phone is in cardiac arrest, as well as trained responders, what we’ve determined is that we’re miserable at feeling for pulse. And I think we probably know that when we’re trying to feel a pulse, when do they have a pulse? Do they not? I don’t know. Well, that’s because that’s dependent on their blood pressure. So if they have it’s hard to tell the difference between Cardiac arrest in a low output state. So where we have ultimately ended up is you check for responsiveness? Are they awake? are they responding to pain? And then you say, are they breathing normally. So the distinction between breathing normally and moving air at all is important. Because one of the natural processes of going into cardiac arrest, particularly sudden cardiac arrest, where you’re walking along just fine, your LED occludes you go into V fib and arrest is that you try to your body naturally tries to decrease center thoracic pressure to increase your preload. And you do that by gasping and you have these agonal respirations. Well, if you ask someone, particularly who doesn’t see this all the time, are they breathing? Well, yeah, they’re moving air, but they’re not breathing normally. And the agonal movement isn’t really doing a whole lot effectively. So are they awake? Are they responsive? And are they breathing normally? And if the answer to those questions is no, then you begin chest compressions, we’ve really de emphasized trying to do mouth to mouth or any sort of ventilation, because we find that it’s terribly ineffective. We also find that it inhibits the likelihood of responders doing something. And that actually does include trained responders, trained responders are less likely to do mouth to mouth or do anything if they feel like they have to do mouth to mouth. So just begin compressions just and the CPR class we took focused a whole lot on exactly how to go and the exact rate and it turns out, that’s probably not as important as we think it is. If you obsess about that, then you’re more likely to not do something. And we’re way better if you do something than if you do nothing. So just put your hands in the middle of the chest push deep and fast. So begin compressions. So that’s the number one thing is identify the cardiac arrest and then begin compressions. And in this scenario, you’re out in the middle of nowhere. You’re just in Not going to get help, there is no help available. look to see if you can find some easily reversible causes. So, unfortunately, if they have an LED occlusion and V fib, there are no easily reversible causes. Your CPR that you’re doing is a bridge to something else. Whether it’s a bridge to reefer fusion, whatever the bridge is, there’s nothing you’re going to get out there in the middle of Idaho as you’re, you’re hunting. So look for reversible things like is this perhaps an airway obstruction? Were they eating protein bars are out hunting? Can you clear the airway? So if you can clear the airway do that, if this is a problem with the airway being occluded, because the position try to reposition the airway. And the way we do that is the head tilt chin left where you just lift their chin up and tilt their head backwards a little bit. We will frequently worry ourselves to the point of inaction about well, is it possible they had a spinal cord injury So two things in this scenario you saw them dropped. So the odds of a spinal cord injury are vanishingly small. And two, if they actually let’s say you didn’t see them fall, and they do have a spinal cord injury, the chances of you of them living in this scenario are non existent, so you’re not going to make anything worse. So the odds are, just go ahead and open the airway,
but just goes back to ABCs. Right? Exactly. Breathing circulation. So you’re not with a s, and spine is all the way down to that. Stick with a, get that airway, make sure they’re moving air.
Bingo. And, and that’s really well, and that’s it. So I wouldn’t worry in this situation about trying to move air for them. Because that’s, that’s a losing proposition. You’re not going to be able to effectively do it in this environment. It’s not like you have an oxygen cylinder and an 82 bag valve mask that’s not available to you right now. So just don’t worry about it at all. open the airway if you think that’s the problem. If it is trauma and One of the other things that can cause traumatic cardiac arrest is blood loss. So you’re out hunting did they accidentally shoot themselves?
So I actually said, camping in New York, you’re in Texas, you took the camping and turned it into hunting. And I think that’s a product of our geographic cultural differences. But
we’re gonna run with it camping. Totally. I mean, hunting, we’re hunting well, so
you’re out camping, and you know, you have a knife there, and you’re trying to, I don’t know, cut some rope and you managed to, you know, hit your femoral artery. So that’s a potentially reversible cause of cardiac arrest. Now, the truth is, is if you bled so much that you’re in cardiac arrest, this is again a losing proposition, but try to stop the bleeding so that they don’t get into that situation and the way to do that, and this has changed a little bit since our pathologists graduated from residency 15 years ago. direct pressure is still great, but put a tourniquet on there. And the truth is, if you You’re out camping. You probably should have a tourniquet. Anyway, I shocking to you as a Texan I do hunt. And when I’m out hunting, I carry a tourniquet with me. So from if there is bleeding, slap a tourniquet on the damage we do with tourniquets that we worry about is really really slim. The benefit is way higher. So, over the past 20 years that we’ve been at war, we have learned an awful lot. And one of the things that we learned is most preventable traumatic deaths are from hemorrhage. And we can control that with tourniquets. So if you have a tourniquet use that about the only other preventable or reversible, cause a traumatic death there might be a tension pneumothorax and if you think if you have a decent history that suggests a tension pneumothorax and in this situation, it’s going to be pretty slim because if something creates an opening in the chest, that opening is probably still going to be there. You trip and land on your tent pole or something but If you think perhaps there’s a tension pneumothorax, you can relieve that, just poke a hole in the Enter chest wall and call it a day, it’s probably not going to help. So where that ends up is you’re out there in the middle of nowhere, about the only thing you can do is compressions, try to open the airway. And if that doesn’t resolve it, then it’s probably nothing is going to work and they’re going to die or remain dead, I guess is probably the better term.
So one thing I didn’t hear you mentioned is the pre corneal thump. And I just want to know is there is it ever inappropriate to do a primordial thumb because I would think maybe, you know, we were talking about a stack sis earlier, right? He’s got a nosebleed. probably not a good idea to do a pretty primordial thump. But I was thinking cardiac arrest, right? You want to put them back into rhythm somehow, right? Again, I’m an ear, nose and throat doctor. So let my depth sure is there ever a role for it?
So the the idea behind the primordial thump it is it is you’re creating a sort of a minute defibrillation, if you will, and if the patient did go into V fib in that scenario, you have a middle aged guy who probably drinks too much exercises too little and eats too much chances of a 50 year old American dropping from coronary artery disease probably pretty high. He clutches his chest goes down, there’s a decent chance that is in tricular fibrillation, arrest and D fit is really what he needs. Well, you rapidly look to your left and right, look into the tent and realize you don’t have an ad with you. The only thing you have is your fists are sure go ahead, give it a shot. The effectiveness of a primordial thump is pretty limited. But the downside, especially in that environment, where really the only thing else you have is CPR. Absolutely give it a shot. I would do it I would probably realize that this is a Hail Mary, but I’ll absolutely give it a shot. And just to remind you, the way you do it, it’s not a john travolta kind of thing. A way back and just stabbed the needle into What’s your port Emma Thurman’s heart oma Thurman’s heart, you put your elbow right on the board process and just forcibly drop your fist onto their chest wall? So there’s no wind up involved.
Okay, well, that was a needle and actually one of my that’s my allergist colleague says his two least favorite movies are hitch and that wasn’t Reservoir Dogs Pulp Fiction because of that scene, right hitch. I don’t know the reason I didn’t like Jose Scott school and then he took Benadryl and then the other is Yeah, you’re going to need no your epi pen doesn’t go into your chest. Yeah.
So right, get that? That it’s not. Yeah, yeah, mine is there’s a, I think it’s a Sylvester Stallone. I think it’s a Buster salon. where he was. He’s a paramedic and they’re a bunch of firefighters who are down in a body of water like in a tunnel and their train hanger
was that cliffhanger
is that where he does the stand handstand and deliberates and everybody jumps up. Oh my god. It was just painful. Ah, yeah, I think I think all of us have our particular painful Hollywood moment.
I can’t think of any empty one. I don’t know. We’re never in the movies. That’s why nobody’s ever. Oh, those lists. We’re never we’re never on. There are no love for the end. Yeah. Okay, so you mentioned the ad, right? Yes. So in the next scenario, we’re actually going to have disposal to that. And, again, for those of us who aren’t practitioners that deal with cardiac arrest. We’re still we’re still the doctor in the room, people are still going to be looking off. So the next scenario, your hand surgeon, 20 years out from residency with an entirely outpatient practice. You’re at the mall with your husband and son, picking out his Bar Mitzvah suit, right again, I’m in New York. Uh huh.
This this is something oddly specific. Yes, almost. So this may have happened to someone.
When the tailor that’s fitting your son for a suit suddenly clutches this chest in collapses, the same scenario as before. But now you’re in the mall and I’m assuming the mall has an ad or an automatic External Defibrillator.
Yeah, let’s hope. Let’s hope so that is an interesting tangent to go off on, by the way about whether public places will have EDS, it’s a fight as an MS. Medical Director, I get in all the time,
I thought whether 13 year olds should really be having tailored suits. Okay, so they
places. Exactly, exactly. So what? So my my 13 year old did not get a tailored suit, I will definitely tell you that he’s 18 and did not get one. No, the public access to fibrillation there are there’s a university somewhere in Texas, let me just put it this way. who does not believe in a days they feel like having it’s not that they don’t believe the science, but their lawyer thinks having an ad publicly accessible will expose them to liability. And I think exactly the opposite. I think if you took someone off of the street, you hop on the subway in Manhattan and you ask someone at If somebody goes into cardiac arrest, do you want one of those ad things? And should the subway have one? I think most people are going to expect that that is there. And that is not
there. remarkable to me that that type of policy is being determined with that type of reasoning, not the reasoning isn’t. Are we more or less likely to save a life if we have this here? Or are we more or less likely to expose yourself to liability? Right? Absolutely. How where, where are we in this country where that’s how we’re making these decisions? Well, I think we all know where we are. But Exactly.
I would suspect that’s a different podcast. Yeah,
exactly. I’m sure there are podcasts solely about that. So yeah, okay. But let’s say let’s say there is an ad at your at your disposal. So, so what do you do now?
So in this situation, you are, the priorities are the same as they were out in the wilderness, you just have more resources available. So when they drop, the first thing you do is Determine if they’re responsive? And if if they are breathing normally, if the answer to those is no, because people have been known to trip, and you know, they don’t really need an ad or CPR, but if they are not responding and not breathing normally, then have someone else your 13 year old son would be a great person to do because Lord knows he’s gonna have a cell phone, call 911 and then find an ad. And while he’s doing that, you’ve assigned him to go do that. You get on the chest and begin CPR, press hard, fast, and do not stop. So we didn’t talk about this much with the last scenario. But let me hit briefly on this because before you go on, I just want to point out something that you said that I think is actually critical shows that you didn’t say someone call 911 You didn’t say someone get the ad, you actually gave a specific person a specific task. And I think in this scenario, it’s it’s important to point out the necessity of doing something like that, especially when you’re not surrounded by trained professionals. Right, you’re run by people. Who are panicking. And oddly enough, having being surrounded by trained professionals doesn’t change it either. So there you are, in a level one trauma center with trained people everywhere. And if you say something like I need to put a chair to get me set up, aside from the fact that it should have been there to begin with, you’re gonna have a whole lot of people who know what a chest tube is no to chest tube setup is and assume someone else is going to get it. So this is a function of the limitation in the system is that we’re dealing with humans who behave in a human like fashion. So you absolutely have to assign someone that task, there would be more than happy to do it. But the default human assumption or psychology is that someone else is going to do it. So yet directly assign someone to dial 911 and track down an ad. Now, depending on where you are, again, if you’re in a mall in Manhattan, you are, I don’t know just Manhattan have malls. That seems like a non Manhattan kind of thing. Yeah, there is there there is near Penn Station. Ah, but very good. So if you’re there, if you’re In Penn Station, for example, your when you call 911, it’s going to go to what’s called a peace app, a public safety answering point. And they’re going to be trained dispatchers there who have a remarkable amount of technology. One of the things they have or I’m assuming Fire Department, New York has this, a listing of where all the abs are. So as they’re, they’re not really entering the location. And because it comes up automatically, they should get notified of where the ad is and can tell your son where to go. But if not, he goes to find the ad, you get on the chest and begin CPR. So what I didn’t mention earlier, when you’re out there in the woods, where honestly, probably nothing is going to help and you’re treating yourself more than the patient is don’t interrupt the compressions. So what we learn is when you begin compressions, you have a actual blood flow doesn’t, there’s a pressure wave that you have to build and it takes multiple compressions to build a pressure wave. To the point where you’re actually producing. So it’s not that you’re perfusing with the first beat, and that’s or the first compression. And that’s really important that takes momentum. Exactly. And it takes 20 to 30 seconds to actually get to the point 20 to 30 seconds of good compressions, to get to the point where you’re proceeding. And then as soon as you interrupt to those compressions, that pressure wave drops off, and you need to another 2030 seconds to build it up. So the key here is minimal interruptions or minimally interrupted cardio, so reverse recitation, which is really what we’re aiming to. So get on the chest deep, fast and don’t stop until help shows up. Really, in this situation. This is an eminently salvageable patient in a modern US city. So don’t interrupt to the compressions. So hopefully help will show up quickly. What we’re looking for here is getting the add on as quickly as we can. And if you don’t know how to operate an ad, don’t worry about it. You open all you have to figure out to do is open the box up. When you open the box up, almost any ad that’s used in public access is going to have voice prompts and it will tell you what to do. There will be a set of pads there and it will tell you to attach the pads and then there’s a nice pretty picture. Okay, plus or minus pretty, there’s a picture that tells you where to put the pads, put the pads on there and follow the directions. And that’s really about it. When it says Get out of the way, then get out of the way. Otherwise, do compressions. Now, if you have some help, what you should do is organize a transfer of compression. So how you’re kneeling, say on the patient’s right hand side, and you’re doing compressions pushing hard, deep, fast in the center of the chest. Have someone else some other bystander on the other side on the patient’s left and around every 200 compressions, switch out and just have them hover their hands over yours and as soon as you back out. They started compressing. And the reason you do this is because of rescuer fatigue. So there’s some pretty good research that shows even, you know, your 19 year old CrossFit firefighter, just the quality of their compressions drops after a while no matter how good a shape you’re in,
so don’t get it. Don’t try to be tough. Don’t try to be tough. Recognize that you’re not doing the patient any favors by saying, No, no, I’m in great shape. I can I can do this forever. You can’t exactly. Even if you think you are you’re not in you’re not
doing them any favors. Bingo. Absolutely. So get on the chest, ask for help determine unresponsiveness and that they’re not breathing normally get on the chest, ask for an ad, don’t come off of the chest until you have someone else who is there to replace you. Or the ad says get off the chest so we can analyze the rhythm. And that’s about it. So the other thing Well, let’s let’s say that so in New York, what’s going to happen is Ms is going to show up or the police officer or someone else. The firefighter who shows up because there’s a An order stemming, when they show up, give them a very brief report. And then the key thing here is they’re the experts, not you get out of their way.
Yeah. And I think most of us that deal with things that are completely different from this are going to have no problem recognizing that we’re not the expert in the room. Yeah,
absolutely. So I get out of the way when I am in that situation, even when it is paramedics I direct, I get out of the way. But that’s definitely been my experience is that there are a lot of very well meaning physicians here, they do exactly what you said. They look around, nobody else is there. So they feel an ethical obligation to help. And then as soon as help gets there, they’re more than willing to get out of the way, just like I would be in a different situation.
Absolutely. So for the first scenario, you were pretty clear about what the odds are in terms of actually this patient surviving. But the second scenario, I’m not giving you any information in terms of their medical history, their risk factors. Anything, but just all comers. What are we talking about in terms of survival for this patient? If we’re the first responder on the scene,
you bet. So all all cause mortality from cardiac arrest is around 90%. So about 10% of all out of hospital cardiac arrest, with a with a system that can respond will survive. So that’s pretty bleak. But it’s better than zero that it was out in the camping in the Adirondacks. So what differentiates that 10%? So it really varies widely, based on the important things like was there bystander CPR that dramatically increased? I think the odds ratio for meaningful survival with bystander CPR is about three. So a 200% increase in the odds of survival, public access to fibrillation, was there a different relator available prior to Ms arrival?
If a lawyer hadn’t gotten in the way? Correct?
Correct. I don’t know what the the odds ratio is, but it’s in the neighborhood of two somewhere in that area. Then obviously, if this was a shockable rhythm, so the odds of survival are greater and a shockable rhythm than a non shockable rhythm. And if you think about it, in the United States, we have determined that no one dies without CPR. I think kind of unfortunate, but that’s now what we consider. So if you’re responding to a nursing home, and you have a 90 year old woman who’s connected, and has been having a fever, and so three days of sepsis, when they walk in the room and realize that she’s in cardiac arrest, that’s clearly going to lower the odds of survival. Your Taylor on the other hand, who was up doing a wonderful tailoring job because I’m sure that clutches his chest and goes to the ground, his odds of survival, let’s say you’re in Seattle, Washington, your odds they’re there. They’re very proud of their success rate, and about 40 to 50% of that scenario of those patients will leave the hospital neurologically intact. So clearly a big difference between that and 10%. But overall across the nation, the best data that we have is from something called cares or the cardiac arrest registry to enhance survival. It’s a national but voluntary registry of out of hospital cardiac arrest, and the of those the people who voluntarily participate, overall success rate all causes all rhythms is 10%.
All right, well, so then we won’t hold ourselves personally accountable for the outcome there if we happen to be the first first responder, although we now we know what our what our priorities are and do things.
I do think that that is an important point that we those of us EMRs. This is really what we do out of hospital cardiac arrest is, this is a big part of our specialty, and we have to understand that Death has a really bad prognosis. So cardiac arrest, even though there are quite a few patients that we can help, overall we shouldn’t be surprised if they did. They’re not resuscitated. Now, going back to your particular scenario, when we see him drop, our assumption should be that he will be able to survive, because that specific scenario really suggest a witnessed ventricular fibrillation arrest.
And I think our assumption in general should be that it will but then when we’re exactly retrospect, yeah, we shouldn’t be taking personal responsibility for the for the outcome after you did everything that you you could have done because you have to think of it like I greatly increased this person’s absolute likelihood of survival, even though they didn’t. So correct. There is there is one more scenario and I’m not sure if we should go into it. I plan at some point to have a podcast about medical emergencies on an airplane. Yeah, you’re the you’re the You’re a radiologists on an airplane and and they call you with an emergency.
Right. But I’m not sure
what they have on the plane that they that they would in addition to an ad, are you familiar with what they have on it? What is there? I tried to look for it, but I couldn’t find it more I got directed towards what your what medical supplies you’re allowed to bring on a plane. But what are the standard medical supplies that are on an airplane? Are you familiar with that?
So I’m not terribly familiar. So fortunately, my experience with the in flight emergencies has been a stroke, which wasn’t a whole lot I could do anyway. So it does vary based on domestic and international. They have more equipment on international flights. And they all flights should have particularly American carriers. And I think most of the airlines that any of us would feel comfortable getting on is going to have an ad, they will probably have a source of oxygen. They’ll probably have an epi pen app they’ll probably have some oral medications that aren’t going to be a whole lot of help in in a cardiac arrest scenario. But they should have the Things that you need, which really is an ad, and maybe a source of oxygen and a way to deliver it. So that scenario though, there are a couple things that I’ll say number one, is, let’s say it’s not a cardiac arrest, and you’re trying to determine you’re feeling really bad. You’re looking around there. 300 people squished in like sardines. None of them want to divert. Wait, wait, let me let me let me go through my scenario then because I yeah,
Ani, so my opportunity to tell a joke.
So absolutely.
What’s your neuroradiologist one year out from residency and you’re on a flight home from a conference, okay, they call asking for a doctor on board. Nobody gets up. You’re looking around, still nobody. The flight attendant comes up to you. And now you’re remembering that when you filled out the form you filled out doctor when you signed up just like you did on your license plate and just like you did on your Tinder profile. Ah, so they grab you, you arrive on the scene
while and you’re probably in scrubs, too.
Good point.
Okay, so why don’t you tell me now what what you want to talk us through what you see arrive on the scene. What are we seeing?
You bet. So step one, go back and change your Tinder profile and change things. Realize that maybe everyone on the planet knowing you’re a doctor is a bad thing. Yeah. So what you’ll do is you will so you get up and head back from your first class seat to I don’t know if you’ve seen it, there actually is a z Dawg MD sketch where Darth Vader or Darth Vader discusses this exact thing. He’s not in first class. He’s on Spirit Airlines, because that’s all he can afford with this. Yeah.
Yeah, right. If you’re in first class, then clearly you haven’t read the white coat investor. So
exactly correct. Right. So you get up, go find the patient, and they’re more than likely still going to be in their seat, you determine their unresponsiveness and the fact that they’re not breathing normally, and you get them down onto the floor. Fortunately, I’ve never done CPR on an aircraft. All I can think of is this ain’t gonna there’s no room. At least on Aircraft I fly, there’s not a whole lot of room, try to get them back to a place where there’s some room to work and ask the flight attendant to get the medical kit, it may be a bit of a surprise to find out what’s in it. But there should be an ad there and the flight attendant should know how to use the ad, get the patient to the back. And by the way, the flight attendants know how to do CPR to so they probably will already have started this, but your priorities are going to be the same. The minimally interrupted CPR. Initially, even if you have a bag valve mask and oxygen, I would not worry about it. Initially, what you need to do is establish CPR and get the ad on and see if it’s a shockable rhythm. If it is a shockable rhythm and the way you’ll determine that don’t worry about having to interpret the ECG. If the machine says shocked, then push the shock button or get out of the way and let it shock itself depending on which one it’ll do. And the machine will let you know what the options are. So different. And let’s say you’re a long way from let’s say it’s domestic, but it’s still going to take you an hour. To get down to help, the key things that are going to reverse this arrest. And let’s assume it’s a witness fee febrace is good CPR and defibrillation. So let me help do a little cognitive offloading here and let me tell you what the science says about all the other stuff that we do. We made them well, this is great. Let me really help you with this because that’s not going to help. There’s mixed evidence comparing intubation to other like blind insertion airy devices. There have been two recent large randomized control trials that basically said there is neither one of them found an advantage to into tracheal intubation. Both of them found that you’ll be just fine doing a blind insertion device that’s easier to use. And one of them actually found that the blind insertion device has a 2.8% improved mortality. So don’t worry about intubating
blind is that like an LMA?
It is so the classic examples are an LMA and there are different versions of LMS. So the one we use And ihL but if you look at it, you would go that’s an LMA. So absolutely Lamaze, there are also things that are called Qing Airways, which look fundamentally different than an LMA. They have to, they’re designed to go down, just pass the trachea into the esophagus occlude the esophagus, and then they have a larger balloon in the oral pharynx. And then there are fenestrations around or an opening right around in between the two balloons. So theoretically, you’ve obstructed the esophagus and obstructed the oral pharynx. And when you ventilate, the air goes out in between the balloons and the
it’s got nowhere to go the path of least
resistance, according to better is going to go into the trachea theoretically. So that’s called a king Lt. And there are some older versions that are slightly different but those are about the only thing you’ll see is some version of an LMA, or a king lt too.
So just for those who aren’t familiar, haven’t been in the ER for a while LMA is laryngeal mask airway, and it’s basically it looks like a triangle or like a small mass. And on top of the trachea, or sorry, it sits on top of the larynx, laryngeal mask airway. And and, and you can ventilate that way sometimes we use it in the operating room. But if the anesthesiologist really wants to have better control of the airway, you’re going to you’re going to intubate So, but it is it is a great option. They’re fairly easy.
Apps. Absolutely. The training requirements are less it really works well. And one of the interesting things here is you would assume that aspiration and a patient with out of hospital cardiac arrest, the risk is going to be high. And I will absolutely tell you it is high. But you would assume that you would have more things like aspiration pneumonia, pneumonitis, from a patient managed with a LMA compared to an ET tube, and neither one of those two studies found that so the two studies by the way, one was called paramedic two and that was into tracheal intubation, versus an eye gel, a type of and that doesn’t stand for anything. By the way, that’s just the name of it. That’s a type of LMA and then part pa RT was An American multicenter, randomized controlled trial using the king lt compared to into tracheal intubation, it does not appear that aspiration risk is any higher.
And even even if it were, I think one thing I remember from being an EMT intern is one of our books said, it’s much easier to revise a trick scar than it is to bring back the dead. So if you think you need an emergent tracheostomy, then just do it. Same idea. It’s much easier to treat aspiration pneumonia than it is to bring up bring back the dead. Absolutely,
absolutely. Yeah. Yep. So and I don’t know, you’re probably not going to have that option. By the way, probably, the only option you’ll have is a bag valve mask. And if once you have done CPR, and then defibrillated, or given the ad a chance to shock, maybe there’s not a shockable rhythm. Those are the things that are going to matter. At some point you’re going to need to ventilate, but it’s around six minutes into the code. So it’s not an urgent priority. And there are lots of reasons for that. Probably not worth getting into. If you do have to ventilate, the one thing that I would recommend making a mask seal is don’t think that you’re going to be able to do it with one hand. When one person gets some help and have one person, squeeze the bag for you. And please, for the love of all that is holy, squeezed gently and slowly. You don’t want to breathe more than 10 times a minute. and in this situation, I can almost guarantee you that you’re going to be trying to squeeze that bag around 60 times a minute. And you may think that’s an exaggeration, but that number actually came from watching trained respiratory therapists in trauma rooms, with trauma resuscitations, and directly observing what their rate was. It turns out that our hand that squeezing that bag seems to have a direct connection to our adrenal gland, and we just get amped up and squeeze too fast. So try to intentionally squeeze the bag once every six seconds, and then have someone else make a seal because if you’re not an anesthesiologist Honestly, if you’re not an anesthesiologist in an O r, you are likely just to occlude the airway more than you are to open it with one person. So try to have one person doing compressions, one person holding the seal another person slowly, gently squeezing the bag. So don’t worry so much about ventilation early. That’s what I’m trying to say. The next thing that you may worry about is, well, I have to get IV access. Turns out you don’t. There are other ways to get drugs into patients. And we’ll come back to the drugs in a second. But on some of these international flights, you may have some IV catheters, but you also may have a little thing that looks like a drill. And that’s an inner osseous drill. And those are incredibly easy to use and effective. So there’s some decent data that says they’re just as effective with IVs just as fast. So if you have to get an IV access, great, go ahead and do it. But if you are not able to, really don’t worry about it, because the drugs that we would typically use in this patient, so what would those be so Let’s say anti or rhythmics. Well, it turns out there was a really nice study that compared me to drone to light again to placebo. in patients with witnessed v fib cardiac arrest, no difference. So none of those anti rhythmics worked any better than placebo. So don’t worry about the anti rhythmics. epinephrine is the big thing. We have all taken ACLs and know that we had the 10 commandments, and one of the 11th commandment was thou shalt give epinephrine. And it turns out in cardiac arrest, that data was based on some dogs. In 1906, there was a paper by guys named krill and Dooley and they kill dogs. They fixated them and gave them some epinephrine and voila, they get pulses back. And we didn’t need any more evidence than that. We just adopted it and kept doing it. There was a very large study, and I’m sorry, I said earlier on I just realized I said something silly when I was talking about the British study of the Agile versus dti that was airways to not paramedic to so paramedic two was the study of epinephrine versus placebo in cardiac arrest. And epinephrine got more pulses back, but it also got more neurologically devastated survivors back. And I don’t think that’s the business any of us are in. So if you’re not able to get access and give up in front, don’t worry about it, because it’s really not. It’s not nearly as important as doing good compressions and getting to fibrillation there.
On top of the fact that these airlines have someone at their disposal that’s going to be talking you through these scenarios. Yes, yes, you act as educated, killed eyes, ears and hands. But you are not going to be alone in this scenario.
Yeah, absolutely. And there are some some legal things to understand we’re used to being the the captain of the ship so to speak. We’re we’re the one in charge. The rules are absolutely different in an aircraft because there actually is a captain of the ship. He sits in the captain’s seat, and there’s a reason they call him captain. He is legally in charge of Everything that occurs on that aircraft including this, so if he tells you that for what he said, he’s not going to do this, or she, they’re not going to try to dictate your medicine, but they will put you in contact with a base station. And they’re able to do that basically anywhere on the planet. They can put you in contact with physicians who are trained in in these types of responses, and they’ll give you advice and figure out what you have. But ultimately, when you when it comes down to Geez, do I want to make all of these people uncomfortable and delay them? By having to divert down Don’t worry about that. That’s the captain’s decision.
Yeah, that’s not your responsibility now,
now, and that Captain will have no problem making that decision.
We covered quite a bit. This was very, very helpful, actually. Now I’m going to be able to go to the mall and go on a plane without less anxiety than I did previously. But is there anything else and this was very comprehensive, but is there anything else that you think that bears mentioning that we haven’t discussed so far?
Really, I think that the key parts to cardiac arrest is realized This is a team based resuscitation. All of us are part of the team and in society outside of your camping trip, we have got to activate the system. So early recognition, early activation of the system, early, minimally interrupted chest compressions with early different relations, what makes a difference? None of the other stuff that we’re talking about makes any difference. So just offload your your mind about any of that and focus on good compressions and getting an eight either.
Great, great. Well, Dr. Jeff Jarvis, where can people find you online? Where can they find your podcast?
So I have a podcast that reviews ms research. It’s called the MS lighthouse project podcast. It’s on iTunes, SoundCloud, or other places. And you can find me on Twitter at Dr. Jeff Jarvis. And that’s not Jeff Jarvis, that’s a TV critic and it’s not profit Jeff Jarvis switches the best I can tell somebody who exists to to troll the TV critic. So
make sure I was
That was my Exposure to Twitter is getting confused with those guys. Yeah.
I will make sure we can tell the difference between you. All right. Well, thank you again for taking the time out of your day to talk to us and to teach us about how to handle cardiac arrest when when there’s nobody else around.
Dr. Bullock, I really appreciate you having me on the show. Thank you. All right. It’s
been a pleasure.
That was Dr. Bradley Block at the physicians guide to doctoring. He can be found at physicians guide to doctoring calm, or wherever you get your podcasts. If you have a question for previous guests, or have an idea for a future episode, send a comment on the web page. Also, please be sure to leave a five star review on your preferred podcast platform. We’ll see you next time on the physicians guide to doctoring.
Transcribed by https://otter.ai

Emotional Intelligence with the Inspired Dentist, Dr. Shakila Angadi

On today’s episode, we spoke about emotional intelligence with the Inspired Dentist, Dr. Shakila Angadi.  She is a dentist and social & emotional intelligence certified coach that is determined to help improve the lives of fellow health care professionals. She graduated from the University of Missouri Kansas City School of Dentistry and has been in private practice for over 11 years. She realized that empathetic communication and self-awareness techniques were the key to expanding her practice and leadership skills exponentially.  You can learn more about EQ and her coaching programs on www.theinspireddentist.comand on social media Facebook and Instagram @theinspireddentist.

We start out defining EIQ, or the emotional intelligence quotient and how she ended up becoming a certified coach in this area.  She tells us the common issues health professionals have that seek her expertise and how she helps them address those issues.  In discussing how it can help the doctor-patient relationship, she gives a particularly powerful piece of advice, saying just ONE THING to each patient, and that will help all of us connect with our patients just a little bit better.

Find this and all episodes on your favorite podcast platform at PhysiciansGuidetoDoctoring.com

Please be sure to leave a five star review, a nice comment and SHARE!!!

Emotional Intelligence with the Inspired Dentist, Dr. Shakila Angadi

On today’s episode, we spoke about emotional intelligence with the Inspired Dentist, Dr. Shakila Angadi.  She is a dentist and social & emotional intelligence certified coach that is determined to help improve the lives of fellow health care professionals. She graduated from the University of Missouri Kansas City School of Dentistry and has been in private practice for over 11 years. She realized that empathetic communication and self-awareness techniques were the key to expanding her practice and leadership skills exponentially.  You can learn more about EQ and her coaching programs on www.theinspireddentist.comand on social media Facebook and Instagram @theinspireddentist.

We start out defining EIQ, or the emotional intelligence quotient and how she ended up becoming a certified coach in this area.  She tells us the common issues health professionals have that seek her expertise and how she helps them address those issues.  In discussing how it can help the doctor-patient relationship, she gives a particularly powerful piece of advice, saying just ONE THING to each patient, and that will help all of us connect with our patients just a little bit better.

Find this and all episodes on your favorite podcast platform at PhysiciansGuidetoDoctoring.com

Please be sure to leave a five star review, a nice comment and SHARE!!!

 

EPISODE TRANSCRIPT

Disclaimer: This is the transcript to the episode. This transcript was created by a talk to text application and the function of having this here is to improve the page search engine optimization. This transcript has not been proofread, so please listen to the episode and don’t read this. The information contained herein will inevitably contain inaccuracies that affect that quality of the information conveyed and the creator of this content will not be held liable for consequences of the use of the information herein.

On today’s episode of the physicians guide to doctoring, we talk about emotional intelligence with the inspired dentist, Dr. Skeleton Gotti. She’s a dentist and social and emotional intelligence certified coach that is determined to help improve the lives of fellow healthcare professionals. She graduated from the University of Missouri Kansas City School of Dentistry, it has been in private practice for 11 years, she realized that empathic communication and self awareness techniques were the keys to expand your practice and improving her leadership skills exponentially. You can learn more about EQ and her coaching programs at the inspired ninjas COMM And on social media, she’s on Facebook and Instagram at the inspired dentist. We start on defining IQ or the emotional intelligence quotient and how she ended up becoming a certified coach in this area. She tells us the combination was health professionals have that secret expertise, and now she helps them address these issues in discussing how it can help the doctor patient relationship She gives a particularly powerful piece of advice, saying just one thing to each patient. And that will help all of us connect with our patients just a little bit better.
Welcome to the physicians guide to doctoring A Practical Guide for practicing physicians, Dr. Bradley Block interviews experts in and out of medicine to find out everything we should have been learning while we were memorizing kreb cycle. The ideas expressed on this podcast are those of the interviewer and interviewee and do not represent those of their respective employers.
And now, here’s Dr. Bradley Block.
Dr. Tequila and Gotti thanks so much for joining us today on the podcast.
Thank you for having me. I’m really excited to be here.
All right, so let’s get right into it. Tell us what is emotional intelligence. And what made you decide to get certified?
Absolutely. So a moment Intelligence is the ability to be aware of your emotions and your emotional state at the time in which you experience them. And that’s a very broad answer because it goes so much deeper into understanding where our emotions come from, and what do they mean and how do we interpret them. But for me, emotional intelligence is all about getting to know a deeper part of ourselves that we can actually use as information. When we start rethinking the way we experience our emotions and use them in a more thoughtful way. We start making decisions in our life that are more responsive in nature, less reactive in nature, and it translates to a happier, healthier balance. And for me, that’s where my journey started. I was the opposite of being cognizant of any of my emotions. I was feeling the symptoms of Someone who was trying to live up to the expectations of being in the field that I was in dentistry, being married to medicine, my husband’s a physician, and trying to do it all right to be the best clinician. I just bought a practice. I just had a child. I had no idea what I was doing in any of that. I mean, I was practicing dentists for about six years, when all of this was going on, but I had to hit my rock bottom because in that rock bottom, I experienced the symptoms of exacerbated stress, right, the insomnia, the back pain, what the heck am I doing? You know, parenting doesn’t really help because there’s no manual with that, but the conglomeration of everything that felt like my world on my shoulders, was really a really trying time for me because there was no easy way for me to solve it. Right and clinical practices, you have a problem, you figure out what’s going on. On and you apply a solution or you apply a diagnosis and you fix it. And that’s really what I thought I could do with my life, I think at that point, and I was very disappointed to find out that it wasn’t easy for sure. Because
it sounds like you were living the dream, right? You were you accomplish all of the goals that you set out to do.
Absolutely. I mean,
that’s all you you got married, you had a kid, right? And yet, that was the goal. That was the end point. You were there, you hit it, and yet you didn’t feel like it was what you had hoped it would be?
Absolutely, including the white picket fence and the house and oh, we are settled, quote, unquote, settled, right? I mean, everything that we crave, when we are training we had right and we achieved this expectation that was put upon me from a young age to work hard and to help others and trying to live a life of purpose and Happiness that was kind of secondary, it was more of Can you reach these goals? And can you have this idea of what success is and when I reached that point, I found myself silently drowning, I found myself silently struggling and it was silent. Because, you know, even before Facebook is what it is today and social media is what it is today, there was a lot of silence in talking about the struggles and it was a really solitary place to be. And I thought that being a new mom and being a new business owner and having my own practice, that that was the problem, right? We look, sometimes we look outward for the solution that may be there. And I did just that I threw a lot of money into consulting, I learned the ropes on how to establish a business, grow a business and be successful at it, which it was and all the others parenting books that I can read, right? So I was trying to tackle the problem for what I saw was the symptoms. Why am I overstressed? It’s because I’m overwhelmed at work, or I’m overwhelmed with parenting, or I’m overwhelmed with x y&z Let me fix it. I put my fixing bandaid skills to use. But I found out over that next couple of months that things were getting better from a metric standpoint, meaning the business was growing. My parenting skills were somewhat growing, but I still was feeling this emptiness within that didn’t make sense to the logic of what was growing outside of me. And it was in those in that moment in those days where I, I think it was over Ben and Jerry’s ice cream, possibly in the middle of the night, wondering what the heck am I doing? Why am I working so hard? What is the point of all of this, you know, these theory of life questions that we find ourselves asking and it was really Really over that where I went, where it kind of came to me that if it’s not everything around me, then it has to be something from me that everything that I’m fixing on the outside wasn’t increasing my happiness. So there had to been something within me. And that’s where my journey started to seek out what that could be. And it really led to a lot of self exploration, which I think that those of us who’ve had these moments where we’re wondering, what’s the point of all of this hard work, we reach for these things? We’re reading books, we’re listening to podcasts, we’re following inspiring people. And we’re figuring out what aligns with us what sticks with us and what speaks to us. And that’s really where my journey started. And you know, I already had a therapist, so there was that no shame in my mental fitness game for sure. Right. And trying to figure out what is it that I am missing in all of this? What is I’m missing to find my own happiness. And it was until I came across the one book that I read, that dealt into emotional intelligence for business owners and leaders, that it really resonated with me the emotional state that we go through, when we are stressed when we have staff when we’re talking to patients, when we are figuring out who we are first, and then applying it outward. And it was really that particular book that started aligning my thoughts with, hey, maybe this is what is going to be the solution to what I’m seeking, because even going to different continuing education seminars and things like that. I’m seeking out the happiest person in the room and I’m trying to figure out what their formula is right? But it’s not that easy to go to someone’s formula and say that’s my answer. It has to really come from within the realization of what is going to work for you and emotionally
My seat. What What book? What’s the
Oh, the book was emotional grip by Dr. Nita Bhushan. Okay. She’s amazing. It is a great read for anybody. You don’t have to be in dentistry. I just think any healthcare professional that is somewhat thinking of any of the symptoms I just said stress burnout, tired, frustrated, wondering, what’s the purpose of life? Yep, all of those, all of those things will be answered in this book. And I ended up going on to coach with her. And it was the most transitional thing that I ever done in my life, including my professional degrees, because it changed and shifted and challenged me to ask questions about myself that I never had to ask before, despite the professional help that I’ve had in the past, right. And so it got me thinking a little bit more about the present and what I was feeling and Ciao Wondering my beliefs and challenging the emotional state that I found myself repeating, and the emotional state and reactions that came across from interpreting what I was feeling. And it was hard. It was tough. There were tears. I won’t tell you how many, but it was definitely the most humbling experience to learn how to be that vulnerable with myself. But I will say as time went on, and even past the point of when I coached with her when I started seeing changes in not just my own inner happiness, but my relationships with my husband, my child, my staff, my team, even my patients. It started kind of dawning on me that I was on to something like I’m happier living this way. I’m happier living with a better understanding of why I’m feeling what I’m feeling and tackling it at the root. Instead of waiting for the symptom and how to communicate better and communicate with and more emotional awareness to myself and to the other person. And it was really that that inspired me to go back and get my own certification. Because I started talking to people when I was feeling all of this improvement in my life, of course, you want to share it right? You want to share it with your friends, you want to share it with other people. And I started sharing my story with other dentists and other people that were struggling or I felt like they may have felt the same way I felt. And I started realizing that it was more common than not the unhappy practitioner. And it really struck me as Wait a second, if this is what’s going on, how can I help? How can I help my industry? How can I help my husband, you know, how can I help other people in my life that truly need this type of instruction? And so that’s what I did. I went back and I got my own certification through six seconds and I FCI. Both of them are emotional intelligence programs that you can get your certification through. And through that process, I was able to gain tools and a system to actually walk people through a program that I can create on my own. And that’s what I did. So doing that and having that in alignment with private practice was incredible because now I can tap into the answers to frustration instead of just feeling the frustration, which a lot of us get to, and it’s been a really great journey with with expressing and sharing that point of view and being able to coach clients from all healthcare professionals, not just dentistry, and it’s, it’s been a lot of fun. It’s been a lot of fun to do this.
So I need you to take a step back for a second to choose what EQ is because You know, my rudimentary understanding is there’s IQ, which is like your ability to solve a math problem put together a puzzle, something like that. Right? And then there’s EQ, which I, whenever I think of EQ, I think of my wife because my wife can I have her read my emails, sometimes I have read my texts, because I’m, I would say, my EQ is, well, hers is significantly higher than mine. And I recognize that and so I might not have the appropriate tone in those messages. And so I’ll have her read them in order to make sure that I’m getting the message across, but also not like a blunt instrument, right with a little bit wanton subtlety, and, and caring. And, and so I think of one’s ability to communicate as being part or even central to EQ. Not necessarily, I guess, it’s called EQ for reason, emotional intelligence or emotional quotient. Not so You know, understanding your own emotions. So any idea why I might be thinking that’s what it is and what how you can kind of bring those two things together?
Absolutely. So, EQ or Ei, as some call it, the emotional intelligence quotient. It’s different than IQ because IQ is what we measure in terms of what we think of as smartness, the actual intellect that we are born with, that we can foster that we can build upon. EQ is your emotional understanding of not just yourself, but other people as well. And the thing that’s unique about EQ versus IQ is that you can grow it, you can actually shift the way we think, to become more aware of our emotions and the emotions of others and actually, EQ has more divisions underneath it, like social intelligence, your social intelligence quotient, which has been shown, there are different programs that like Google and Apple and these big companies, they’re onto something because they’re figuring out how do people actually relate to each other? How do we connect to each other? Because it has been found that emotions truly are the currency of connection. And when we connect better, we can grow better. And I think it’s something that’s become very trendy, right as far as the emotional intelligence concept, the word the term, but ultimately, it comes down to do we understand why we’re doing what we’re doing, and do we understand why we’re feeling the way we’re feeling. And what does that mean. And when we get that knowledge and we use our emotions as information, we now think differently about the type of response we’re going to have versus this hurt me. I’m mad at you. Let me go and shoot my mouth. Right. We’ve all had those moments where we said possibly something we regretted an argument with a spouse, disciplining a child or Whatever else I mean, those are reactive responses. We’re not processing that emotion when we think about what our return reaction is. I think as far as emails and texts, like you were talking about, I think it’s a very different bear when we are seeing words, because it is harder to convey emotions through words in a text or an email, unless you know that person because I feel like if you know that person, you kind of understand what tone they’re using without actually reading the tone.
But I think within the within the definition of EQ, I think that makes sense because she is able to read the email and then understand the emotional implications of what it says and how someone might react to that. So I because I’m not so EQ inclined, my thoughts going, I’m trying to convey this information. Here’s how I’m going to convey it in as few words as possible, send, right and whereas whereas if If the emotional reaction is taken into account, you might start the email with Hi, I hope your day is going well or something like that. Right? So
write that because the emotional,
yeah, your own emotions, but knowing how someone’s else’s emotions might be impacted by your actions,
right. And you know what, no one can blame anybody for getting to the point in this day and age, right? Because we’re busy. We have things to do places to be. And this time in 2019, we are at an information age where we are bombarded with so much information. So our prefrontal cortex is constantly going it’s constantly making sense of all of this information that we’re getting. But what we’re lacking as far as our human connection, the way we connect with each other, and build up our compassion and build up our empathy and I mean, these are all areas of EQ when we break down what does EQ involve? It includes empathy, intentionality, and communication and interpersonal effectiveness. All these terms that I can throw out there, but what it comes down to is, are we tapping in to the emotional center of ourselves? And can we convey with a connection standpoint, what we’re trying to say? And you’re right when you ask, how is your day or how’s everything going, or I hope this email meets you at a good space in your life or have an inspiring day, it does convey an element of emotion that we don’t realize somebody can take. So it was very smart that you have a very amazing copywriter, it seems to your emails to be able to convey that emotion. I think that’s great. We complement each other very well.
So everything that’s very general so far in terms of and and it all makes sense. But what I want people to take away from this is it’s something they can start doing tomorrow. So I don’t want to get to that. Right now. What I’d like to how I’d like to get there is give us an example of a problem that says Someone might be having in their practice that they come to you for. So what are what are like one or two common issues that you see, and then one or two actions that you give to your clients to help them improve those problems?
Absolutely. So the number, the two highest things that I see is a feeling of burnout and an uncontrollable stress response. So this feeling that they are at their wit’s end, they’re burning the candle at all ends, there’s no hope in sight that that’s going to change. We’ve convinced ourselves that this is our state of being and the stress response of all I can live and breathe is work or I feel like my life is not balanced or I’m not happy with the choices that I make. Those are all in response to stress. And these end points symptoms that drive people to either say, this is my life or I want to To make change, and it’s the latter in which is when I feel like we reach out to somebody, at least it was for me years ago, and it has been for my clients that have sought me out. Because ultimately, we get to a point many of us that we don’t want to stay in that space. We know that despite how we’re feeling, how tired we’re feeling, how tired of feeling tired, we’re feeling if you’re following me that there has to be something more than what we have in our toolbox of acceptance. And when someone comes to find me, they’re looking for an answer. In fact, I will nip this right there. They’re looking for a quick answer. And my answer is always
that’s what I was looking forward to.
Of course, you are not alone. You are in the majority because what people don’t realize is it took years to learn what we know. It took years to learn patterns. It took years to learn behaviors, we are a product of our environment. And our experiences. So will it take an overnight process to undo that? Absolutely not. I mean, if we put it with terms of patient care, someone’s having symptoms of cardiac issues, is that going to take a day to undo? Absolutely not. It’s multifactorial, and it takes time to therapeutically get them to where a healthy state would be. And it’s a similar way. Now, it’s not I don’t delve into the psychology aspect of it. I would say most of my clients have either dabbled with therapy before or are in therapy at the time that they reach out to me because what they’re looking for is they are looking for habits. They are looking for accountability. They are looking for a system to challenge what they know. So they have the repairs, the mental blocks that have come their way from trauma and things like that. I don’t go into that stuff. I refer to my very well educated psychology sector of this and they do a very Good job with it. But I find that it’s what comes after that what comes after I know, I have dealt with the stuff. That’s what we’re going to use in our head. What do I do from here? How do I create a lifestyle that is sustainable? How do I introduce positive psychology elements that are based off of cognitive behavioral therapy because that’s essentially what EQ coaching can do. It trains and allows actionable tools for people to now align with their lifestyle and be consistent with which then the habits like with CBT with cognitive behavioral therapy can now rewire the way we think as in Okay, let me give an example because you wanted an example of something somebody can do something as simple as a gratitude exercise, right? Studies have shown that recalling three things you’re grateful for on a daily basis for 21 days, instigates that pattern of looking for something you’re grateful for And so the small things that add up over time by changing and shifting the way we think about our day to day, instead of focusing only on the survival instincts of, oh my gosh, I need a glass of wine at the end of the day, and don’t get me wrong. I mean, a glass of wine is fine or vegging out in front of the TV or numbing your day away. But that isn’t productive, to help the happiness levels that we want and instigating the right hormones and the right healthy patterns that we want to live by and that are more sustainable, frankly, than numbing our life from the information technology that’s there. Now, I know I kind of shifted a little bit there, but it really does come down to understanding that it’s not a one day reversal. It takes time to challenge to undo the things that we thought to unlearn really to unlearn the patterns that we’ve gotten into you know, residency does that sleepless nights, stress everything else and how What patterns do we then take on to our life? For me, as a dentist, we’re drilled in dental school to be everything we do with our hands has to be perfect down to the millimeter. And that is how we think. So we started sorry,
was that a pun drilling in dental school?
Oh, absolutely.
Absolutely. I mean, you are literally measuring down to the millimeter. So you are constantly being bombarded with this idea of perfection. What happens outside of dental school, you start thinking that things in your life need to be perfect. And that is the number one thing I see with dental professionals, for instance. And so it’s not that we’re looking for these things. It’s what we’ve acquired through our experiences, and how do we challenge that? What am I
I think, I think one thing that I’d like to go back to when the gratitude you mentioned, you know, it’s important of gratitude. And so what you what you’re doing is by recognizing something that you’re grateful for, that that’s helpful, but with that training, you to do is notice things then later on as you’re happy as as as they’re happening. Absolutely. And rather than just at the end of each day saying I’m grateful that this thing happened or I’m grateful that I’m able to pay my mortgage and I’m grateful that we have food on our table. Right, right you what you’re doing is each day, then you’re on the lookout for things to be grateful for. So that takes that’s that’s a habit that needs to be developed so that you can be on the lookout for those things, as opposed to what our brain has evolved to do, which is not die. So you’re looking for, you’re looking to reproduce and don’t die so that you can reproduce again and then so so this is anxiety is actually adaptive. Because if you were the most anxious, you were the least likely to get eaten by bears. So like these are these are but that doesn’t work in today’s society, right? Because we safety we’re not we’re most of us aren’t being chased by bears or lions, whatever. So then you have to get out of that mindset of trying not to get eaten. Instead of trying to notice the bears, you have to notice the flowers so to speak,
right and we put ourselves in that state of being stressed and having our elevated cortisol levels and we start to get the terms fear and anxiety intermixed, right fear actually being chased by a bear Yes, you should be afraid you need to survive Ah, but anxiety, the perceived fear, the perceived fear of something that hasn’t happened, how many times you talk to somebody they say, I can’t sleep at night I was thinking about x y&z It’s a perceived fear, but your body doesn’t know the difference. What happens to us over a course of a lifetime. At that state, what happens we are giving and feeding into that negative feedback loop. That happens because we are very adaptable. We are amazing creatures. Our brain is an incredible organ. And so when we’re constantly giving and feeding the negative state and allowing ourselves to believe in that negative state, and we’re not taking a cognisant way of taking a step back In saying, Wait a second, is this truly what I’m thinking right now? Or is this something I have learned to think when we start being that aware of what we’re telling ourselves, we want to change? And the incredible thing about increasing your EQ, whether you do it with listening to a podcast or reading books or doing coaching or whatever venue you choose to do taking a seminar, it doesn’t matter what day
you look, podcast, listening to podcasts is the way to do it.
Well, this step is the step. Yes. listening to podcasts is the way to do what you are. I recommend doing
podcasts,
but you have to be open, right like the podcasts. If something reaches you. That’s where you’re stepping stone to learn about more. That’s where you start. And I think that we’re
sorry to keep interrupting but that being open because I just want to pivot from there for a second. It sounds like what a lot of people people end up coming to you. There you said they’re they’re perfectionist, they’re looking for the everything needs to be just right. And when it’s not, it really stresses them out. And so you end up one of the things is you help them with gratitude so they can appreciate all the things that are going well, and all the good things that are, are in their life. But what about for those people who things are going really well, right? With their practice, they like their patients, their life is going well. But they’re listening to this because they’re in a good place. And they want it to be better. And and I might be wrong. But my assumption is, most of the people that are going to be looking for things like this, are people who are already doing well and want to be able to do better not necessarily like when you when you encounter the physician who’s stressed out and so he might be he or she might be lashing out and you know, short tempered patients and short tempered their staff. They might not have the wherewithal to recognize that that’s what’s happening to them. Whereas people that are doing well I think are more inclined to be like I’m doing well, hey, but I want to do better. So those people what, what are some actionable things that they can do to their emotional intelligence? Absolutely. So
usually the people that you say that are okay, or they’re doing well, they’ve already started the journey to self discovery, because EQ is not the answer for everything, right? It is a tool, and it is a very important tool, but it’s not going to solve a plethora of every other issue, it’s going to address an area of your life that you might not have given the thought to improve. And so yes, people that are looking to improve themselves have already been on this self discovery of figuring out why am I working as hard as I’m working? Why am I doing what I’m doing? And how am I as happy as I could be? Because that’s usually the question. Do I have balance in my life? Am I as happy as I could be? And this seems to fall into their path of Wait a second. Maybe I’m not as emotionally aware and gratitude is Just one. I mean, it is one tool of the many more tools that I use in my particular program. But it all starts from emotional self awareness. Because we run a life of automaticity. We are constantly going we get used to things very easily hedonic adaptation. We’re really adaptable creatures. But we don’t always slow down enough to practice the mindfulness to be aware of where we are, in the moment that we are. We are not always aware to think why do I think the way that I think so a lot of the exercises that we work with Well, let me even backtrack there. My process is I am a certified EQ coach, I actually administer a test. And it’s not an IQ test. It’s an EQ test. And what it does is it helps give a visual to a client per se, to see where their strengths are and where their vulnerabilities are and what we can do to create a program to utilize their strengths to help where They are struggling because a lot of times until we see a visual, we don’t realize where we’re actually struggling with, are we struggling with personal power? Are we struggling with the self talk self esteem and having self compassion for ourselves? What are the tools we need to do with that? So the first step is always the awareness. The first step is always the self awareness. Because if we’re not accurately looking at ourselves, if we’re not accurately gauging our emotions, or understanding and being proud and having self compassion for ourselves, how can we then manage it? Right? How can we how can I give
those to find that? Is there a place or does this need to be administered by an emotional intelligence coach? Or is there like a platform that we can find online to take a questionnaire because if we think maybe we think we’re doing really well and then we take the questionnaire and find out actually, we’re a terrible person?
I don’t think anyone can be a terrible person. I just think that their emotional state, just maybe not as developed as someone who’s done the work, you know? That’s what I’m gonna say.
Like, it’s a smiley face and yours. And the question is, is this person happy, sad or I don’t care? It’s
the questions are more how, how would this make you feel? Or what would this mean to you? And so they’re more thought provoking questions to see from a gut instinct standpoint. So there is not a right or wrong when I go through an evaluation with someone, it’s not to point out what they’re horrible at No, my God, like, you’re never going to communicate with anybody because that was your weakest point. No, it’s it’s literally looking at it and thinking about why that is such a struggle, and what are the patterns that we’ve acquired in our life that contribute to that struggle? Right. And as far as to answer your question about, is there an online test? Well, there is an online everything, right? Because we can diagnose everything and the healthcare field online with our friendly friend, Dr. Google, and is there And EQ tests out there, I’m sure there is, is there somebody who can make sense of it and apply it to exactly what you’re doing? Most of the time, you would have to seek a certified coach through one of these programs. And the only reason why I say that is we have the training to decipher it, apply it and produce not a cookie cutter program. But something that actually applies to you to encourage growth because I can create programs out the wazoo, but if someone is not motivated, to really, truly dig that deep within themselves and do the hard work to improve their emotional well being, then it doesn’t matter what I do, right. So I think that there are resources out there, anybody can Google them, take a look at them, read, read upon them. But ultimately, what it comes down to is how motivated are you to go to the other side and the clients that seek me out, they want accountability, right? And they want to actually see change, and I don’t promise some change in a day most of my engagements or at least three months, because I’m not going to To tell somebody, first of all, I don’t take on everybody that reaches out to me because not everybody’s ready to shift. And that’s part of the process is to figure out if someone is ready, but when they are, that is where the growth happens. And it keeps growing even beyond the time that they are working with me the clients that I now touch base with, when I started this years ago, I mean, they are doing some really stellar things. And it’s a cool ripple effect to see. But it all starts from within it starts with taking emotional inventory of how do we feel during the day, how can we check in with ourselves? What kind of responses are we having during the day? Do we understand that maybe when we snapped out that colleague that there might have been something else going on? Do we understand that that moment of joy or happiness when our kid took their first step that was fleeting? How can we reproduce that feeling in other aspects of the way we move our life and, and shifting the way we go through life instead of automatically doing it when we’re more aware of how we feel we are now managing it better. And then when we take that second step, when we understand how to manage our own emotions, now we can take it to a social environment, we can take it to what is this person trying to tell me because their words are saying something, but they seem pretty pissed at me, right? So we can now take the emotional awareness we have for ourselves and understand another human being differently and we are able to now communicate with them and manage a social, emotional environment in a better way, which is where my practice personally, that’s when my practice grew, when I knew how to manage my team, and I started talking to them differently, communicating with them differently, connecting with them differently. And even my patients my case, acceptance was a lot easier when you come from a place of compassion and understanding someone’s emotional state versus telling them what they need, which is a very different kind of conversation.
The fact that you’re, this is coming from again, DENTIST actually took me by surprise, just because you’re most of the time, the patient is sitting there with their mouth open, and they’re not doing much talking. But I guess there is a whole lot of interaction before and after. And also your visits tend to be much more time consuming than than the typical doctor’s visit. So you’re spending a lot more time with your patients. And I actually, I guess that that emotional intelligence, all that more important, because all you’re seeing is how the patient is moving their brows. And you.
They’re saying from all
right, right, it’s not so much the amount of time that you have with a patient. It’s the quality of what you’re saying. And are you able to convey compassion in that few seconds that you have? Are you able to create a connection, where they believe and trust you? That’s where emotional intelligence helps in the healthcare field because we can now connect with someone a little bit deeper than Hey, Mrs. Jones, how’s your day going? You know, versus Hey, what What’s something amazing that’s happened to you lately? I’d love to hear about it. Or remember Melanie’s wedding. I mean, it takes your conversation to a different place. Now, a lot of us don’t have more than five minutes to establish a rapport per se, right. But there is a difference between scripting. And there’s a difference between connecting. And I think when we learn how to connect based on emotions, of course, our care is going to become more efficient, and it’s going to be more productive as well, especially when your team starts to learn that language as well.
So let’s let’s get into that, because I’ve heard you talk about this on other podcasts that you’ve got your team on board. I would think that would be challenging, because you’d encounter some skeptics and all of that. So how do you convince your team that this is something that they should buy into?
Absolutely. So you know, there really wasn’t a whole lot of buying into, even though I do like that term, just because a skeptic is always a challenge and I’m up for a challenge and I don’t know, there’s something to that. But when we start improving ourselves, we can’t help but want the people around us to also be in a happier state, right? If you’re happy and you’re having a great morning and nothing got you down, including that spilt coffee and your kid that didn’t want to put their shoes on 10 times and we’re late for the bus, but we got to, we got to work on time. And we’re grateful for that. And we’re, we’re thinking, Hey, you know what, my day started over, I’m at work, I have a good healthy mindset. I know where I am. I know where I want to be. You walk into a room full of miserable people. Do you really want to be in that environment? Absolutely not. So for me when it came to what do I need to do for my team? It was kind of a selfish thing to For me it was I don’t want to work with people who don’t want to be awake. I don’t want to work with people who are miserable inside because that toxic attitude and the toxic energy, it is just that it translates and spreads to the rest of the office. Including the patience. And so what I had to do as a team leader was to teach them tools and not just tools more than the tools, give them the conversation to be vulnerable and allow them to do the work that needed to be done. To learn more about themselves, right to talk about what are we grateful for this morning? We had yoga sessions we did. I mean, you don’t have to go that extreme. Of course, since at this point, I was certified coach and I’m now doing all of this with my team. But it came down to looking at a stressful interaction with a patient what would what could we have said different? What? What would we have said different? How could we create more connection and doing connective exercises within each other? How do we get to know each other better? What are we as humans? What makes us happy? What makes us sad? Are we aware of our emotional state? So to answer your question, and bring it all back to what that answer would be, how did I get the most motivated, happy people are contagious, right? Just like negative energy is contagious. So when is
syphilis?
Well, yes. And you know what, we have very good people that can address that it will not be me. But as far as a mindset and what people want to see, I think as humans, we all want to find a sense of purpose and happiness somewhere along the way. And I think when they when people see other people that are happier and have a lighter energy than possibly where they are, of course, they want that. So it didn’t take a whole lot of convincing. It took a whole lot of leading and communicating in a way to help me understand what they’re going through, and how can I as a leader, help them with whatever they were going through, because ultimately that investment of time with my office manager with her then empowering the rest of the team, it translated to patient care, because now when my patient are being heard and they are felt like they are cared for. It’s a trickle effect. And if my patients love me, and they love our office, then hey, happy doc. Right?
Yeah, I think that’s an excellent point. I think leading by example, it’s certainly easier said than done. But if you’re getting all stressed out, and you’re running behind, and the next patient shows up late, and you’re saying, oh, man, you know, why can’t this person have the decency to show up on time for their appointment, and now they’re going to set me back for the rest of the day, your your stuff is going to respond to that right then, and then act in kind right then then when they’re confronted with that patient, the patient they’re going to be addressed them using similar verbiage to what you just used. So if you’re someone that Listen, I understand that Oh, man, that person must have been stuck in traffic or, you know, no, they might have had something going on at home. Let’s try and be understanding and help them out. Right, then that also gets passed on to the staff. So I think that leading by example, really easier said than done, right? But but it has a reason effect.
Absolutely. And empathetic communication is one of the things that I actually trained teams on. I do local coaching and train teams locally in dentistry where we actually talk about what does this sound like with each other? What does this sound like with our patients, and I’ll give the rubric right here. I mean, it’s not something that I particularly made up, I’ve honed in on how to use it in healthcare settings, but you’re really using active listening as your main tool, but instead of going straight to solving which, hello, anybody in there, anybody out there wanting to solve a problem as soon as they hear it, but once you go from active listening, the key the cream of the Oreo, if you want to call it that is reflecting the emotion. This changes the way we have conversations with each other because if someone comes in and they’re upset about something, right, and you’re seeing that they’re upset about something, what is it that we’re listening for if we listen for the emotion, and then we’re ready reflect that emotion. Hey, I understand you must feel overwhelmed right now, this is a lot to take in. I understand it wasn’t the news you were expecting. Right? That that pause right there, that reflection of that emotion now leads to more accepted case acceptance. It leads to people understanding that when you come from a place of caring, and to you understand them innately as a human being, and that’s what we want people that come to us as healthcare practitioners, innately, they want to be heard, just like we want to be heard. But that little tool right there, it doesn’t take more than three minutes, not even and most of us have a few minutes to at least acknowledge that emotion before we give them the solution. And it changes the way we practice at that time. My husband’s use it and he’s an anesthesiologist, and it’s interesting when I hear him how he’s translated it into his lingo, because it still does come down to addressing the emotion I understand. This is scary. Understand this. is overwhelming and using the language in that way, because people then go to that place of trust that no matter what comes out of his mouth next, they already are connecting in a way that they didn’t connect before.
So I think for my patients, right, I’m an EMT. So they come in with a sinus infection, rather, so I take the history, I think ending the history with Wow, that sounds really uncomfortable. And then moving on to the exam and then moving on to the just taking that pause for a second to acknowledge their how they’re feeling right now. That’s really uncomfortable. That sounds really anxiety provoking, like a lot of people come and see us with. It’s called Globus fringy. It’s just a lump sensation in their throat. And most of the time, it’s, you know, it’s nothing scary or dangerous. So acknowledging that they’re here because they think they have cancer. Right? That’s what that’s what’s going through everybody’s mind because like you said, they went on to Dr. Google and they looked it up and it told them that there are cancer. tells everybody, right? Even if you put you have the right so, so saying, Wow, that, that sounds like it’s making that would make me really nervous just pausing for a second acknowledging, raise the distress, the discomfort, whatever it is the emotion that they’re in, and then moving on to solving the problem. I don’t think I think you could do that even adding a few seconds to each visit. Not you know, not even a few minutes, just a few seconds and it’ll it’ll buy you a whole lot of new fans and maybe a couple more Yelp reviews.
Absolutely. Absolutely. Because then what do patients remember, they don’t remember how quickly you solve their problem. They remember how much you cared, because that’s how we’re wired. That is how we are wired, we are looking for connection. We are looking for the innate need to connect. And by just spending that few seconds to say, I understood you or I hear you, I acknowledge what you’re feeling. It shifts it definitely shifts not just the patient perception but it also makes your day easier when someone is going from a high stress state of thinking they have cancer to Oh, now You are the hero because it was this, you know, I think they would come a lot better when it’s Wow. And he cares so much about me. Wow, I am referring all my friends, friends who are
less likely to feel like the patient that had their concerns dismissed. Oh, you’re fine. Nothing sounds very different from Wow, that sounds like it’s really uncomfortable. Oh, turns out it’s nothing to worry about. Right? I think right. Just a few seconds. That was that was a really powerful tip.
Absolutely.
Or any any other tips that you think bear mentioning any any other little bits of advice that you have? or resources that we can turn to to help us improve our emotional intelligence and emotional awareness?
Absolutely. I think that the the other thing I really see a lot of high achieving, professionals do especially healthcare professionals is we spend a lot of time taking care of our patients, and not putting the emphasis on taking care of ourselves. And I think that if there’s something I can definitely suggest out there is not waiting for the signs of having to take a break or needing to take a break or needing to get away, rather fulfilling our life a little bit more microscopically, where we can add moments where we do things for ourselves to take care of our mental well being our emotional well being on a regular basis instead of waiting for I mean, don’t get me wrong, vacations are fantastic. But if vacations are the only time you’re detoxing from social media and you are taking a break from everything, or picking up a book and reading it that is not like medically profound, then there is a problem, right? And we want to make sure that if we take a step back and think of ourselves as humans, what inspires us what makes us happy, is it going to concerts more often as indulging in something creative. I remember that time where I used to ride bikes Or remember that time where I used to do this kind of going back to what brought us true happiness and joy along the process of learning how to be how we are, if we tap back into that, and get that into our day a little bit more frequently, I think we would see happier practitioners who feel a little more balanced. Because sometimes we think, hey, if we work really hard now, we’ll have all this time later. Whereas it’s the quality of time that we have now. And how are we using that to sustain for the time that we need to sustain a little less in the survival mode, and a little bit more in the happiness and joy mode? I think self care, self compassion and understanding that we as humans are not robots, and that we need breaks. And it is healthy for us to take breaks and it is healthy for us to say no, when we need to. I mean, there’s so many things that I would love to say, but we only have so much time on this podcast, so I’m trying to speak really fast. If anyone is putting me on two or three X, you might want Go back and listen to all of the stuff I just said. But really, I think the main thing that I would you know, advise anybody who’s finding themselves going, Okay, what do I do from here? really evaluate what your days look like? And are you putting enough items in your day that make you feel like you other than what you do and the titles you have and the roles that you wear? Because I truly think that’s more sustainable for a longer period of time than waiting to the point of us getting to that stressed burnt out state where people are now thinking I have to do something
where you’re gonna end up one of those old curmudgeon II doctors in the doctors lounge that retired and can’t seem to leave the doctor’s lounge.
Absolutely. Because you know what, if you don’t think that you deserve happiness, you’re not going to look for happiness. If you don’t think that you deserve to be joyful and find things that make you feel more centered and fulfilled. Then you’re gonna you can live an entire lifetime and not find those things. But are they truly happy? Do we want to be happier for the people around us too because a happier you makes you better to everybody else as well. And that’s not the reason to do it. You should be happy innately. But it’s a nice side effect when your spouse or your kids or the people that you work with, notice that you’re taking care of yourself as well just like when you come back from a vacation and you look recharged, and it’s not just the tan.
Absolutely, absolutely.
All right, well, Doctor, she killed john Gotti, the inspired dentist, thank you very much for all the time you’ve given us. Where can people find you online?
Absolutely. So you can find me at the Inspire dentist calm. That’s my website. I have a lot of resources, reading podcasts, all sorts of fun stuff over there. I do speak and write as well. I have some projects in the works. So I’m excited to share all of that on that platform. I’m also on Facebook and Instagram. Same handle the inspired dentist and keep in touch because I’d love to hear what you guys think especially about this episode.
All right, well, thanks again.
Thank you.
That was Dr. Bradley Block at the physicians guide to doctoring. He can be found at physicians guide to doctoring comm or wherever you get your podcasts. If you have a question for previous guest or have an idea for a future episode, send a comment on the web page. Also, please be sure to leave a five star review on your preferred podcast platform. We’ll see you next time on the physicians guide to doctoring.
Transcribed by https://otter.ai

Be Calm and Queer On with Dr. Crystal Beal

Be Calm and Queer On – What Your Trans and Gender Diverse Patients Want You to Know

Dr. Crystal Beal answers the questions that will helps us better care for our transgender and gender diverse patients.  They went to med school at Florida State University, and completed the Valley Family Medicine Residency program, part of the University of Washington.  They are the physician- owner of QueerDoc.  Dr. Beal hopes to change the experience of care for the trans and gender diverse community and raise the bar for gender affirming care.  Through QueerDoc, Dr. Beal provides increased access to expert, affirming, and culturally competent care for queer and gender expansive children, adolescents, and adults.  They currently serve Washington and Alaska (through partnership with Full Spectrum Health), and have dreams of expanding service to several more states as an online queer and gender affirming healthcare provider.

We talk about why Dr. Beal created their practice and we talk a little about some of the specific needs of gender-diverse people.  They make some suggestions about how to best introduce yourself to patients who may be gender diverse, and as it turns out, it really sounds like the best way to introduce yourself to all of your patients.  Dr. Beal educates use about issues they have faced when interacting with the medical establishment as a patient and gives some pointers for how we can all interact with gender diverse individuals to make sure the relationship develops as it should, based on trust and free from stigma and biases.  We end with some great resources for learning more about the gender diverse community and a great place to start is QueerDoc.com.

Be Calm and Queer On with Dr. Crystal Beal

Be Calm and Queer On – What Your Trans and Gender Diverse Patients Want You to Know

Dr. Crystal Beal answers the questions that will helps us better care for our transgender and gender diverse patients.  They went to med school at Florida State University, and completed the Valley Family Medicine Residency program, part of the University of Washington.  They are the physician- owner of QueerDoc.  Dr. Beal hopes to change the experience of care for the trans and gender diverse community and raise the bar for gender affirming care.  Through QueerDoc, Dr. Beal provides increased access to expert, affirming, and culturally competent care for queer and gender expansive children, adolescents, and adults.  They currently serve Washington and Alaska (through partnership with Full Spectrum Health), and have dreams of expanding service to several more states as an online queer and gender affirming healthcare provider.

We talk about why Dr. Beal created their practice and we talk a little about some of the specific needs of gender-diverse people.  They make some suggestions about how to best introduce yourself to patients who may be gender diverse, and as it turns out, it really sounds like the best way to introduce yourself to all of your patients.  Dr. Beal educates use about issues they have faced when interacting with the medical establishment as a patient and gives some pointers for how we can all interact with gender diverse individuals to make sure the relationship develops as it should, based on trust and free from stigma and biases.  We end with some great resources for learning more about the gender diverse community and a great place to start is QueerDoc.com.

 

EPISODE TRANSCRIPT

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Crystal Beale went to med school at Florida State University and completed the valley Family Medicine Residency Program, part of the University of Washington. There’s this an owner of queer.com Dr. Bill hopes to change the experience of care for the trans and gender diverse community and raise the bar for gender affirming care. Through queer doc Dr. Bill provides increased access to expert affirming and culturally competent care for queer and gender expansive children, adolescents and adults. They currently serve Washington and Alaska through a partnership with Full Spectrum Health, and have dreams of expanding service to several more states. As an online queer and gender affirming healthcare provider. We talk about why Dr. Bill created their practice. When we talk a little about some of the specific needs of gender diverse people. They make some suggestions about how to best introduce yourself to patients who may be gender diverse. And as it turns out, it really sounds like the best way to introduce yourself to all of your patients. Dr. Weil educates us about issues they have faced when interacting with medical, the medical establishment as a patient, and give some pointers for how we can all interact with the gender diversity individuals to make sure the relationship develops as it should. based on trust, and free from stigma and biases. We end with some great resources for learning more about the gender diverse community, and a good place to start is career.com.
Welcome to the physicians guide to doctoring A Practical Guide for practicing physicians, Dr. Bradley Block interviews experts in and out of medicine to find out everything we should have been learning while we were memorizing kreb cycle. The ideas expressed on this podcast are those of the interviewer and interviewee and do not represent those of their respective employers.
And now, here’s Dr. Bradley Block.
Dr. Crystal Beale, thank you so much for joining us on the show today.
Yeah. Thank you. You marry Dr. Black.
So you have a very robust website queer doc.com which shows your your practice where you treat the trans and gender diverse community. So why did you feel the need to create your practice or why did you create the practice?
Yeah, well, I was doing locums Family Medicine at Kaiser Permanente, which used to be Group Health in Seattle, Washington. And several of our gender care navigators sort of typically people with that MSW, helping gender diverse people jump through all the hoops that insurance, ask them to jump through to get the care that they need. I found out I was personally part of the queer community and asked me to start seeing patients that mean I had very, very little education around how to medically care for diverse people. That being said it was a need that needed to be felt. So I spent some time doing a lot of CME and Reading, as well as like the Fenway webinars and a few other resources within our community, like local providers, I shadowed and started taking care of patients there.
I just want to unpack that for a second. Because I think I think this is something we spoke about before the show was that you said don’t ask your patient to educate you, right? Do you do the legwork yourself? And so what you said was being gender diverse yourself? Right? You needed to learn about the community and about the medical needs of the community. So and I think I am sure there are physicians out there that would assume that just because you are gender diverse yourself, it means that you know everything about the community and the issues that are faced. Yeah,
no, there’s no one way to be a gender diverse human, just like there’s no one way to be any other kind of human. So my personal experience isn’t necessarily my patient experience. Obviously, being part of the community, I did have some, maybe what we would call a medicine some of the soft skills like I can walk into a room and not assume someone’s gender based on their presentation. not assume someone wants to use their legal name not assume I can know their pronouns right off the bat. That being said, I had no clue what to do with hormones or anti androgen therapy or how to kind of meet the needs of the insurance system when it comes to writing referral letters. I think one of the hardest things was like how to order the right syringes and needles for injections. I don’t know why. That seems impossible sometimes, but it does. Like the pharmacy gives my clients mismatched pieces that don’t fit together. It’s, it’s great.
There was a lot of learning to do.
Oh, I can imagine how navigating the insurance situation would be. So I mean, if I have trouble getting my patients with asthma, the right medicine I can’t imagine the the hoops that you have to jump through in order to get your, your gender diverse patients right medications.
Yeah, totally. I was fortunate. You know, I work in a community in Seattle, where we do have quite a few providers who have been doing this work for, you know, 20 years and they’re so generous with their time and their expertise. So I was fortunate enough to get to reach out to them, in addition to doing just like formalized CME. And the there’s some online, the Fenway Institute, which does a ton of LGBTQ free CME video webinars, has a ton of resources that are super helpful as well. Oh, great. Yeah,
we’re definitely going to cover other other places are the doctors that are looking to learn more can turn to, but something that you mentioned was when you walk into a room, you know how to address the fact that you can’t assume someone’s pronoun, right. So For the physicians out there who aren’t comfortable asking a question like that, what are your What are your recommendations?
Yeah, well, when maybe examine your own bias and like implicit internal experience of that what is so uncomfortable about asking someone a pronoun like why does that feel challenging as an individual, just like we would in any other situation, whether it’s racism or socio economic status issues or substance use disorder issues, kind of looking at our own feelings and trying to pull those out of the exam room. Also, I typically walk in and introduce myself, as Dr. Beal and I say Dr. Crystal crystal is fine. Whatever feels better for you. What would you like me to call you? I think that’s a great way to approach it because even non gender diverse people might not use their legal name as their email address, and it kind of starts opening the door. And then after we have that part of the conversation, that Next thing I say is, I have no strong preference and pronouns, I use a them and writing. What pronouns do you use? And some, some providers actually just wear a pin or a button, like a piece of flair on their badge or something like that, that says their pronouns so people can start people want to talk about it, they can see it and open the conversation themselves. I think there’s kind of a couple different ways to approach it. flare, flare, yeah.
Just makes me think of office space.
Exactly.
Is there a minimum amount of flair when people are working with you? They need to where in your practice.
Now
777 was the minimum?
That’s right. That is definitely an office space reference. I’m glad you caught it.
Okay, so if you have if you have a group of physicians in front of you, because because you you do right now there are beliefs it or not, they’re physicians out there listening to listening to this podcast. And, and you want to teach them one or two things that they should know about the gender diverse community issues that you end up addressing with your physician colleagues over and over, but now you have an opportunity to talk to them and say, so you don’t have to keep saying the same things over and over. What what are the things that you would like them to know the top top issues?
Yeah, I think top issues are janitors people are scared coming to the doctor’s office that there was a huge survey in 2015 of over like 20,000 gender diverse people. And absolutely fourth of all gender diverse people delay care because of fear of mistreatment at a provider’s office, and so, and up to about half of us have experienced at least like one negative interaction with our provider in the past year. So anything you can do to make us feel more welcome and safe, walking into the room, as skinny be amazing. And those things include like, asking us our name asking us our pronouns. They mean having multiple boxes and options for gender on the form, when we check in at your office, all of those things just set the tone, you know, because that’s the first thing we do is sit down and fill out a form that just has a male or female gender box. It’s like already, we don’t exist to you, which just makes us not very willing to share who we are or what we need medically. To be fair, though, that issue might be much harder to fix, because a lot of the data that we’re producing then gets utilized by say, CMS, right, like there, there are certain minimums that we need to hit on questions that we need to ask that might be part of the demographic information. So as a provider, I don’t have as much control over stuff like that as I need. In fact, I don’t want you to have to check a lot of the boxes.
Because it’s a profound waste of your time, and it doesn’t want me to take any better care of you. Yeah, but but your point, right, the patient maybe has some trouble filling out the paperwork. But if they walk into a room and the first thing the physician says is, it’s nice to meet you, how would you like me to refer to you? Clearly, this physician gets it more so than probably 99% of the healthcare workers that this individual has encountered in the past.
It’s so true, don’t you like that? The bar is really low. I would like you to refer to me as
Brad Thank you very much. Sorry.
red bar is really low. Like we’ve had so many providers like not ask us our name, not ask us our pronoun, much less like, discriminate against us, kick us out, refuses care, misdiagnosis, mystery or conditions like all those things have happened. If you just start like you might not know very much, but if you’re kind of open to like actually seeing us as humans, and honoring who we are, you’re already ahead of most of the animals. So be be open and willing to learn. But the other point that you mentioned was, don’t ask your patients to educate you.
Yes. Can you unpack that a little bit?
Totally. So I think, you know, typically, one of the like, really common experiences for gender diverse people, if you get a bunch of us in the room is that we go to the doctor, and the doctor is like, a generally nice kind person who wants to be of service and wants to help but does not have the education or training because, right, I think, I don’t know, when you went to medical school, I had one one hour lecture on LGBTQ health issues in my entire four years there and then I had nothing in residency. So even like, willing providers might not have the training they need and so for whatever reason, we sometimes think it’s okay to ask patients to teach us what we need to know to take care of them, particularly within the gender diverse community. I would encourage providers So just let patients know that they’re willing to learn and that they’re going to spend some time educating themselves. And maybe we could reschedule after they’ve done that, versus referring someone out someone who does know, and then finding those resources that give us basically guidelines and and protocols to use and treating gender diverse people.
So rather than saying, so what medication Do you take for, rather than that say, let me look into this and get back to your admit to the egg. You’re basically you’re admitting to ignorance, which is being vulnerable, right? I’m Brittany Brown, right? It’s a good thing and make more relatable, but but then, but I’m looking to learn, I’m looking to learn, you’re you’re basically you’re saying, Listen, I’m not familiar, but you were important enough to me that I’m willing to take the time to figure this out.
Right, which is generally how like as a when I was doing traditional primary care high approach most scenes when patients pay you know Bring us something they printed off the internet or something they saw on TV patients about things all the time that I knew very, very little about. It was always a positive. Okay, great. I don’t I can’t answer these questions right now. Give me a month. And I’ll write you a long secure message or Well, I have a phone visitor. I’ll see you back in office.
So what are some of the issues? Aside from the ones that we’ve touched on? Or maybe just go into a deeper dive about those that we touched on that you’ve faced? the medical community as a as a patient as a gender diverse patient?
Yeah, I, you know, primarily, I went through five primary care providers before I found someone I felt like I actually didn’t judge me just for being who I am. And that was really tough because I started to think you know, have you ever heard the expression if you meet three assholes in one day who is the common denominator
Actually, no, I’ve never heard that before. But that sounds like something that sounds like something my grandma would say.
Yeah. Well, I started to really wonder like, Am I am I just like a horrible patient? And am I expecting too much to my, what’s wrong with me? And so much so actually, like my fourth primary care provider, I went, my actually my partner who is also a physician, come with me to one of my visits because I was like, I think he’s, like, I don’t I don’t know. It seemed like really weird. And, and so they came with me and they were like, Oh, no, he’s just an asshole. You just need to find a different doctor. I was like, okay, so it’s not, I’m not totally crazy. And I’m not this like horrible demanding patient. But I had, I had a provider in the southeast who, when I went from being like, presenting as this like, cisgender straight heterosexual person who was married, I actually, I then became divorce and how to partner and other partner ovaries and this provider Miss diagnose me cheated my condition and appropriately and then when I called back to say I wasn’t getting better well we into his office instead of a patient room and told me he was worried about my choices and that as like one of his I was a med student at the time he said as one of his future colleagues, he felt it was really important to make sure I was like making the right decisions for my life. And I was like, okay, all that’s great, but I didn’t get any better with this mess and you gave me it was never apologized and his concerns were so he turns out he was a Seventh Day Adventist and
I just I just assumed that there’s religion playing a part in there and they weren’t worried about your sinus infection. They were worried about immortal soul.
Yes, that is exactly what happened. never apologize for missing the diagnosis either and Needless to say, I didn’t I didn’t go back until I was a student.
But But in that physicians eyes, I mean, that’s holistic care right there, right? Because in his eyes he’s treating you’re not treating your medical condition, which is what you’re there for. But he’s been holistic. He’s not he’s just you treating your soul too. Right? That’s, that’s concerned right there.
But yeah, exactly what I went there for.
Yeah, check the check your biases at the door.
Yeah, so that was fine. I had, I had another provider who was like, Oh, this is fine for you now around like my choices in sexual disease testing, but like, you don’t want to be doing this when you’re 40. And I was like, Yeah, I do. Like, this is exactly what I want to be doing when I’m 40. Now, I’m not 40 yet, but you’re obviously seeing some judgments around my decisions that I think are totally like, safe and healthy and adult and mature. consensual, so we’re not we’re not going to do that either. We I
mean, before you say that, just wait till you get to 40. I’m looking down to the barrel of 40. And I’m just just always so tired.
That was the thing at the time, I was like, Oh, why? Why? Mmm. I don’t know for sure that that’s what I want to be doing when I’m 40. But I do know, I don’t know
when I’m 40 So,
all right, but so those things, those things seem, those things seem pretty blatant to me. And just that the people that I think listen to my show are people that I would assume do things well, right. They do things well, because they’re, they’re somewhat honest with themselves because it’s really, I think, completely to be totally honest with yourself, but really good at reflecting on what we’re good at what we’re not good at and trying to improve. So these are people that already have heads are ahead of the curve because they’re trying to do better right now. And those people that are making those statements to you, I would lump them into the people that like that would say things like all my patients love me, I do everything great. I don’t need to improve at this. Right. But you’re right now talking to a bunch of people who are who are looking to approve, so they’re probably ahead of the curve. So what are the more maybe insidious things that have happened from very well meaning people that didn’t realize that they were maybe alienating their patient?
Yeah, well, I think anytime I get referred to as like, ma’am, Miss lady, like any of those things like that, assign a gender and a gender role to me that I don’t truly identify with, or feel affects who I am, which happens in conversation in exchange because people have been socialized and trained to do that. Really can be a moment where I miss a connection with my provider whether relationship, the potential for the therapeutic relationship to develop as loss. And then I think this doesn’t happen as much in in Seattle as it did in the southeast, but for sure, people assuming that my partners specifically have testicles, or assuming that if my partners have testicles, like there’s a certain way we have interactions or intimacy, or you know, even worse asking me if I’m married, because until recently, I couldn’t legally marry most of my partners. So I think those are kind of some insidious things that can happen around doctor patient interactions that it’s it’s really helpful if you change your language to a more open, inclusive and like gender neutral stance.
I’m just trying to think how that would, how I could apply that in my own practice, you know, I’m an otolaryngologist, so the gender or sex organs of your part I don’t really don’t really factor into the conversation that I’m having with any of my patients. So just just helped me to understand instances in which that becomes relevant. Even like when when is it that you’ve encountered aside from just them assuming your pronoun? Yeah. When is it has your partner even come up? I mean, you mentioned earlier, right? Like if you’re being tested, tested for a sexually transmitted disease, fine. specific situation, right. When is that? When does that come up in your interactions?
Yeah, well, I think a lot of times in in the south, it just came up in like a small talk that providers would try to make silly, like, Oh, are you married? Are you having kids like, kind of things that aren’t applicable and kind of my life? And so maybe you just asked me more open and open ended questions or if you’re trying to make that connection and start that question. rescission, letting clients draft that a little more as opposed to closing it assumed question.
I would even say, asking someone if they have kids is because I’ve done that and regretted it, because there we go. And then there was silence.
Right? Oh,
that doesn’t sound like I learned very quickly. Do not ask that question. If they happen to bring up the fact that they have kids, then definitely ask them about their kids. Because there’s nothing that most parents like to talk about more than their children. Right. But like, yes, what are you doing this weekend? sounds much better for small talk. Do you have any patients coming up? What do you like to do for fun, right? Yeah, these are all pay. These are all questions that can help you learn more about your your patient,
pay, and even I do a lot of what I do. We do. I do checking with patients around social determinants of health. So like, who shares your household with you as opposed to like, just assuming certain people are in that household with them, again, just leaving that open ended space for people to answer in a way that maybe you don’t personally expect but like lets them be who they are. Yeah, safely.
Are there any other issues that you’ve encountered that you want to that you want to touch on? Because I think that was those the few that you covered were definitely they’re definitely gonna help me in my practice, and I’m sure they’re gonna help the listeners as well. See, to open ended to open ended. Okay, so you said to me, I
say the major thing is, which may be your listeners because they’re actively seeking input on how to be better. providers don’t need this reminder. But I think a lot of people from any minority, whether it’s gender diversity or just being you know, having a sexual orientation that’s in the minority or being of a race that’s in a minority, a lot of us can be fairly forgiving. If you’re at Like intentions are in the right place and you have kindness in your heart when you’re talking with us. If you’re open and willing to risk like people just outside of the doctor’s office, people refer to me as Lady or ma’am all the time. And if you’re willing to like allow me the space to correct that and change it without making it about you and getting defensive and shutting down. Like I can move past it right? Like there’s a whole theory around micro trauma and chronic trauma that we don’t have time to go into today that occurs when we do those kinds of things. That being said, as a gender diverse person, I’m willing to work with you if you’re just not like a totally, totally closed off person in that area.
So normally my episodes I click the clean button so the but but since you said asshole before now I have to click explicit so we’re gonna continue so don’t be an asshole.
Yeah, defensive.
Like if someone’s if someone’s correcting You write, and and listen, we all do this all the time and could benefit from improvement in that area, certainly myself is if someone corrects me, I shouldn’t take it personally, it’s not it’s not a judgment on my character. They’re not telling me I’m a terrible person. Just take that as an opportunity to improve. Right, exactly. I think when someone assumes something about my gender, and I redirect that to like a more, a more fitting pronoun or reference to me as a person that has nothing to do with them, it is entirely about me and asking them to see me as I am as opposed to how they assume I should be. So I’m not upset with you or angry with you or mad at you. I recognize that we’ve all been socialized to interact in specific ways, and we’re trying to undo years and years of social training here. And so, again, if you can avoid being an asshole and can kind of Kinda open minded. It’s such a great starting place at least and then it’s going from there, you’re willing to do the legwork to educate yourself around some of our health care needs and issues, right like not assuming what organs we have based on the way we look right? I can’t tell you how many case studies I’ve had people who didn’t feel comfortable coming out to their primary care doctors as transgendered after they had already transitioned pretty significantly. And so like weren’t like maybe they have facial hair that were born with a cervix, so weren’t getting cervical cancer screening and had advanced advanced stage like cervical cancers, things like that. So they, we, if you create a space that feels safe for us by like doing these small things with like, more inclusive gender neutral language, you’re more likely to have patients Be honest. And then you can kind of explore those healthcare needs together, right. Or, you know, we also had a similar case With a trans woman and person who was not getting any kind of screening for prostate cancer, you ended up with like fairly advanced metastatic prostate cancer as well.
And I think it all starts with that introduction. Hi, Dr. Brad block, you can call me, Dr. Block. You can call me Brad, you can call me Dr. Brad, how would you like me to refer to you, man, that and that way that can work on so many levels, right? I mean, I don’t know how many of my patients are gender diverse we because this is just not something that I treated as an ear nose and throat doctor, right unless, unless the changing like someone’s larynx is is part of their their transition. It’s not real thing that I treat. I mean, those are just not issues right, like sinus infections is a sinus infection and hearing loss in Iraq, right. But still, right. That’s how this works for because I was thinking about behind before the episode, right? Like if I have patients that that that are by All right, I’m going to just assume but how do I know which patients should I be asking? How would you like me to refer to you? And the answer is follow up. Because some patients because I and that’s, that’s a problem that I’ve encountered. I’ve some patients that I’m very familiar with, because I’ve been seeing them for years. And like, I am totally fine with them calling me Brad. And I can call them by their first name because I mean, I you know, I might take care of their kids and their parents and like, you know, and we’re right, and I want to make them comfortable feeling that way. And so it takes all the you know, all the question out of that is still a story from from my family, which has nothing to do with being gender diverse, but I’m just going to talk about myself right we talked about beforehand was my my mom’s mom said to my dad when they were first married, call me mom, and he said, I can’t I have a mom So then when he was telling me that story, he I said, well, then what did you call her?
Nothing. I just waited until she looked at me.
And they were married for like 35 years before she passed away. So that’s 35. Yeah, like an ambiguous title total may give your patients the opportunity to be more comfortable with you. Like in all in all situations, irrespective of whether they’re binary or gender diverse.
I totally agree. I think, you know, I heard somewhere in my medical training that patients perceive the doctor patient relationship is more therapeutic when we introduce ourselves as doctors first, which is great. We also never know who has been traumatized by doctors in the past. Unfortunately, it does happen. I most of your listeners are going to be like lovely people, but occasionally there. There’s who more than just like negligence or discrimination, but actually assault and abuse patients. And so we never know when we’re talking to someone who’s had that experience. So giving them the opportunity to choose how they address me, and potentially avoid a very traumatic and triggering word is I think, important. And unfortunately, trauma is more common among gender diverse people than their cisgender counterparts. Think offering that even before we check in about their name is a great starting
place as well. How would you lead into that?
You know, I don’t I don’t say that. Like that whole long spiel, I just I just offered to let them call me. Dr. Phil, Dr. Crystal or crystal, whatever. I misunderstood. I thought you meant like, if they’ve had a past trauma, like oh,
with with that, like asking that question at the beginning of the visit.
No, I don’t I definitely don’t talk about that at the beginning of a visit. I again, I think them these little steps of like how to how do you want me to call you and what pronoun to use start this station. face. Yeah. That that may be able to open up about a trauma like that I do might not be relevant to all of your patients. But if you anytime I’m referring gender diverse people out, I’m trying to refer them to providers I know have experience in cultural competency and working with gender diverse people. But you know, if I know I’m referring them out for something that has the potential to be traumatizing, like I’m referring a trans man out for a pelvic procedure or something like that. We do totally talk about trauma. Then we talk about past trauma, potential future trauma and how we can minimize that up to including offering like a Lorazepam for the visit or something like that. Wow. Yeah, yeah. So and that’s the thing, right, like a lot of primary care providers who maybe maybe have done some like reading on UCSF and watched a few of them with webinars are super excited to be offering hormones and like meeting some of their patients needs. That’s really amazing. And awesome, but they might not have the skill when it comes to doing a pelvic exam on a trans trans person. But, again, it doesn’t just apply to trans people like we never know when the person we’re doing a pelvic exam on has had previous trauma. So I think it’s always worth asking that question. And then maybe talking to providers has done a few pelvic exams on people like that to get like tips and tricks and skills and how we approach that and using different instrumentation on people who have been on testosterone therapy for a while than I am on people who haven’t. So if our listeners are looking to learn more about the gender diverse community, what are some resources that you would recommend? Yeah, I would say for providers, UCSF has an amazing University of California, San Francisco has a center for excellence in Transgender Health and they have an amazing kind of guideline, basic textbook that’s all available online for free their primary care protocols. That gives you like a basic introduction to gender diversity, it’s going to go through like the alphabet soup and language, you know, like what the hell is the G is what the T is what the Q is and define non binary gender queer, gender, diversity, transgender, all those things. So that’s really helpful but then it’s also going to give you preventative care guidelines. So like recommendations for preventative care screening is going to give a recommended protocol for transition related hormonal support. And then it’s also going to give you the common complications or issues that pop up within that community on on treatment for that, which is really fabulous. The endocrine society and W path the world professional association for Transgender Health both both also have guidelines and protocols. The w path text is a little bit more dense than the UCSF it’s really worth reading, but it could be a little harder to get through as a busy person in practice. And then the endocrine society guidelines I think are a little more of a restrictive than maybe the other two. And so those are kind of great starting points. The Fenway Institute does free webinars which are also fabulous. You can sit down for an hour, watch it, do the little quiz at the end and get, you know, an hour’s worth of category once you need for free, which is always, I think, fairly motivational for me as a writer trying to pay my boys and then going, going to CMU is great. I’ve been to several great ones on the West Coast as far as gender Odyssey, gender diversity. Some of my local institutions do kind of an annual LGBTQ situation as well. Reaching out to providers who do this work and asking for like more local support in your area is great. There’s another provider doing something I do most of my work through telemedicine, and there’s another provider in the southeast doing something kind of similar. We’re med calm. And then I’m also part of the console group. So a through one of our local nonprofits that supports gender diverse people, they organize kind of like a listserv of a whole bunch of different providers from all different modalities of care who care for gender diverse people. And so whenever you run into an issue, you don’t know how to handle it. There’s like an immediate email console right there, which is super valuable resource to have.
So that segues well into where can people find you online?
Yeah, queer.com and my emails cleared off@clear.com and they also have Facebook, Twitter and Instagram that I’m not as great. I was just wanting to messages on but usually within make a couple of days, get to them
and your Twitter handle is.att.com Yeah,
yeah, Doc, cuz that’s someone else. Probably
That Yeah, there was a documentary movie called query.
took it from Facebook and Instagram. It’s clear doc
crew, Doc. Okay, great. And just take a moment to tell us about what your website is all about.
Yeah, well, so it is like the launching pad for my private practice, which I do do telemedicine based queer focus care, we’re in gender affirming medicine. So basically, people can do just video visits with me to do things like prep, contraception, STD testing, and gender affirming care, like hormones for transition, and referrals for surgery for gender affirming procedures. And then I also kind of tried to basically compile all of the resources that I had into one place and parts of it totally self serving way, right because I think doing primary care and being a physician, so much of it was about being able to live point people in the right direction for information that they want it. Right? So that kind of prevents resources for them. So they weren’t just googling things and finding a shady answer. So in part, it was a place for me to kind of dump all the things that I had been using, and then just make them available to my community. And so there are research sources around gender expression around changing your gender identity markers on legal documents, and there’s also practice in Alaska. I’m partnered with another clinic up there called full spectrum. So there’s resources and in Washington and Alaska for like, we are friendly, mental health providers or speech pathologist or hair removal, things like that. So I tried to make it a pretty accessible resource for people who needed things and information around those things. There’s also a ton of information on hormone therapy. There’s videos on self injection There’s videos to watch on feminizing therapies and on masculinizing therapies, there’s giant seven page documents about everything you want us to know about testosterone therapy or everything you want us to know about therapy. And there’s a physician resource page where they can find kind of all the things I’ve mentioned already for self education. And then they can reach me too. I’m always open to helping point people in the right direction if they have questions, or having trouble with any kind of care while
you through your, your email out there for potential patients and
it’s very, very brave of you to do
Yeah, well, it’s a business email so
I mean, I am the one check again, it’s just me. It’s on the website and on the Facebook anyways, so
good, I guess I guess you found me because I put my podcast related email address out there as well. So that’s that’s that’s a good point. Yeah. Dark crystal Beall, this has been extremely informative. And I think we all have a lot to think about. We all have a lot to work on. And I will definitely be at the very least introducing myself to every single patient in a very different way than I’ve done it in the past. And I think even something that’s small is going to is going to help me connect with my patients all the better. So really, I appreciate you taking all this time out of your Saturday afternoon to talk to us and educate us.
Thank you so much. I appreciate you taking time and being interested in learning not everyone is so thank you.
That was Dr. Bradley Block at the physicians guide to doctoring. He can be found at physicians guide to doctoring calm, or wherever you get your podcasts. If you have a question for previous guests, or have an idea for a future episode, send a comment on the web page. Also, please be sure to leave a five star review on your preferred podcast platform. We’ll see you next time on the physicians guide. doctoring
Transcribed by https://otter.ai

Choosing the Right Financial Advisor

Ryan Inman is a fee-only financial advisor who works exclusively with physicians and he teaches how to pick a financial advisor.  How did he end up in the physician niche?  He understands us.  His wife is a pediatric pulmonologist and part of why he understands the struggle so well is that they’ve been together since college.  He graduated from the University of San Diego and has two masters, one in business administration and another in Accounting and financial management.  He manages Physician Wealth Services, which does financial planning for physicians, and he has his own podcast where he answers physician specific financial questions, called the Financial Residency and manages with Physician Finance Facebook group.

We discuss how to find a financial advisor and answer questions like, what is a fiduciary, who should I buy life and disability insurance from, is picking stocks and timing the market possible with enough research, what services should a financial advisor provide and what is the most common financial mistake he sees physicians make. 

Find this and all episodes on your favorite podcast platform at PhysiciansGuidetoDoctoring.com

Please be sure to leave a five star review, a nice comment and SHARE!!!

Choosing the Right Financial Advisor

Ryan Inman is a fee-only financial advisor who works exclusively with physicians and he teaches how to pick a financial advisor.  How did he end up in the physician niche?  He understands us.  His wife is a pediatric pulmonologist and part of why he understands the struggle so well is that they’ve been together since college.  He graduated from the University of San Diego and has two masters, one in business administration and another in Accounting and financial management.  He manages Physician Wealth Services, which does financial planning for physicians, and he has his own podcast where he answers physician specific financial questions, called the Financial Residency and manages with Physician Finance Facebook group.

We discuss how to find a financial advisor and answer questions like, what is a fiduciary, who should I buy life and disability insurance from, is picking stocks and timing the market possible with enough research, what services should a financial advisor provide and what is the most common financial mistake he sees physicians make.

Find this and all episodes on your favorite podcast platform at PhysiciansGuidetoDoctoring.com

Please be sure to leave a five star review, a nice comment and SHARE!!!

EPISODE TRANSCRIPT

Disclaimer: This is the transcript to the episode. This transcript was created by a talk to text application and the function of having this here is to improve the page search engine optimization. This transcript has not been proofread, so please listen to the episode and don’t read this. The information contained herein will inevitably contain inaccuracies that affect that quality of the information conveyed and the creator of this content will not be held liable for consequences of the use of the information herein.

Ryan Inman is a fee only financial advisor who works exclusively with physicians. How did he end up in this niche? Well, he gets us. His wife is a pediatric pulmonologist and part of why he understands our struggle so well is that they’ve been together since the beginning of college. He graduated from the University of San Diego and his two masters, one in Business Administration and another in accounting and financial management. He manages physician wealth services, which does financial planning for physicians, even has his own podcast where he answers physician specific financial questions called the financial residency. So if you’re looking to take a deeper dive, find him there. He also manages the physician finance Facebook group. In this episode, we discuss how to find a financial advisor and make sure that they’re working in your best interest. He answers questions like what is a fiduciary? Who should I buy life and Disability Insurance from is picking stocks and timing the market possible with enough research What services should a financial advisor provide? And finally, we end with what is the most common financial mistake he sees physician make warning. He’s a bit of a killjoy here.
Welcome to the physicians guide to doctoring A Practical Guide for practicing physicians. Dr. Bradley Block interviews experts in and out of medicine to find out everything we should have been learning while we were memorizing kreb cycle. The ideas expressed on this podcast are those of the interviewer and interviewee and do not represent those of their respective employers.
And now, here’s Dr. Bradley Block.
Ryan Inman, thanks so much for being on the show today.
Hey, thanks for having me. I’m really excited to be here.
So you’re a fee only financial advisor so today we’re going to help people decide how to choose their financial advisor if there are many making their first foray into attending ship. They don’t feel comfortable managing their money. They want they want some expert assistance. And you know, before the show we were talking about Dr. Google, right. So our patients will look up their symptoms, try to figure out their diagnosis, and think that they can match our expertise given medical school and residency and all their user experience. And I find that there are a lot of financial bloggers out there that have this as their side hustle. And they think that they can match a professional financial advisors input. So today, we’re going to take the time to really explain why there’s a lot of value in a financial advisor and then how to pick one so you chose a fee only model. So there’s an assets under management model, which is if I have a million dollars in the bank, and they take 1% of it as their annual fee, then I would think, right, they’re trying to make me more money because the more money I have, the more money they make. Right? But that’s not the model that you chose. Why did you choose a fee only model?
Yeah. So let me let me back up real quick. And I joke By the way, just so everyone’s clear all the time with my wife of that I’m in a Web MD something and prove her wrong, which never ends up working. But I threaten and it loses every time. But so the the there’s a fee only model and a fee based model. And they’re the difference. I mean, it sounds super similar. Everyone gets a confused even when they’re trying to recommend a fee only advisor they say yeah, work with a fee based advisor. So I think we should probably start their fee based advisors, which NAPFA did a study then said basically, night over 97% of anyone who calls himself an advisor or a planner is fee based. And what that means it’s not only can they charge, like let’s say a financial planning fee to do work, whether it’s a one time fee, or An ongoing fee doesn’t matter. But they can also sell products. And then with products you’re going to earn either Commission’s or some kind of like let’s say kickback from either whatever you’re selling typically insurance, but also it could be investments and a lot of the big brokerage houses. So I’m going to say like the Merrill Lynch’s the Morgan Stanley’s Edward Jones is Raymond James. Those guys, they’re all fee based advisors. And it doesn’t mean that they’re bad people. It just means that their compensation structure is bad. Because their compensation structure the way that they bring home money for their family to eat, is essentially selling you products, some products you need. Most products you don’t, the investments that they can actually give to you are with those big brokerage houses are actually coming from essentially like their headquarters, their head office. So at Merrill Lynch, it’s coming from New York, they say, hey, you can all of our advisors, you can only put your clients into these X number of funds. And that’s all you have to choose from you couldn’t go off and try to buy individual stocks or do other things like they’re really kind of handcuffed. Because from a compliance standpoint, they need to make sure that their 20,000 advisors are doing the right thing. So that’s what fee based advising isn’t. Just because they work for a big brokerage doesn’t mean again, that they’re bad. It just is a different form, even if you don’t work for a big brokerage house. And I could have started off my own firm and done fee based planning, which again, because more than 97% of all advisors are fee based. All you can imagine that anyone out there most often are going to be fee based. They’re selling products. And the reason why I chose not to go that route, is because I don’t want to have any conflicts of interest with my clients. I want them to know that they’re coming to me for my experience in my advice, and they should be able to trust that that’s what they’re paying me for not, huh Brian told me that, you know, I should buy this disability policy that he’s selling me Is he telling me that because he makes more money? Or is he telling me that because it’s the right thing for me. So I wanted to eliminate as many conflicts of interest as I possibly could. And that is really I mean, we’re fee based is fee only is they can actually charge assets under management just like the fee based people. Or, you know, you can charge a variety of ways a flat fee ways the way that we charge. But I chose that because it was I think allows me to sleep better at night knowing that I’m giving great advice for a fair price. And even though I make less money by not selling products, it allows me to remain a fiduciary as well as allow clients to know that I really don’t have any conflicts of interest. We
just use the big word fiduciary. Oh, okay. What is a fiduciary?
It’s someone that is legally responsible to act in your best interest. And who wouldn’t want that? Like, I’m not gonna go to the doctor and let’s say like, I know you’re an EMT, but let’s say you’re just paid by time writing prescriptions, which I know there’s some out there that are that way. But let’s say that you’re the only way you were compensated by is by writing more prescriptions I go to you, you’re likely to give me a prescription, because that’s the way you’re paid. Why would I want to go to someone like that versus someone who can actually assess the situation, look, labs and everything. Maybe if you just exercised and weren’t overweight, maybe you don’t need this prescription to lower your blood pressure, whatever it is. And so I just I look at it as you know, this, this fee only fee based thing is is is very black and white to me, and I want to make sure that I’m on the side of conflict free. And not is Ryan, tell me this? Because he makes more money.
So is it possible to be fee based and be a fiduciary?
Yes, it’s just a lot more rare. So how,
yeah, how would someone even go about doing that? Because if they can’t really objectively, offer that well if they’re not able to offer them a variety of products tomorrow Because they’re stuck with what’s in their firm, how can they really say that they’re acting in their clients best interest?
Well, it’s hard when you’re at a big brokerage. But let’s say you’re a small independent shop, and you can actually sell insurance from principal and guardian and massmutual. And you’re an independent agent, you’re not technically tied to one that you sell all. I still think you can claim that you’re a fiduciary in that in that perspective, but it better be in writing. So similar to like the Hippocratic oath, I sign a fiduciary oath with every client, and it sounds like common sense, like, Oh, yeah, just put it in writing. We’re good. Most advisors do not put anything in writing like that. But the fiduciary piece is just really important to me. So we do, but that doesn’t mean you know that if someone was fee based, they couldn’t do that. It’s just really rare, to be honest.
And then how do you prove that someone is or isn’t a fiduciary? Right? They sign that piece of paper, can’t they? How does that restrict them from? I mean, at some point you have to go selling your product. This aren’t right for you.
Yeah, you have to go off some trust. And I mean, if they’re not acting like a visionary and they put it in writing, like they’re legally held to this and you’ve got it in writing, if they don’t act in that, then you obviously have a case to kind of build against them if they weren’t acting in your best interest. And there was a lot of hype several years ago around advisors being forced to be fiduciaries. I mean, this is so bad that in my industry, we’re having to create laws to tell people like you need to be good and kind and respectful to other people and be fiduciaries and put their best interests ahead of your own. Unfortunately, that literally was only in retirement accounts. And it was essentially saying like, you can’t sell these crap products in someone’s IRA, but then you could take your fiduciary head off and put on I am a horrible person had and go sell them this terrible annuity or whatever it is, in basically a non retirement account, and the entire industry freaked out because it would have crushed all of their their other advisors that were basically selling These products into retirement accounts. It’s kind of unfortunate,
I think, Well, I think when it comes down to it any industry can’t regulate itself. Right. I think you always need to have outside regulators. I think so of medicine as well. I think the current system doesn’t work. But I think I think that’s true in any profession, that that we all like to think that we can regulate ourselves. But in reality, you really need some outside perspective to keep everybody in line. So so I really don’t. Yeah, I don’t think that’s specific to your field.
Yeah. But But back to the original thing with the assets under management model, right. So there’s the a un model, as it’s referred, sometimes a ua assets under advisement. advisors can charge on that and what that means, I guess I should say is that the AU M or assets under management is accounts that we would actually manage from our firm like at, let’s say, TD Ameritrade where we do where we custody, clients funds, the assets under advisement would be, let’s say you have a work sponsored plan like a 401. k. And I’m going to give you recommendations on that and then charge for my recommendations on that. And people, other advisors do that all the time. I mean, some advisors are even charging on 529, which is ridiculous. Their advisors charging on 529. That’s, that is just a terrible, terrible advisor, to be honest.
Well, I think in New York State, we have two options for 529. Do you want to be aggressively invested or not so aggressively invested? I, if I remember correctly, when I set up my son’s accounts. So if someone’s billing me for that, then you’d better be a pretty small bill.
Well, unfortunately, it’s not it’s usually that same one or one and a half or 2% that they’re charging. On top of that. I mean, I’ve had we actually have had people come to us and being charged one and a half percent on 150,005 29. And didn’t really realize it because they actually build the assets under management but build for the advisement On top now they have to give you a breakdown of invoice of what they’ve built. But most people don’t actually open their mail and look at it or they know Oh, that’s just my bill from my advisor and they rip it up or they don’t see or sometimes they just stick it in like a, you know, their financial planning vaults or software like a Google Drive. And most people don’t look at it. And that’s why the assets under management model, they’ve one of the reasons I should say that the industry is so for it and is built around it is really rallied around it is because most people don’t actually know what they’re paying their advisor. And it’s because it comes out of your investments and doesn’t come out of your actual bank account, which I think is ridiculous, because you’re not seeing the money. Leave your bank account. You don’t have the pain if the money’s coming out of your retirement account or your IRA that you’re not touching for 25 more years, and you’re not really paying attention to it because most people honestly don’t. You have no idea what you’re paying your advisor They know that and that’s why they in our business assets under management is the sticky business. When you manage money for a client, it’s hard for them to move and change advisors and change everything over to do it themselves. And you actually are going to probably make more money because they’ll stay longer, because they don’t realize what you’re paying them.
Well, very tricky, very tricky.
And that this is like the the real basics. I mean, it gets real complicated real fast when they’re selling products that have real, real crazy compensation structures or just really tough to understand whole life, variable life annuities, you start getting into those things and like the compensation structure is through the roof. If you were just sold, let’s say a million dollar, whole life policy. Let’s make it real easy. 35 year old female, you’re probably your advisors probably gonna make 12 to $15,000 commission right then in there, and then they’re probably going to make let’s call it an average of 5% Trail. So five percent of the premium you’re paying every year is going to that to that advisor or that insurance agent for selling that policy. So what I don’t know if you’ve actually seen or been exposed to it, but most planners will actually try to target residents or new attendings and say, Hey, we’ll give you all the planning for free. They’re like, Well, great, this is awesome. Well, one no one does anything for free. But to the Here comes the pitch for well just buy this disability insurance and buy this term policy that we’re ultimately going to pitch in a year or two to convert it to whole life so we make a huge Commission on the back end, but they’re gonna make Commission’s on the Disability Insurance, which you likely need, but they’re gonna make commission probably 2500 to 30 $500 just on that one policy. So of course, they’ll do the planning quote, unquote, for free, because they sell you one policy and they make 30 $500. And very, very little work, maybe an hour of FaceTime.
So do you sell life insurance and Disability Insurance
Not at all. No, that’s what makes me fee only is I don’t earn any kickbacks or commissions or anything from anyone anywhere I don’t. If I give you the name of my accountant who I think is a great guy and love sending him business, he can’t buy me a Starbucks cup of coffee, even though I’m his client, because I sent him a client. He can’t even buy me a cup of coffee. It’s that black and white.
Like, we have the star clause, right. In medicine, we have the star clause where you are not allowed to make money off of sending someone to like if I if I refer someone to a pulmonologist, I can’t make money off of that referral. That’s illegal. It’s the same thing with you.
Very Yeah, it’s very much the same thing with me. Except for those fee based planners that greater than 97% of all planners or advisors are fee based, right? So when you go to an advisor and they say, hey, I’ve got this really great accountant or this really cool estate planning attorney you’re gonna love them. Well, that estate planning attorney, maybe it’s just a they bought me a beer. More than likely it’s like Hey, here’s $500 for referring that client over a finder’s fee,
right? finders fees occur all the time in all sorts of business models.
Yeah. And it’s it’s hard to find out, they don’t have to be like, hey, just so you know, I’m referring you this really great guy. He’s gonna pay me $500 for this referral, they said that you’d be like, Huh, wait a second, like, why are you referring that guy to me? Is it because you make money? Like he’s, you’ve already pre arranged this or is he really the best for my needs? And that’s the biggest, biggest piece between fi only and fee based, is that giant middle part? That’s a big ball a conflict of interest. And that’s what I want to avoid. So is that what makes someone a fiduciary? If they don’t have those conflicts, or can you have those conflicts and still be considered a fiduciary? Oh, man, you’re getting some gray areas because like, I it personally, in my opinion, I don’t think you could be a fiduciary to someone and get paid on the back end somehow and not disclose it. But if you fully disclose Everything in theory, probably, but I mean, this is, this is so far, Greg. So I’m such a nerd. I’m like, I’m black and white, like you either do this or you don’t. But I want people out there. And they’re, they’re thinking, well, I’ve signed this fiduciary, with this individual, like they are acting Now I know that they’re acting on my behalf. And what you’re saying is a very difficult conversation to have, oh, I need life insurance. I need disability insurance, can you? Can you recommend anyone? Then you have to say, do you make any money off of sending me to that person? Like now you’re basically saying to your financial advisor, I don’t trust you. Right. And that’s, that’s a very difficult conversation to have. I think you’re asking more disclosure, like, hey, how did how do you benefit from this? And their answer should be, you pay me for my advice and my experience, I benefit by helping you. I don’t make any extra money. That’s, that should be it. And I hope everyone asked that question. Because we will see the inverse, the more people that asked that question, the more people will switch to fi only because they will lose a lot of business a lot. Because once most people start asking that question like, how do I actually pay you? Like, what am I paying you? And how is it calculated? And do you make money from any other sources? Like on my behalf? Or is it just coming from me? And the answer should be the only money I make is coming from you, the client. And if it’s not, your advisors, fee based and they have conflicts of interest, again, doesn’t make them bad people. It just means that their compensation structure is faulty.
And I think that’s a good point. You say they’re not bad people, because I
I just, I have friends that are fee based advisors, and they won’t ever switch because they have a giant book of insurance business that pays them six figures a year and if they decide to go fi only they take A $200,000 pay cut. Well, I mean that who would want to do
that? But I would also think that these individuals genuinely think that they’re doing the right thing for their clients. Well, totally hidden. I don’t think they’d be able to sleep at night, but at the same time, and I’m not saying that they’re villains
said, You’re giving people a lot of credit. Some people are like, I’ve got to eat, I need to put food on the table. How can I make the most money possible? I didn’t finish the statement yet.
interrupted Al Capone. I thought he was the good guy of his story. Right? He was bringing fun to the masses. It was, you know, clearly, to what end to what what means that he used to get it there. But he was providing prostitution and alcohol and gambling and entertainment to these people that had no other sources of entertainment. He was a good guy, and that’s how he slept every night. Because he was the star of his show. He was the good guy in his story. He wasn’t the villain. Nobody’s developing their story. So You know, I think these these people don’t genuinely believe that they’re doing the wrong thing and they’re pulling the wool over their clients eyes. I think they’re probably all believing that they’re that they’re doing the right thing for them. We’re not comparing to them to Al Capone, but you see.
But you know, we all tell ourselves little white lies about everything. As much as we don’t think we do. Right? I’m I can’t lose weight. It’s so hard for me to lose weight. Because I’m so busy. I work too many hours. And I promise you someone out there works more than I do and is losing weight. That’s just mindset. And in this case, they might be telling themselves like I’m doing the right thing. I’m putting food on my family’s table and like, I’m not hurting anyone they would they would have needed this disability policy anyway, of course, I think is that that is the most important policy that you should buy. buy, buy it from an independent third party that has no other vested interest other than to help you and to give you the best thing possible and quoted out at many different sources. And that advisor might be able to do that, but then realize that this is the person you’re trusting with all of your financial data, and that you hope that they’re telling you the right thing and doing the right thing. And it’s just a lot of gray area that gets introduced. And that’s the best case scenario. Assuming that they’re a good person,
assuming that they’re a good person, yeah.
Know how much negative press my industry gets, right? They say no bad presses, you know, no, lol press is good press. But I don’t know. I just personally, I can’t do it. I can’t sell products. Even I could literally make like four or five times more. I can’t do it, though. I love the idea that people are coming to me for my expertise and for my opinion, and being able to help them and I can do that in a conflict free way.
You help them get their financial house in order. Exactly. Yeah. All right. So in a similar vein, let’s talk about asset management. So now the the physician has their Assets being managed either by someone who’s fee based fee only assets under management. But active management versus passive management. Let’s talk about that. Which, which do you typically recommend? Like are you telling people to buy apple and sell Google and buy 3d stocks? Because, you know, there are radiologists and they’re they’re seeing all that 3d printing is doing and or are you telling them buy the whole market?
So do you know Jim Cramer is and he’s on CNBC and he gives you like advice to buy this hot stock and sell this
Oh, yeah, he’s a caricature of a human being He’s like, Well, you know, right like, like he’s a radio host that you can see cuz he’s on TV because he’s got all those sounds and everything yeah,
yeah. If someone doesn’t know he is here you go, sell sell, sell, buy, buy buy, right. He’s like buy buy buy buy this sell, sell, sell sell this like it’s it’s a game to him, right? It’s he’s, he’s going through and he’s producing entertainment. While That’s active management. Basically, he’s essentially saying, this stock is going to outperform the market as a whole, which is their benchmark, okay? And he’s saying, hey, Apple is going to do these amazing things, it’s going to come out with the iPhone 400, because we’re probably at that at this point. And it’s going to blow everything out of the water, and it’s going to outperform the market and we think it’s going to do 20%. Right. Whereas the market, you know, we’re ballpark and it’s going to do 8%. Well, that that’s, that’s their belief. They think that one stock or several stocks are going to do better than whatever benchmark they’re going to put it against. And typically people think of it as the Dow, which is only 30 stocks, but let’s look at is like maybe even the s&p 500 right, which is the 500 biggest companies and they’re trying to beat that benchmark. And that’s, that’s called active management. And there’s mutual funds out there that spend millions and millions and millions of dollars on research and staffing and just all sorts of stuff to try to Figure out how to beat the market. Some people are really good at it. Think Warren Buffett, okay, that guy is amazing. How many Warren Buffett’s are there in the world? Well, obviously, there’s one. But there’s a few people that are like him. But he’s very, very rare. Whereas you have thousands and 10s of thousands of these mutual fund companies out there trying to be basically the Warren Buffett’s of the world and trying to beat the market. And there is Nobel Prize winning research that shows that they are incorrect. And the longer you go out in time, the more likely the majority of them are going to be wrong. You go I think the numbers are you go out 10 years, and almost nine out of 10 of those mutual fund companies are 90 out of 100 are not going to beat the market as a whole their benchmark. If you go out like 15 years, it’s like 95% of them aren’t going to beat the market. So Do I go, I go on to the passive investment management style, which is, let’s buy the market, let’s own the market as cheapest possible be as highly diverse as possible because now instead of owning, let’s say those five stocks that we mentioned before, whatever it was, I’m going to own 3000 or 3600 stocks, I’m gonna own the whole US stock market. So if Apple does really well, great, I own it. If Microsoft does really bad bummer, I own it, but I’m not concentrated at 8% or 10% of my whole net worth or my whole accounts. I own maybe 1%. It’s all based on market cap. So I’m in that passive camp because I can tell you, I’m not smart enough to be in that 5% that is going to beat the market over that 15 year period, or it’s less than that I being kind this point. But, you know, I’m not Warren Buffett. If I was, I probably wouldn’t be doing what I’m doing and I’d probably be relaxing in Hawaii on the beach. And not doing planning if I was. So I
don’t even know how that’s mathematically possible, I would think half would beat the market and half wouldn’t beat the market. Because if you have like a random smattering of stocks, some of them are going to be more successful than the market. And some of them are going to be less successful. How is it that only 5% of them end up beating the market?
I mean, trading, they’re sitting here and they’re trying to buy and sell some, I mean, some of those like firms and the the big quants that they get really close that ASIC and they’re trading in milliseconds, right? That’s their whole algorithm is based on that there’s somewhat, you know, other funds that are, well, we’re going to do a more buy and hold approach. And you know, we’ll rebalance infrequently, but they’re still trying to actively beat it. There’s a long, short funds, there’s all sorts of different funds out there that are doing things and they’re transacting all the time. And it’s just the way that the results lie. And they’ve done studies on this like crazy. And again, it’s like Nobel Prize winning research and it just shows up They can’t outperform the market as a whole. Got it? I guess, try to join that 5%. And, and not only are you like hoping that your advisor does it, that’s one advisor, some most financial planners who are part of these big, you know, mutual fund companies, they’re buying 810 15 or 20 different people hoping that some of these guys are right. Oh, these guys by all large cap growth or whatever. Like they’re hoping that some of these do well, the more you add to it, have one advisor had a 5% chance, what is 15 advisors gonna do? Like the the percentage goes down so much, it’s crazy. And then you’re overpaying because because they think they’re going to beat the market, they’re going to charge a ton of money, and that that is in the form of an expense ratio, which most people have no idea what they’re paying in that expense ratio. But that’s to keep the lights on at the mutual fund company but also pay their their analysts and their portfolio managers And water in the water cooler, pays everything right? It’s all wrapped in. But because they think that they’re providing more value, they charge a lot more money. And it’s anywhere from one I think the industry average like one and a half percent at that point. So if you’re paying your advisor 1% to manage your money, and you’re paying someone else one or one and a half percent to beat the market, you have to add a real basis basically make two and a half percent to just break even. And that is mind blowing to me.
I guess if if they were passively just picking stocks and then holding that and you and you bought, say half the market instead of the whole market, then there’s a 50% chance that you’re going to beat the market and official percent chance that you wouldn’t buy Sure. Active active management that really buying at the wrong time and selling at the wrong time. Because there’s no way to predict right, which is your whole argument. There’s no way to predict when the right time is without insider trading information. It’s illegal. There’s no way to Know when to do that. So the active portion of it is really the self defeating portion.
Yeah. And then how do you decide like when you have new money, right, you work right now you make money every month, you got to put money in into the markets every month you’re doing it likely in your retirement account, if you’re not doing it elsewhere. How do you know when to buy what to buy and what to do without trying to time the market? So if you dollar cost averaging, which just means you’re buying the same amount, or close to the same amount every month, how then in your case, if you picked half the stocks out there, and you were trying to buy that, like, how would you pick? Well, I got to pick this one versus that one. And keep in mind, like it’s $8 or $10 to trade every time. Like that gets really expensive if you’re putting thousand bucks in and you’ve got to buy a ton of these, which is why these ETFs came out and with passive investing, you can buy, let’s say the total stock market 3600 Let’s use Vanguard everyone pretty much knows Vanguard, you know, their total stock market. They’re charging like point 05 percent in an expense ratio. So when I said that the other ones that are trying to beat the market are charging 1.5% and you’ve got Vanguard at point oh 4.03. That’s a ridiculous savings like 99% cheaper, but you buy that one fund, and now you own 3600. So there’s no trading costs of trying to figure it out. And if you’re not a custodian, let’s say TD Ameritrade that doesn’t allow you to trade Vanguard for free, seven bucks, but or you could just choose like State Street or I shares and those are on the ETF for the no transaction fee list, and then it’s free. It’s free to trade. So now you’re, you’re investing in 3600 you know, stocks, and you know, it’s free to trade inside it and you’re paying point oh 4% it’s pretty hard to ignore what the other side’s doing when you have to pay that much money for them to do it. So I probably should say like, really quick like disclaimer like, I I’m not telling you to go buy this. This is like we’re just talking hypothetical general in nature like, this is not suitable for everyone to put all your money into this. I’m not saying that. Just want to make sure like we’re very clear
the disclosure will be at the end of the episode, or the not the disclosure. The disclaimer will be at the end of the episode. So full disclosure about my my background, my financial situation, we actually have some money with a company that has a fee based on assets under management. And they are actively trading. And we have meetings with them. And they were referred to us by a family member who’s in the financial industry. Right? So seemingly, they know that these people do well and have done well, that we have these meetings they get we get these quarterly reports. They show us all the research that they’re doing. And what you’re telling me is that that is all like why would they Why would they do this? Like why Would these people do this for a living? And really, research shows that that passive investment is the way to go?
Well, I mean, some people just think that they’re part of that 5%, or that 3%, or whatever that number ends up being that they can beat the market. And maybe they can, and maybe you picked the best advisor out there, that does all this research and knows what’s going on. And it happens to be in that 3% that over the next 15 years, they’re gonna beat the market, and hands down and you’re gonna make more money, great, like awesome, you chose correctly. Or we look at it as Do you think you chose in that, let’s say 3%, or in that 97%, that can’t beat the market and you were better off not paying all those expensive fees, and going to them because likely, you’re probably only getting Investment Management help. Maybe I’m wrong, but either way doesn’t matter. And now you’ve saved that you can actually turn around and invest more of that money and you’re writing that now. 97% you’re gonna know like, Hey, I’m gonna beat 95 97% of the other funds out there for very little effort. It’s pretty much no brainer to me in terms of that. And, I mean, again, much smarter people than myself. I’ve written Nobel Prize winning research around it.
All right. I’m gonna let that sink in for a little bit. So, yeah, I just know. And I know so many people that do things the way that I do, right, like, well, how did you find your financial advisor? Well, he’s my dad’s financial advisor, and he seems like a totally nice guy. And he took me out for dinner, and he seems really knowledgeable, and he’s been doing really well with my dad’s money. So I’ve just realized that everything that just came out of my mouth was extremely sexist because everyone in that interaction was male. But that aside, I just know so many people that find their and keep their financial advisors That way and it sounds like you’re
saying what are what are the one that I got hold up. It was good for Dr. Barnes It was good enough for me. Exactly. Well, I qualification that blows my mind. But hey, I mean, he could be there your she could be your great adviser and be able to help you walk through cash flow and budgeting and other investments and your insurances and your employer benefits and just the behavioral side of money, they could be doing all these great things to earn that fee and more. And maybe they’re awesome and can pick stocks on top of it. But the likelihood the probability of that happening is low.
I would imagine that those 3% or 5%, that do beat the market, because your example was Warren Buffett. Warren Buffett doesn’t just buy stock, I’m pretty sure he buys stock in a company that he then takes over and actively manage this. So he’s not actively managing when the you know what stocks to buy in. and sell and when he’s actively managing the company in the stock that he bought, or at least, or at least, has significant influence in, in things like that. So
is a lot more communication with people in a lot higher powers than any of us listening or talking to. Right I mean, he’s, he’s been around a long time, not calling him old but he is old. And he knows the ways and he he moves billions of dollars around to acquire companies that he thinks he can add value to, in some way shape or form, that he can add value to those or that have a significant moat around them. Coca Cola everyone knows what a you know, a soda is a Coke is most people call it Coke, even if they’re drinking Pepsi. It’s kind of ridiculous, right? So he invests in high quality companies like that, that either have that value or he can provide that value. None of us are putting a billion dollars into anything when we’re investing 500 or 1000 or to thousand dollars at a time. It’s very, very different.
So you mentioned that there are other services that a financial advisor should be providing or can be providing. At that one company, they, you know, they’ve advised us on matters but we really don’t come to them with you know, I, you know, we, my wife and I make most of the financial or make all the financial decisions, they just happen to have a bit of our money that they’re managing. Okay, so what else should we be asking them or what are put another way? What else? Would a financial advisor provide? What other services? Yeah,
well, one, I mean, just to recap on this, you should know what you’re paying them. I’m not saying you I’m just saying anyone listening you should know what you pay your advisor and be able to look at and go Am I getting the value out of this relationship? Yes or no. Your advisor should be looking at your whole financial picture. Whole it like very holistically I mean, literally all the way down to like your car insurance. Have they looked in analyzed? are you protecting your income completely through disability through term insurance, they’re selling you whole life insurance, you need to just part with that advisor go find someone else, because they’re taking you to the cleaners. That type of policy is like, good for 2% or less of the population, that it’s sold to the other 98% who shouldn’t be buying it, unfortunately. But we should be looking at, like I said, your employer benefits, they should be able to tell you like, Hey, this is how much is you know, using your 401k? This is how you should be managing the 401k. But also like, what are your other benefits? Oh, you have long term disability of short term disability, like, Hey, you should be taking some of the term coverage because it’s a half a million bucks, and it only cost you $4 a paycheck. Hey, make sure you’re taking the legal services because you should be getting estate planning done. But you don’t know what that is, oh, well, how about this come in, and we’ll act as like a pair of planner or paralegal. And we’re going to ask you all the questions you need to know in order to go and make the best decision and optimize your time with a true estate planning attorney. And having that discussion with you. You should be understanding all of your insurances, and honestly not being sold by that person, what the insurances are, but they should be doing a full review of everything, making sure that you have it, making sure you have umbrella coverage, as your car insurance adequate and up to speed. Most residents, they’re just trying to get by and it’s survival. totally get it. My wife and I were there. It’s literally survival. But when you finish and you’re you know, making like what you really should be worth honestly, you’ve most times forget to actually increase your auto coverage. And if you got umbrella, they’re gonna force you to get something. But usually it’s not enough. Are you doing cash flow planning the first five, maybe 10 years out of your training, investment returns don’t matter as much. And I’m going to say that because you don’t have a lot of money to invest. So make sure that you understand where your money’s going, how is it coming in and how’s it going out and I did a show The dreaded B word, and that’s for budgeting. And most people don’t like budgeting and I think traditional budgeting just doesn’t account for like life’s goals and what you’re trying to accomplish. But you need to know from, let’s say, a cash flow planning standpoint, which is like today, looking forward, what do you think you’re going to spend? it you need to know those things. And your advisors should be right there helping you. We do monthly cash flow reporting, like literally every month, we send clients, a report that we’ve hand built that says, here’s what you thought you we thought you’d spend, here’s what you actually spent and here’s what you saved. And did you save enough? Yes or no? Yes. Cool. We already know where we’re putting it. No. How would you make some changes next month to make sure you get back on track? If you’re not having those conversations with the advisor? Something’s wrong. They’re not really advising. They’re just a money manager, pretending to be an advisor.
How does one go about finding is there like a list of all of you guys somewhere is there
They’re a club you all hang out at where we can meet you like, how do we because you’re really your industry is very based on sales, right? Like that’s, that’s what you were getting out earlier is that, like, the entire financial industry is based on selling the concept that this is all very opaque, and they can actively manage your money better than the market. So they’re selling that concept. They’re selling a black box to you saying I’m smarter than you in this, which by the way is totally fine. You’re in, you’re an expert, you know, you’re, you’re an EMT Doc, right, you’re you’re an expert in your field. You’re not supposed to be an expert in mind. But my industry throws it in your face and says, You don’t know what we do. We’re not going to tell you what we do, but we’re going to charge you a bunch of money just to do this one little thing. So it comes down honestly,
but you’ve been doing an excellent job selling. Wi Fi only is the way to go. So how how do I find someone? It’s tough. I mean, it really is tough.
I was looking for like a website or something,
right? Generally we all have websites, right? But you’ve got to look at it. As you know, there’s 100,000 planners out there and less than 3%. So there’s less than 3000 planners out there that are fee only. And then out of those, most of them specialize in something, right? Like I only work with physicians, I don’t work with dentists or attorneys or anything like I only work with physicians, and I happen to be married to one. That’s what I do. If I if you were an attorney that came to me I go find your referral through maybe a, you know, just a connection or community or something that maybe I have like the the FPA NAPFA, xy planning network. There’s a couple like big networks that we can all belong and become members of, but those are still not, I mean, those are great places to start. But then once you find a fee only person, like find someone that deals in your situation. all day every day, I don’t want to go to an EMT doc when my stomach hurts, like, that’s not the right thing. So like, why would I go to a planner who specializes in working with everybody when there’s someone out there that as an attorney, I want to go to the person who knows in and out what I do all day every day, and sees my situation for 10 hours
a day. And just so our listeners know, if you do type into Google fee only financial planner for physicians, that top listing is the white coat investor, who is an emergency department physician and not a financial adviser. The third one is Ryan in the gentlemen we’re speaking to right now. So if you aren’t going to use Google to find your fee, only financial advisor, you’ll end up with this guy right here. So it seems like Google for this particular question is spot on.
Yeah, I mean, they they know what people search for. They know what people need, and when you put something in, hopefully you’re getting a good results. So happy to know I come up in that. But yeah, I just I would go to someone who literally specializes in what you do all day every day. And to find someone, I feel like sometimes like a unicorn, because I’m not targeting physicians because I think they’re wealthy. Honestly, they’re not. Most of them are income statement rich and balance sheet poor. And that’s why I’ve advised on like four times as much student debt, as I have in manage my money that I manage, just happens that way, you know, in back to the advisor, what they should be doing, they should know a whole lot more about student debt than you do. Even though you took out the loans and all the paperwork like they should know, the ins and outs of all the repayment options and all the things that go with student debt.
And we had a couple shows ago was with the physician philosopher, and one of the things that he goes into is that we just touched the surface of the different repayments. And for and that’s, that’s very complicated. It’s very opaque. So, and that’s, you know, pay repayment of debt for physicians is such a huge issue. So if your financial advisor doesn’t know about the ins and outs of repayment options for physician loans, and then they either they learn about it, or you find someone who does,
yeah, we’re actually teaching them. One of my side projects is a company called loan buddy. And it’s software Actually, that’s targeted for advisors. And it allows them to understand and analyze their clients student debt, without really having to be a nerd at it. And so allows them to get all the information they need, plug it into my software, and then do it and I think we’re at, I don’t know, close to $200 million of debt analyzed on that platform already. So I’m helping advisors learn how to do this, like it’s that big of a problem. I hate student debt. I hate how hard it is. It’s, it’s I mean, it’s it’s very frustrating. Our average client is almost 300,000 in debt. Don’t care what the AMA puts out at 180,000 it’s wrong. Like everyone that we see is our average is literally it’s like 298 it’s it’s a lot of money. And it’s it’s frustrating. And I see people delaying getting married, delaying having kids. There’s, they feel horrible that they’re walking around with this amount of debt. I mean, it’s it’s sad. It’s frustrating like we were there. We were fortunate that my wife was able to essentially live at home, have in state tuition, did all the right stuff. And you know, we were able to squash her debt really fast. But, you know, we had a lot going for us. She had tons of scholarships for undergrad. Again, she lived at home, she took out the least amount of loans possible. Like we were fortunate that you know, when she finished, it was just under 180,000 in total, but not everyone’s that lucky.
It’s just usually what I tried to do in medical school, which is I tried to marry a doctor. That’s why I went to medical school. It just
didn’t work out for me. My wife and I actually met when we were 18. Like freshman year college, so I got in really early before anything better.
You know, man, I, I’m going to be married to a doctor and then then the debt hit you find out what it really what it really means.
It’s funny when when we were dating in college like her, her dad was pushing her to be a doctor, my wife’s extremely smart, like, perfect score on sh T and AC T, like, she’s brilliant. I’m totally cool saying it publicly, privately, whatever. Like, she’s way smarter than I am. But because dad wanted her to become a doctor, she was really pushing back and then all of a sudden, it was like, you know, I think I’m gonna become a doctor. I was like, Oh, it’s about time. Okay. She goes, don’t worry. It’s just four years of med school and three years of residency and I’m like, Wait, is that sounds like a lot? It sounds like a lot honey. Like you sure you want to do that? Because Yeah, yeah, let’s do it. Like, alright, I support you. And, and then it was, you know, as residency is starting to wind down. It’s like, by the way, I kind of want to do three more years of pediatric pulmonary like that fellowship. And I’m like, oh, Okay, let’s do it.
So this is never gonna
end. I’m like, Yeah, I mean, sometimes it felt that way. But, you know, that’s why when, when he came out, I mean, she only took like, 120 some thousand. But, you know, making those income driven repayments where it’s based on your actual income and poverty line and family size and all that, you know, we weren’t even covering the interest on it. So interest accrued, and it was not 180, about almost $180,000 when it was all said and done. And we opted to not go for public service, loan forgiveness and to just pay it down. But some options for people or Public Service Loan Forgiveness is the best. And some like us, it wasn’t, so we refinanced and paid it off.
So we’re running short on time right now. So I just wanted to give you the opportunity to give just one piece of advice. I mean, this has been chock full of great, great information and great advice, but when you take physicians on as clients, either they’ve never had a financial advisor Before where they’ve had a financial adviser that’s been giving them advice that you wouldn’t agree with. What’s just one common mistake that you see that you that you want all physicians to be aware of lifestyle inflation,
seriously, like, you delay gratification, we were there, I totally get it. Like you’re putting all these things off, you don’t make a ton of money, you finally are out, you’re finally making great money. And you’re like, well, I deserve this. And you go buy the Tesla in the big house. And you might forget that you have student debt that’s coming due. And you’re, you know, you’re off the income driven repayment plan. And maybe you need to whether you’re still going to be on the standard plan and going for PSLF or you refinance, whatever it is like that payments coming to you. We’ll have to calculate that out into your spending. But most time it’s while I’ve been waiting, I now need a new car. I’ve been driving the same car for 12 years and it barely works. And it’s a safety concern. Well, it makes sense, but you don’t need it necessarily in the Tesla The new Doctor $1.25 million home whatever it is, get a starter home, you deserve it. I agree. But don’t let your lifestyle inflate like crazy. And I look at it as give yourself a 50% raise. And if everyone just gave them a 50% raise, which by the way, anyone in the corporate world would freak out if they got a 50% raise. But if you just gave yourself a 50% raise, and then you actually saved the rest, whether that was to pay down debt aggressively, or to actually increase your savings or 401 Ks and IRAs and taxable accounts, whatever it may be in your situation or paying off consumer debt because you racked up some credit card debt while going around for interviews at the end. Like if you can do that, you will be on your way to financial success. Unfortunately, I see a lot of the opposite.
Where were you when I finished residency my two two of my best friends both orthopedic surgeons, both can be To me to give up my trans-am, which I loved. Yes, I was driving a trans-am awesome. And get an Infiniti coupe, which was totally not my style. And the worst part about it was I, I was living in Manhattan, commuting to Long Island and for you live in San Diego, so it’s not the same, I get it. But there is surfing on Long Island. And I couldn’t there are no surf racks for an infinity coupe. That was the worst part about it. And yes, I was spending a lot more money on a car that I then I needed to well, and then I had to find parking for it in living in Manhattan. So I needed I needed you cry, and I needed you. And you weren’t there.
I’m so sorry. I’m here now. I’m here. I’m here to help.
And I appreciate that. Well, Liz, this has been extremely informative. And you know, for all those people that have someone else managing their money right now, even if they’re trying to Do it themselves. This is you asked a lot of a lot of excellent questions. And it sounds like even one meeting with a financial advisor like you would be extraordinarily informative, and probably a huge wake up call for for the physicians out there. So really I appreciate you taking the time and letting us know all know what we should be doing with our first phone call tomorrow.
I appreciate it. Thanks so much for having me on.
That was Dr. Bradley Block at the physicians guide to doctoring. He can be found at physicians guide to doctoring comm or wherever you get your podcasts. If you have a question for previous guests or have an idea for a future episode, send a comment on the web page. Also, please be sure to leave a five star review on your preferred podcast platform. We’ll see you next time on the physicians guide to doctoring.
This interview should not be considered personalized financial advice and we will not be held liable for the use of any information contained within this interview. It is your responsibility to verify anything you’ve heard using other trusted and reputable resources.
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Wealthy Mom MD, Dr. Bonnie Koo, Discusses Female Physician Finance

Dr. Bonnie Koo, is a dermatologist and former systems administrator at Morgan Stanley. She is a graduate of Barnard College and Columbia University’s College of Physicians & Surgeons and completed her dermatology residency at UC Irvine. 

She created the website WealthyMomMD.com to fill the void of knowledge and resources specific to women physicians on how to take control of their finances. She directs the Women Physicians Personal Finance group on Facebook–the largest online community of women physicians mastering their finances.

We discuss some of the financial issues that are more common to female physicians, from prenuptial agreements, taking care of financial ill-prepared parents or other family members, the importance of having your financial house in order, outsourcing to buy more time, and why it is importance to secure disability insurance before you get pregnant.   

Find this and all episodes on your favorite podcast platform at PhysiciansGuidetoDoctoring.com

Please be sure to leave a five star review, a nice comment and SHARE!!!

 

 

Wealthy Mom MD, Dr. Bonnie Koo, Discusses Female Physician Finance

Dr. Bonnie Koo, is a dermatologist and former systems administrator at Morgan Stanley. She is a graduate of Barnard College and Columbia University’s College of Physicians & Surgeons and completed her dermatology residency at UC Irvine. 

She created the website WealthyMomMD.com to fill the void of knowledge and resources specific to women physicians on how to take control of their finances. She directs the Women Physicians Personal Finance group on Facebook–the largest online community of women physicians mastering their finances.

We discuss some of the financial issues that are more common to female physicians, from prenuptial agreements, taking care of financial ill-prepared parents or other family members, the importance of having your financial house in order, outsourcing to buy more time, and why it is importance to secure disability insurance before you get pregnant.   

Find this and all episodes on your favorite podcast platform at PhysiciansGuidetoDoctoring.com

Please be sure to leave a five star review, a nice comment and SHARE!!!