Month: November 2019

Overcoming Our Racial Biases to Better Serve Our Patients

Dr. Uché Blackstock is an emergency medicine physician who is passionate about addressing the detrimental effects of structural racism on health outcomes. We discuss the origins of structural racism and how this continues to influence the health outcomes of minorities. She then gives us some tools for reflecting on our own biases and how we can work to address them. In addition to patient care, we talk about improving the diversity of faculty, and the importance of mentorship and sponsorship. We end by discussing something each of us can start doing tomorrow in order to address our own biases.

Dr. Blackstock went to Harvard for both undergrad and medical school, did her emergency medicine residency at SUNY Downstate/ King’s County Hospital Center and then a fellowship in ultrasound at St. Luke’s Roosevelt.  She is now associate professor at NYU as well as the faculty director of recruitment, retention and inclusion at the office of diversity affairs at the medical school.  She recently started her company Advancing Health Equity, which aims to partner with healthcare organizations to address some of the critical factors that contribute to health inequity, through educational trainings and racial equity culture analytics.  She can be found at advancinghealthequity.com and on Twitter @dr_uche_bee.

The implicit bias test that she discussed can be found here: https://implicit.harvard.edu/implicit/takeatest.html

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

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Overcoming Our Racial Biases to Better Serve Our Patients

Dr. Uché Blackstock is an emergency medicine physician who is passionate about addressing the detrimental effects of structural racism on health outcomes. We discuss the origins of structural racism and how this continues to influence the health outcomes of minorities. She then gives us some tools for reflecting on our own biases and how we can work to address them. In addition to patient care, we talk about improving the diversity of faculty, and the importance of mentorship and sponsorship. We end by discussing something each of us can start doing tomorrow in order to address our own biases.

Dr. Blackstock went to Harvard for both undergrad and medical school, did her emergency medicine residency at SUNY Downstate/ King’s County Hospital Center and then a fellowship in ultrasound at St. Luke’s Roosevelt.  She is now associate professor at NYU as well as the faculty director of recruitment, retention and inclusion at the office of diversity affairs at the medical school.  She recently started her company Advancing Health Equity, which aims to partner with healthcare organizations to address some of the critical factors that contribute to health inequity, through educational trainings and racial equity culture analytics.  She can be found at advancinghealthequity.com and on Twitter @dr_uche_bee.

The implicit bias test that she discussed can be found here: https://implicit.harvard.edu/implicit/takeatest.html

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.

TJ Blackstock is an emergency medicine physician who’s passionate about addressing the detrimental effects of structural racism on health outcomes. We discussed the origins of structural racism, and how this continues to influence the health outcomes of minorities. She then gives us some tools for reflecting on our own biases, and how we can work to address them. In addition to patient care, we talked about improving the diversity of faculty and the importance of mentorship and sponsorship. We end by discussing something each of us can start doing tomorrow. In order to address our own biases. Dr. Blackstock went to Harvard for both undergrad and medical school did her emergency medicine residency training at SUNY Downstate Kings County, and then a fellowship and ultrasound at St. Luke’s Roosevelt. She’s now associate professor at NYU as well as the Faculty Director of recruitment, retention and inclusion in the Office of Diversity affairs at the medical school. She recently started her own company advancing health equity, which aims to partner with healthcare organizations to address some of the critical factors that contribute to health and equity through it Educational trainings in racial equity cultural analytics, she can be found at health advancing health equity calm and on Twitter at Dr. JB.
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.
Now, here’s Dr. Bradley Block.
Dr. ej Blackstock, thanks so much for being on the podcast today,
having me.
So you are the director of recruitment, retention and inclusion in the Office of Diversity affairs and the founder of advancing health equity. So how did this becomes such a passion of yours.
Oh, good question. So I mean, the issues that I deal with in my role as Faculty Director and officer diversity affairs issues have always been, you know, very important to me as a as a, you know, as a position of color. And I had the opportunity about two years ago to take on this role. And so some of the things that I have developed while I’ve been in the role is focusing on unconscious bias trainings as a way to help educate other physicians about unconscious biases that they have that may be influencing how they communicate and make decisions about patient care. And then I started doing this work and I really enjoyed it and I got a great reception and I started giving grand rounds at other academic institutions and then other health care organizations came calling and I decided to start my own company advancing health equity, because I felt like it was my way to help to contribute to this problem of healthcare disparities. By focusing on educating the healthcare work for, for us, right unconscious bias and structural racism.
So So let’s take a step back and talk about the the origins of the unconscious bias and structural racism, racism, right? In theory, we should all be treated equally, but we aren’t. So why is that? Like, how did this How did this all start? If you want to talk about America specifically?
Yeah, yeah, no, this is such a great question. I mean, you know, when we look at, like the health care disparities today, you know, we talk about we’re in the middle midst of a black maternal mortality crisis now, where black women have three to four times more complications around pregnancy as white women and we wonder why we’re in this situation, and a lot of it, you know, has to deal with actually legacy certain practices and policies that sort of encompass structural racism. So we talk about no slavery and Jim Crow and black codes that have really led to chronic generational poverty. That, you know, influences inequality, lack of access to care. And then even when the Civil Rights Act was passed in the 1960s, and black people were allowed to being taken care of in hospitals, there were still issues with receiving quality care. And then there are also issues of internalization of racism, like we know that there’s data that shows that there’s a weathering effect on people that actually can be passed down across generations. And so, these are some factors to why we arrived where we’ve arrived right now.
So Dr. Blackstock, can we take it back even a little further, like, let’s talk about even the foundations of racism because I think in order to understand the unconscious biases, it’s going to be important to understand the origin of all of this. So where did this all come from?
right and so you know, the foundation in order for, for slavery to to persist in order for there to be society. Where one group of human beings or another group of human beings, there had to be a narrative that those people that were more felt they were more superior held true. That was that black people were inferior. And so there were different ways that this was communicated, right. Like there was. There’s phonology where, and that phonology is something that originated in Germany, it’s now been debunked as pseudoscience. But it’s this idea that the bumps on the surfaces of a person’s skull correlate to certain personality characteristics. And so the bumps that slip that enslaved Africans had, were supposed to be correlated with the fact that they were tailorable or able to be tamed. So, so obviously, like there’s this idea that, you know, throughout slavery in order to justify slavery, this idea that black people are inferior, and that has obviously been perpetuated across generations across centuries. And it’s still really embedded in In our medical culture and within health care overall,
right, because everybody’s the hero of their own story. So in order for these slave owners to be able to sleep at night thinking that they were an upstanding and decent human being yet perpetrating these these horrible things, they need to be able to rationalize their actions and you rationalize these actions through the racism by thinking that, that these other people are inferior to you in these certain ways. And so, therefore, what you’re doing is, is justified, right Al Capone is the example that I that I use for this is he’s the hero of his own story. He was bringing entertainment to the masses. So that’s how he slept at night, even though he’s responsible for murdering countless people, right? you commit these horrific acts, but you’re still able to sleep at night because you find a way to rationalize it. And then that crept its way into the culture and has stuck around Yeah, trees later.
Yeah. And even also in the 1800s che Marion Sims, which many people know up as the the grandfather, the father of ob gyn obstetrics and gynecology because he’s the one who discovered the battle speculum. He’s the one who developed surgeries to fix vesicle vaginal fistulas. He actually performed all of these surgeries of these experimentations on women who were enslaved. And there was one slave who actually performed, I think, almost 20 to 30 surgeries on and at the time, I believe local anesthesia had not been created yet so are developed yet. And so these surgeries were obviously very, very painful. But in order to for him to do these surgeries on these women, there had to be this acknowledgment that they were not he did not consider them to be full human beings, right? Because otherwise how would you be able to justify doing that, although the discoveries ended up being leaving to really ground the ground, our ground for And, um, contributed greatly to medicine. They were performed on women who could not give consent to the procedure. Wow.
Wow. And I’m sure for a long time this individuals picture was up in a hall in a medical school. And
yeah, actually, there’s a statue of him in Central Park across the street from the New York Academy of Medicine. And it was taken down last year after multiple protests by people who just said, No, this is not right. And actually, it’s been moved to Greenwood Cemetery in Brooklyn, where not many people can see it.
Yeah. Yeah. Well, and to think you know, how far we’ve come and that was just a year ago.
Exactly, exactly.
Okay, so that’s, that’s the origins of it. And so how do we start addressing it so if I want to improve my ability to treat myself Patience, and yet want to be able to recognize not yet but not and yet, but I want to be able to recognize my own biases in order to improve my ability to do so. Hey, where do I start?
Right, I want to back up just a little bit and saying that I do think that our medical education system and our training system could do a better job in terms of preparing us. So I mean, I think probably like you, I really didn’t learn about any of this in medical school. I didn’t learn about the origins of racism or origins of racism in healthcare. And so I came to being a clinician almost very unprepared because I didn’t know about this history. So here we are, and what do we do now? You know, I think that people talk a lot about unconscious bias trainings, and even I provide unconscious bias trainings. I think that’s only part of it. So you can have the unconscious bias trainings where you take I have participants take the Implicit Association test, which is on the Harvard implicit website. And you can take a lot of different tests, often I have them take the race Implicit Association test. And that uncovers a lot of unconscious biases that people don’t know that they have. And often people are really shocked by their results.
Yes, I’m sure. I’m sure most of not all of us would be. So we’ll definitely include a link to that in the show notes. So, so we’ve taken the test, we recognize that we have these biases. So how do we say now that we’ve not not recognized that great, I’m a terrible person? How do I improve that?
Right? So not a terrible person. I like to see that we’re all like good ish people. We’re all works in progress. And so a lot of times when I run my sessions, I tell them, make sure you have a growth mindset, meaning that realize that with effort, time and feedback that you can get better at anything and so I say the same thing about unconscious bias. That you can actually help to mitigate your bias by using certain strategies. And really the major strategy that is often recommended is self reflection. And so you got you have your results and sort of thinking about when you say when you go to see a patient, like, Is there something about this patient that is reminding me of a person I know, like, Is it good or bad? So that’s kind of like a priming questions that you ask yourself, just to make sure that you’re not making assumptions about the patient. And so those are different strategies you can use there actually are more advanced strategies called like, one is called stereotype replacement, like replacing sort of the reaction that you have about a patient. So the assumption that you’re making like labeling it and saying, okay, that’s not right. Let’s replace this with a positive feeling. And let’s move forward. There’s another one called counter stereotype imaging, where you can replace the image of the person with a positive Have a positive image or like a positive stereotype, like people say, oh, like brock obama, you know, he’s like a positive image of a black man, right. But these are strategies that you have to use every day. Like they don’t just use them when you’re seeing your patients use them in all aspects of your life.
So I just want to take a step back to the whole, I’m a terrible person thing, because I think a lot of us are going to be reluctant to even want to take the test because I show things about ourselves that we would rather let what we would rather leave covered. And I think it’s important for people to recognize that the fact that you are taking the test means that you are not so even if you have the biases, the fact that you’re looking to improve on them. The fact that you have the means that you’re human actually we covered cognitive biases in in a podcast a few episodes ago with an evolutionary biologist named Nathan lense, who, who wrote a book on how imperfect human the human body really is. And you know, the biases are there. functionally, to help us simplify the world so we can actually process it. So this is just a function of being, being being human. what actually makes you a good person is the fact that you acknowledge that and you’re, you’re willing to work on it. So,
yeah, exactly. That’s what I tell people. I said, you know, we all have biases, right? Like, like, My children are biased towards me, if you put me and you next to each other and asked my kids, like, Who are you gonna run to? They’re gonna run to me, right? Because they are biased. And they I’m their mom, you know, I mean, so they’re, and that’s protected to them. That’s like, that’s for survival reasons. That’s like, that’s evolutionary. And I think also, it’s important for people just to realize that we do grew up we, you know, we do grew up in a society where there’s a lot of discrimination, and that sometimes it’s, it’s impossible not to sort of sort of read that in, you know, even if you don’t explicitly want to. And so I think just acknowledging that and saying, Okay, I see that I appreciate that. Now, I’m going to try to do better. It’s really important.
So can we can we go back to that example that used of of putting a positive image in our head? Like, like brock obama? Mm hmm. So can you give me a scenario in which I would use that?
Oh, for example, like, an example would be to say that you were on your way to a meeting, and you saw a black man in front of you. He had like a long trench coat on he was like carrying a lot of bags. But and and just for whatever reason, your immediate impression of him was you just kind of got a little bit tense. And then like five minutes later, he actually ends up going to the same meeting as you like, he’s actually in the meeting with you. And you had sort of made this assumption that this guy was actually a threat to you. And so what you would do is, we would rewind and so instead of that initial feeling of apprehension, you would say you would acknowledge that apprehensive feeling, label it and Say, you know, that’s me being bias, replace it with a positive feeling. Or think about Oh, I know, other black men that have positive images like brock obama or like Martin Luther King, you know what I mean? Like some think about that. And so that should engender more positive feelings. But again, it’s something that you have to do all the time.
So how do I if I if I’m with, say, a trainee medical student resident, how do I talk about something like that? Because I think especially as a white male physician, if I if Hi, if I walk into a room with a black male patient, and I say to my trainee, okay, when you’re addressing this individual if he makes you tense, think about brock obama. That sounds
Yeah, that sounds horrible. No, no, it’s not. So I mean, these are, these are strategies I would talk about in a training but the self reflection piece is the piece that I think is Not necessarily offensive. So it’s sort of a general conversation that you have with your trainees, it may not necessarily be specific to the patient, but just say that I want you to before you go see a patient, be really open minded. Try not to make assumptions about a patient. I know that in medicine, a lot of times that we’d like to categorize patients, right, we have a 50 year old person with cardiac risk factors coming in with chest pain, we think heart attack, right. So we, you know, we’re just used to this pattern recognition. By being sometimes it’s important, we take a step back, realize practice what we call a constructive uncertainty that we don’t have all the information at hand. Don’t make assumptions about your patient and try to go in with an open mind. So I think I think you can speak generally like that, and that will be fine. Got it
and it and it doesn’t necessarily just pertain to race, right? You’ve got anything, a white patient with torn clothes, missing teeth, lots of tattoos, right? You’re gonna you know, you’re gonna walk to the room and make a bunch of assumptions. If you have a train With you make sure that the first thing you do first is that you acknowledge, listen, you’re going to walk in the room, you’re going to see what the space looks like, you’re going to have some things that go through your head that some assumptions that you’re going to make, really to take a step back, reflect on those know that you don’t know the whole story. In fact, you don’t know any of the story. Right? And you need to you need to build from from there.
Exactly. Okay. Okay. And a lot of times, you know, I see my trainings, a lot of times why sometimes I will, I will emphasize race is because just because of the healthcare disparities that we have in the country are mostly the health outcomes are along racial lines, like the most profound disparities that we have in the country are not along gender or sex, sexual orientation, but they are along racial lines. And so that’s why I do tend to emphasize that more in my trainings, but yes, you can be biased about a lot of different aspects of a person down to their accent, right, or how they’re dressed right or whether their clothing looks clean or not. Yeah,
So that’s for the physician seeing patients, but but you also do this for recruitment. Right? That’s how you’re the director of recruitment, retention inclusion in the diversity affairs. Wait. So let’s take us through the three steps. How do you recruit, retain and include?
Well, so so you know, in even thinking about unconscious bias, and all of those different areas. So even like in in terms of recruitment, sort of thinking about like, what kind of language we use for ads that we put in, you know, magazines, or journals, or websites, make sure that we’re not being exclusive of certain types of people. And so of course, we all have blind spots. So we want to make sure that we’re as inclusive as possible in the language that we use. And even in interviewing processes, you want to make sure that you use structured evaluation tools. So you always want to ask everyone the same question because we know that the same questions because we know that off the cuff interviews, like where you’re like, hey, Oh, I’m sorry. New York Oh, you’re familiar. Oh, cool. And you just sort of start talking about being from New York and you end up feeling like you’re developing rapport between this person, and you think this person is great, you get like Halo bias, like this person will be great for the job, when 30 minutes later, you really don’t know much about their skills, you all you know, is that you get along really well. And so we know that that actually, that’s a situation where unconscious bias could actually really flourish. And those off the cuff interviews, so you always want to use structured evaluation tools or structured processes in the recruitment process.
So aside from trying to standardize the recruitment process, that how does that help you to recruit more, once you got to the interview, but what about even pre interview? How do you go by recruiting a more diverse medical staff?
No, no? Yeah. No, great, great, great question. And that’s the challenge because you know, only 4% of physicians are black. I think another 5% are Latino No. So the numbers are already quite quite, quite small. And so we really have to be intentional about our efforts, we will go to certain professional organizations, so like the National Medical Association, which is the largest organization of black doctors, so we’ll try to focus our efforts, they’re the same for predominantly Latino organizations as well. And so we’re go to different affinity groups, or actually talk to faculty of color that we have and find out what they have any people that they can recommend for positions, but I will say that the recruitment part is really a challenging piece because the numbers are ready are very small. And New York is a high cost of living, you know, as you know, city to live in and so you have to really incentivize the offer to people.
Okay, so now you recruit you found them, you interviewed them, you’ve hired them. The next step is retain Yes, recruiter to include, so How do you retain? How do you retain?
Yes, stuff? So yes, so I think the retaining and the inclusion piece are become hand in hand because you need an inclusive environment in order to retain people. So you need an environment where the faculty aren’t just surviving, but they’re thriving. So where they’re feeling like their voices are heard and appreciated, you know, their unique issues, that issues that are unique to them that they feel like they’re being addressed. But I think importantly, and we see this even among women faculty that you know, mentoring efforts are very important because we know that with mentoring, if people have mentoring, that’s a huge key to success and promotion. And so having focused mentoring programs or, you know, assigning junior faculty, a mentor in the senior faculty that often helps. Sponsorship is important. So making sure that institutional leadership is aware of opportunities for faculty of color They may be interested in if there’s a position that opens, make sure that you are considering, you know, a diverse group of possibilities for that position. And so mentorship and sponsorship, we know are key to retaining and promoting not just faculty of color, but all faculty, we know that faculty of color definitely do have special needs that need to be addressed as well.
So does the mentor and Does the sponsor need to look like that?
That’s such a great question. Because sometimes the numbers are so small, but that necessarily cannot happen. But I also often tell people that, you know, your mentor does not have to look like you, but they, but they do care about you as a person. And they do care about the issues that affect you. And so there’s some literature about mentoring across differences. And so there, there are resources that are out there, if there is a mentor of a different race than them a junior faculty member and just sort of kind of being attuned to the specific issues that may come out of that mentoring relationship. So, for example, for me, perhaps my mentors with nothing, nothing like me, but they’ve been incredibly supportive along the way since I’ve been at NYU, and I, and I credit them with a lot of my success.
I would think that if you were to assign a mentor to a minority, trainee or faculty member, that would lead to siloing. Right? Like, if you’re like, well, you look like this person, so you should be their mentor. Oh, and, you know, then they end up like doing your fellowship, because you’re their mentor, and now, like, you’ve got one department that’s filled with one race, and then another department like,
That hasn’t happened. They’re not they’re not in the faculty of color. So that, you know, that hasn’t happened. And then also, I mean, these are people like on both sides, that the mentors are people that are interested in helping, they’re all all different departments. And I mean, because what you’ve seen is that actually what does happen? often is that minority faculty often don’t have mentorship. So that’s what a lot of the literature has shown. And so targeted mentoring efforts have been shown to be really, really helpful to promotion and success.
So are you saying if there is someone that can mentor this individual that does look like them, you should try to match them? Yes. And if not, you’re not available then then someone else plays is fine. Yeah. Or do you think you know, diversifying their mentors would be more advantageous?
No. I mean, I think that if there are enough people to mentor one person, that’s great. But often that’s not the case. Okay. Yeah, unfortunately.
Okay. So you should try and someone that that’s able to understand their experience more is going to be able to be more effective men. Yeah. Okay. So, okay. Is there any advice that you give to your minority trainees that you think that it’s either not necessary that may not be necessary to give to Non minority training. Yeah,
I mean, yeah, I mean, I think, you know, I talked to a lot of our medical students and our residents, I think, I think often they feel very isolated because their numbers are small. And sometimes they feel like the certain experiences that they have, like maybe dealing with microaggressions you know, I had actually a student who came to me like very, very upset after she was on rounds with her team. And a patient like, singled her out and basically was asking her if she had enough education, or should she if she had a good education to be at that medical school, like, you know, were grades good enough, you know, and, and no one said anything No, and her team her attending didn’t say anything. Her clear coat her co students didn’t say anything. And so she came to me and I just, you know, I felt horrible, but I, I told her, you know, these things like this are going to happen if you try to speak up when when you can, but I also want them to know that in the Office of Diversity affairs, I think we are a resource for them. And that’s my way they’re like, where they’re at To help support them, especially when these sort of situations happen, and we were actually able to talk to the attending and the situation. And he didn’t realize like, it totally went over his head, he didn’t even realize that this interaction was so painful and traumatic to the student. And so I basically tell the students that, you know, we’re here to support you, you’re going to have these experiences, and some of them are going to be very, very unpleasant and we affirm, you know, we affirm those concerns, but we’re also there to support them.
Right? Because Because imposter syndrome, right, that’s much more prevalent in women that’s much more present prevalent in minorities and that’s because of everything we’ve been talking about today. And so then you have some someone calling them out and physically vocalizing their imposter syndrome. And if someone’s there, that doesn’t have imposter syndrome, right? Because it’s much less common in white males right? Then they’re not going to understand that that’s even a problem like of course your your your grades were good. You deserve to be here. While up, they don’t know what’s going on in that individuals head. I guess that kind of makes your point about trying to pair minority faculty with married trainees for mentorship and sponsorship because they, they get it more I know.
Yeah, exactly. Okay.
So, one thing I like to cover is is brass tacks, advice for physicians, right? Okay, something that we can anything given doctor can start doing tomorrow, like, put on a sticky note and leave next to my computer so that every time I go to my computer, I look at it, I remember to do it, and hopefully it becomes habit. So what should I write on that sticky note so I can start doing better with regards to my, my biases?
Oh, it’s here biases. Okay.
Anything else that we’ve talked today about whether it’s trying to recruit, retain, retain and include, you know,
any anything over today? Yeah. So so there’s this idea that I would write to two notes, two words of a sticky note, structural competency and when That is, is the kind of this idea, but it’s actually been in development for over the last 10 years with this idea of structures and systems sort of influencing the health of communities, right, and the health of patients. And so, there’s this idea that, you know, we always talk about cultural competency, like, as if a physician could actually become competent in someone else’s culture. But more importantly, it’s understanding how systems like you know, like structural racism can impact a patient’s health. And so when you’re seeing a patient, you want to think in the larger conscious, the larger context of society right, in terms of how they ended up in front of you with the issues that they’re having. So I would ask opposition’s really to think broadly, about how um, practices and policies have influenced your patient’s health status.
That sounds complete anathema to that recent article that came out in the Wall Street Journal, about how we need to hire What does it call me by my pronoun or something like that? Which is just the lead in? Yeah, it was. It was just it was very disappointing. And effectively, what it comes down to I think what that what it was Stanley gold for progressive. Yeah, Pennsylvania. Yeah, what was trying to say was that these these issues should not be at the detriment to learning the sciences. But I think one thing that I try to make my podcast all about is everything we should have been learning while we were trying to learn the Krebs cycle.
Exactly. We need
to learn the Krebs cycle because I know the fact that I now no longer remember where Fumarate and maleate are in the Krebs cycle aren’t going to help me to treat my patients. Yeah, but acknowledging that there are structural systemic issues that that occur outside my office that led this patient to be now in front of me. Yeah, are gonna help me to become a better doctor. Exactly, exactly. I didn’t Put that in the questions. I apologize because that that article isn’t out yet. But I’m wondering what what were your without making your head explode? Right, because I’m sure I’m sure you wanted. I wanted to break something after reading that, but what what were your thoughts on that article? Yeah.
I mean, my, my immediate thought was that okay, well, that perspective is how we’ve gotten ourselves into a situation where we are, like the of all industrialized countries, we have the highest rates of health disparities and health inequities. It’s because of that idea that we’re always what’s the focus on the clinical aspect and not thinking about the broader structures and systems and so I think we can do better. I disagree wholeheartedly with the premise of that article. And I think a lot of a lot of physicians who want to do good work, I think they disagree as well.
I would agree. I would agree. I think I think all my listeners if you’re listening to this right now, and you’re trying to improve Prove your ability to interact with your patients. Clearly you think that that is, yeah, that is more important than memorizing some of the basic science that
Yeah, never end up applying. Because Because when we look at like, which interventions make the biggest impact and health outcomes, actually what we do as physicians, like the clinical interventions we make, we make the smallest impact, what makes the biggest impact on health outcomes are so sick anomic factors like poverty, education, housing and inequality. And so that’s why we as physicians need to be aware of those issues and to be educated about them as well. And humbled by them.
Yep. There’s, there’s and I could see how you’re right. You’re in the emergency department. I could see how that could be extremely frustrating, right? Because you’re treating the malady that you’re seeing in front of you, right, but, but you can’t improve the person’s housing situation Exactly. Right. You can’t help them find healthy food, you can’t help them to afford their medications regularly, which is why they keep ending up back In the Er,
yes, exactly.
Okay, well, let’s let’s go back to what we were talking to earlier. Is there anything that cringe worthy that you see doctors doing that you just want to throttle them and say, Stop doing that, right? What’s something that that that you see? Maybe regularly maybe not that you would want to just take someone sit them down and say, Stop doing that?
Oh, not related to bias, right? You’d be in general right
would be in general. Or, or you know, either way,
you know, I think for me, because I am, I’m in emergency medicine. I think often what I see is physicians, like not really listening to patients. And so, I know it sounds so simple, but a lot of times I will try to just sit down on the stretcher with the patient. At least look them idi and try to try to really listen to them because I feel like a lot of people come to the emergency department and a good number actually ended up being okay but they come for free. assurance. And the thing sometimes we don’t realize that because we’re in a rush. And so I think just sitting down with them for a few minutes, and really listening to them can do a lot of good.
Right? That empathy that that empathic listening in and of itself is, is therapeutic. Yeah. Because if they came in for insurance and they feel like you weren’t listening to them, they’re not reassured. Right? Exactly. Okay. Same question, but now related to bias. So anything cringe worthy that you see doctors doing really?
Yeah, I mean, like, in the emergency department a lot. And I see people saying, Oh, yeah, I got it, you know, this patient with sickle cell disease, or, oh, here is all I got a domiciled homeless guy over there. I’m like, we’re just like really quick to put patients in categories. And I think because our brains are kind of lazy, and we like to do that in order to conserve energy. But sometimes I just tell them like, hey, just, I know you feel like you’ve seen this patient before, but you haven’t seen this one before. Even though they may seem similar to you, just take your time and go over there and just talk to them without making the assumption. So, practice that constructive uncertainty that you need to do so that you’re not making assumptions about information that you don’t know.
Excellent. Yeah, I think that’s that that’s, that’s very helpful. But But when we’re we are, you know, if you have a resident that’s that’s presenting to you, how does the presentation differ? If they’re doing that, right, at least like the first line of the presentation? How would How would you see that change?
Well, that’d be like, Oh, yeah. So I got this this guy, you know, this little call, like, oh, a stickler instead of seeing a patient and a patient with sickle cell disease, you
know, like, they’ll
just, and so that kind of signal to me that they are just sort of,
it’s flippant, exactly. Flipping gas.
Yeah. And we know that a lot of these patients actually ended up being very sick. But because you’re like, Oh, yeah, I’m just gonna give them some pain medication. That Hopefully, they’ll go, then you end up actually missing something very serious on them.
So I actually did an interview a while ago with with Stephanie SOG, who’s a PhD in the weight Center at Harvard. And we just talked about obesity. And one thing that she said was referring the pain refer to the patient as having obesity, not as the obese patient, the patient with obesity, actually, she talks about not using the word obesity. But yeah, that her whole idea was that language matters. Yes, because language shapes our thoughts, sometimes in the direction that we don’t think it’s not just thoughts that shape our language, but language that shapes our thoughts. And if you change the way that you’re speaking about patients that can actually be infectious and affect others. So you know, so So use that goes back to the modeling that we were talking about earlier. So if you start saying this is a, you know, 24 year old male with sickle cell anemia, that right then becomes infectious. There. Hopefully the residents We’ll start thinking of the patient’s different talking about the patients differently and then, right and that improves everybody’s outcomes. Yeah. Yeah. So So tell us about I think that’s a good segue. Tell us about advancing health equity, your business venture.
Yeah. So financing health equity actually formed the company earlier this year, I never thought I would be an entrepreneur, especially going into medicine. It definitely wasn’t something I had considered that as I may have mentioned, before, I started getting these unconscious bias trainings and getting really great reception that I started being asked to get them outside of outside of the organization. And then I realized, okay, I need to take this show on the road, I should start my own business. And so I’ve been working with public health organizations, large position groups and doing trainings around unconscious bias, inclusive leadership, structural racism, and health care developing an analytic tool to assess race equity in the culture of organizations. And so this is my my small contribution to helping to To address health disparities by making sure that we have a workforce that is trained to take care of a diverse patient population, and to make sure that we have work environments and workplaces where a diverse workforce can can thrive.
So if people are interested in learning more about it finding you online, how do they find you?
You can go to my website www advancing health equity. com.
Any final thoughts for our listeners on either advancing health equity or recruiting, retaining and including people and I just, I read this on Twitter. I think it was fod foreign, other different someone who has foreign other different organization?
Yeah, you know, I think I just want everyone to remember especially if people who are in the health care professions realize that we have a huge impact even in personal interpersonal interactions with our patients on their health outcomes. And so we should really be thinking about the biases that we’re bringing to that encounter. But also about the systems and structures around that patient and, and where that patient lives and where they work that are also influencing their health status. And so I think if we realize both those things that we can actually provide better care to our patients.
Fantastic. Well, you are extremely busy between your family, your practice and this new business. And I wish you the best of luck with advancing health equity. So thank you so much for taking the time to talk to me today.
Oh, thank you so much for having me.
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 webpage. 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

Rheumatology Made Ridiculously Simple

Adam Brown, MD, is a rheumatologist at Cleveland Clinic and the host of the Rheuminations podcast. For the med students out there, we discuss why someone would choose rheumatology and why they are frequently the smartest doctors in the hospital. We discuss the basics of arthritis, how to interpret an ANA and why we shouldn’t be so laser-focused on our own organ systems if a patient isn’t improving as expected. We also discuss why gout is such an underappreciated phenomenon.

Dr. Brown went to med school at the University of New Mexico and then did residency Georgetown in Internal Medicine. He then did fellowships in rheumatology and vasculitis, both at Cleveland Clinic, where he currently practices. He authored Rheumatology Made Ridiculously Simple, a herculean feat for such a complex specialty.

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!!!

Rheumatology Made Ridiculously Simple

Adam Brown, MD, is a rheumatologist at Cleveland Clinic and the host of the Rheuminations podcast. For the med students out there, we discuss why someone would choose rheumatology and why they are frequently the smartest doctors in the hospital. We discuss the basics of arthritis, how to interpret an ANA and why we shouldn’t be so laser-focused on our own organ systems if a patient isn’t improving as expected. We also discuss why gout is such an underappreciated phenomenon.

Dr. Brown went to med school at the University of New Mexico and then did residency Georgetown in Internal Medicine. He then did fellowships in rheumatology and vasculitis, both at Cleveland Clinic, where he currently practices. He authored Rheumatology Made Ridiculously Simple, a herculean feat for such a complex specialty.

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.

Adam Brown is rheumatologist at the Cleveland Clinic and the host of the ruminations podcast. On today’s episode, we discuss why someone would want to go into rheumatology and why they’re usually the smartest doctors in the hospital. My words, not his. We discuss the basics of inflammatory arthritis, how to interpret an abnormal ama, and why we shouldn’t be so laser focused on our own organ systems. If the patient isn’t improving as expected, then why rheumatologic conditions should be considered. We also talk about why gout is such an under appreciated phenomenon. Dr. Brown went to med school at the University of New Mexico and then did his residency at Georgetown in internal medicine, where we overlap for a year. He then did a fellowship in Rheumatology and a second fellowship in vasculitis, both of the Cleveland Clinic where he stayed on as an attending. He’s also the author of the book rheumatology made ridiculously simple making him the perfect person to explain rheumatology on this podcast. He has a way of making complex and esoteric conditions easy to understand and even funny and I You’ll enjoy our conversation.
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 Krebs 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.
Adam Brown, thanks so much for being on the podcast.
Thank you. I’m very excited to be here.
So why what made you decide to go into rheumatology?
Yeah, so it is kind of a strange field and in my opinion, I don’t think people get they don’t get like exposed to it early enough. I for one did not either like I didn’t really hear much about it through medical school. And then I just happened upon a rotation in my second year residency actually, and prior to that, I was gung ho, I was into cardiology. And then I happened to do this rotation. And I found out this specialty is one of the only specialty that I saw that actually kind of expands instead of like narrows. And because still, all these diseases are multi systemic, so you’re still dealing with the lungs, you’re still dealing with the kidneys, you’re dealing with the heart, you’re dealing with the brain in Rheumatology, and I thought I liked that a lot. Because what kind of drove me into internal medicine in the first place is kind of the diagnostic aspect of it. He’s like, putting the puzzle pieces together, which a lot of internal medicine doctors do. And I thought rheumatology really kind of set up really well and and kind of all you do, pretty much it’s like, exactly, cuz
once you arrive at the diagnosis, you’re just gonna give everyone steroids anyway.
That is somewhat correct. Yes. Let me let me let me expand on that. So what one of the tricky parts is, how do you get them off the steroids, right. So that’s like, we have these these lists look at like vasculitis for instance. That is 100% fatal, it’s not treated. And even back in the days when we had first got to steroids in the late 40s and early 50s, the disease was still fatal. So steroids is not actually completely take over. You can use it forever. These patients still died.
I wasn’t planning on plugging your podcast until the end. But you had an excellent episode on the history of steroids. So yeah, we’re on the topic of steroids. Listen, to listen to listen to ruminations episode on the history of steroids. Just
really, really interesting history and involve lots of different things, including the government and the military. And yeah, and like how much of a game changer was steroids came now it’s pretty exciting. But we learned pretty quickly if steroids was not the answer, it kind of gave us an idea that inflammation was a major player in these conditions and we’re able to stop the inflammation rapidly, but it’s not the long term solution. So yes, you’re right. So we give the gifts there was quite a bit and they work rapidly and The drugs do not work as rapidly to like, but to get them off steroids is kind of the trick. And now we have a whole lot of options. Let’s answer your question further. Why wouldn’t rheumatology is that we have like a new, really amazing drug like out every year, like every year, we have something else to use on people and like conditions like rheumatoid arthritis, which were previously completely debilitating. People couldn’t use their hands, they couldn’t pick up things that couldn’t eat, because their hands was in so much pain. And you got such severe deformities. And now we have now if I go to someone’s room first Oh, great, here’s this. Here’s these medications you’re gonna feel great and there’s just like this amazing turnaround and not that long of a time. Once we started understanding the immune system better so it’s like it’s this cuz feel that has really nebulous diagnosis that people kind of consider a kind of like a black box like I don’t know what to do this and I don’t know what to do this anchor, send them to rheumatology. It’s you know, it’s it’s like kind of blackbox medicine that most people don’t really know what to do with this. It’s a synonym for rheumatologists. There’s also a multi systemic, so we’re dealing with the brain, we’re dealing with lung, and kidneys. And we’re working with a whole bunch of different specialists and EMT as yourself, we work with all the time. And so it’s kind of like putting the puzzle pieces together, I think in degree, rheumatology and, and now we have this much better understanding of the immune system. So we’re able to like take advantage of that and use these very targeted therapies that are kind of like a knife, but it’s like take away one aspect of this cascade that stops inflammation, hopefully, with much less side effects and the medications of your as they say, one of the
one of the questions that I like asking my guests whenever I have a specialist on is, for example, if I’m going to be having a dermatologist on in a couple of weeks, I would say what should every radiologists know about dermatology? Right? Because how much would a radiologist really need to know in their practice about doctors? They’re not bad. I would imagine they’re not getting many scans. But I thought for rheumatology, you don’t really have that. There’s everybody Every specialty out there needs to know. A good rheumatologist to send their patients to because it really touches every organ system.
Yeah, you’re absolutely right. Yeah, literally I can’t think of a specialty that I don’t interact with at all just because I just, I just I was gonna say trending. Maybe geriatrician, but I just spoke with a geriatrician last week about a patient. So you’re right, no, you’re absolutely right. We sit down with pathologists, and sit down with neurologists sit down with neuro radiologists, sound DMT, sit down the pulmonary, your toe touch on everything. But I can still answer the question and what things I think everyone should know about because they’re, they’re very, very useful.
Well, let’s start. Let’s start more general. So you have a med student in front of you. They’re rotating with you and they have no idea. They don’t know what they’re going into. You don’t know what they’re going into. So you don’t really have any focus in terms of make sure you know this or that. So what would you want them to take home about your field? What is what does every specialist really need to know about your field? What are the basics of the most common diseases that you treat.
So I think the most, the most basic is recognizing inflammatories, joint pain versus non inflammatory joint pain and I don’t think I really got a good understanding this until fellowship and are extremely simple. Joint Pain is extremely common that everyone knows and it’s very common reason why people go and see the doctor 99% of it is considered non inflammatory so you know they pull something, they hurt your rotator cuff or they’re painting the ceiling or you have kind of wear and tear arthritis or your thumbs for opening jars which is non inflammatory or you have fibromyalgia which is non inflammatory which is kind of through the muscles and the joints causing pain. So 99% joint pains non inflammatory so what happens is you have these kind of aches and pains and usually it gets worse the more you use your joints, hurt your shoulder, it hurts to move shoulder right. If you have wear and tear arthritis and your thumb or your fingers. It hurts to type or hurts to you know, grab your hand on the steering wheel or Heard open jars. So the 1% is the inflammatory, inflammatory can be broken down further, but I’m going to talk about mostly autoimmune inflammatory. So that encompasses rheumatoid arthritis and companies, lupus, psoriatic arthritis, so much, much more rare cost the joint. So these present very differently. So this is the pain that you wake up with. So the autoimmune diseases loves to attack when you’re resting. So it will get you when you first pick up in the morning or your fingers will be really stiff and swollen and it’s like, oh, it’s hard time moving on. Once you start moving, it feels better but it takes a good hour or two hours to start moving and start feeling better. We have a patient says yeah, it’s actually worse when I first get up or worse when I get off the airplane. Or worse when I’m sitting down watching TV and get up for the first time in a while. But once I start moving, it feels good. So if you get a joint if you get joint pain that feels better, the more you use Use that join that’s pretty suspicious that this is an autoimmune inflammatory condition doing this. You might say what about gout? So gout is separate. It’s a different process. It’s not autoimmune, there’s got to auto inflammatory because if you move a joint attack by gout that will not good it’ll hurt like crazy. So it’s a little bit different. So autoimmune is more enhancing by rheumatoid arthritis, lupus or riotous those that kind of category. But if it gets better, the more you move the joint that’s kind of a pigtail. This could be inflammatory, autoimmune, inflammatory, so that’s a good one to know.
I feel like this applies to me because because if I try to exercise in the morning, I feel like the Tin Man, right? Like I can’t, I can’t move at all. But if I, if I try to exercise it in the afternoon or in the evening, then I’m able to move a whole lot better. That’s not what you’re talking about. Talking about. So stiffness is pretty
common, stiffness lasting like two hours it’s not. So if you have pain or sickness, it takes like two hours to get movement. It’s a little unusual. To 1520 minutes or jump in the shower after the time the time to go out the shower you feel pretty good. That’s normal that’s from living just a side note about that is back pain. So back pain super common but if you have a person their 20s or 30s they have back pain worse in the morning and it gets better the more they do you really should have them see a rheumatologist to make sure this is not an inflammatory back pain, which is very treatable, and it’s good to treat early on so that’s one thing so back pain is really common. So he get it worse in the morning and it gets better the more you move that back. It’s It’s because you should probably see a rheumatologist just to make sure that’s not included since apparently ankylosing spondylitis.
Oh, wow. definitely keep that in mind. So one thing that you mentioned earlier in the podcast was that rheumatology is this black box and I would 100% agree with that statement. So you authored rheumatology made ridiculously simple right that’s that’s one of those review books that I remember from med school microbiology made ridiculously simple So help us make something ridiculously simple, right? So take a diagnosis that you frequently see after the patient’s had it for a while, meaning basically had symptoms but it’s been hard for other physicians to pinpoint what’s causing those symptoms and try and simplify it for us so that it can, it can expedite their recovery. Sure.
So let’s give two examples. Let’s do ankle vasculitis and let’s do lupus. Let’s start with ankle vasculitis. Ankle vasculitis is comprised of three different masculinities I’m gonna focus on just one of them’s called granulomatous, we’ll call the Angie itis or GPA, formerly known as Wagoner’s. granulomatous osis. So, this is a disease that causes sinusitis, and it causes lung disease that could be a lot of different things from just nodules in the lungs, or it could be on the other end of the spectrum is Frank, this called diffuse alveolar hemorrhage or actually all the blood and all the capillaries start leaking in the lungs and the lungs fill up with blood. And then become rapidly fatal if not recognized. And it can also involve the kidneys where it causes what’s called a rapidly progressive glomerular nephritis, which is rapid inflammation of the kidneys, leading to rising Kraton and rapid renal failure. This disease can involve lots of different organs, those are the most commonly ones. So if you take them one at a time, let’s say the sinuses which normally presents what you see someone was sinusitis you activate, oh, this is what this is going on. So So the plan G is right, no, science is very common, as you can attest to. But when you start thinking about underlying rheumatologic diseases when other organs start getting involved, right, so if you have sinusitis for a couple years, and that’s it, then I wouldn’t think very long since the Plan G itis. But if something’s changed in science, itis you get lots of crusting, or let’s say you have a perforation, the septum of the science, that means some pretty severe right and it’s not getting better with normal therapy. So it Science is not getting better, trying different sprays, trying rinses, is getting worse and worse. Maybe you get a chest X ray right because then in ankle vasculitis you’ll see infiltrating the X ray. So you’ll say hey, it’s like an ammonia. Okay? And but here’s science plus plus that infiltrate. That should kind of clue that something more systemic could be going on. And autoimmune diseases are often systemic, so involving multiple organs. So it’s one kind of this key thing to note about is that if you’re have one organ involved, say the sinuses, treating and treating and not having it out or not getting better, maybe just look somewhere else. Make sure it’s not involved anywhere else or ask the patient Hey, get in shortness of breath, you coughing, you ever have any blood when you cough up? So that’s like one of the diseases that can take a while to diagnose, understandably because people aren’t jumping to antibiotics when they see a sinus patient with sinusitis,
right? I’m not gonna start ordering those labs on every single sinus infection that I see. Because then some of them are going to be slightly abnormal, and they’re going to end up needing to see you for no good reason. Absolutely. They’re, they’re, they’re, they’re one point out of the reference range or something that
right yeah. So they have like, if they don’t respond ever and getting worse, that should kind of open your mind like, hey, something’s going on, we should look elsewhere. Another example is it could start in the lungs and the patient, short of breath and coughing and again, not thinking very long. So the plan G is the rare disease. So you get treated for pneumonia. This happens all the time, and they don’t get better. And then there it gets worse, and progressively worse and progressively worse. And then the scientists get involved and then someone notices the Kraton starts going up. So multiple other systems start getting involved, which finally includes un so that’s what you should and that’s, that’s my kind of two cents about it is if you have something common, like pneumonia or sinusitis, and normal treatment isn’t getting better. And in fact, it’s getting worse and then something else gets involved like either the cratons going up but we don’t have a good explanation for Long’s are getting involved. For the science of all advice versus start looking elsewhere, and then that’s a reasonable time to order this test is when conventional therapies not working and other other involvement starts happening. And lupus, lupus is not one that usually gets delayed because everyone orders in and everybody, but that’s probably not a good way to do it. So
we’re definitely going to talk about that a little bit.
Okay, gotcha. So hold on that then
on the admin rather we’re gonna be talking about the what to do with the abnormal and a Jenny with a lupus. Okay, gotcha.
So lupus is a strange disease that again involves a whole lot of different organs. And what should clue you in is not body pain. It should be a lot of people they owe their hurt all over maybe it’s lupus. lupus usually presents with inflammatory arthritis, right? So it actually has the worse in the morning gets better as the day goes and they have like visible swelling, okay, so they have kind of like pain from head to toe. bloopers shouldn’t be first language differential Okay, so lupus is actually usually causes an inflammatory arthritis again in combination with other organ systems such as the skin or they have like a mallow rash, another pearl about malar rashes, you hear patients that have mal rashes all the time, but it’s a malar rash is can be confused with flushing very often or rosacea. And those conditions you flushing and rosacea often get worse with alcohol use or being in like a hot shower the facial facial flush, okay, so if you have like
it’s gonna make you visit dilate.
Exactly, exactly right. So you have
peripheral vision.
So if you have a patient they Oh, every time I get in the shower, I get a rash. rash is like so malar rash from lupus like last days, two weeks, okay, doesn’t scar but it doesn’t just come and go rapidly. So your patient was like coming going rapidly think rosacea think flushing, especially gets worse with heat or alcohol, I think rosacea as well. So it’s Mallory’s true mal Rasha should be last for a while. So it’s not a good thing that comes and goes rapidly. So another thing about lupus is that it causes the marijuana fires as well. And that’ll often be visible protein area. So if you have a patient, especially a young woman, African American woman with unexplained nervous a reasonable thing to check for, which is kind of a hallmark of lupus nephritis. And then it can also involve the bone marrow. So if you have like a side opinion, either a low platelets, low white count, or unexplained anemia, then lupus is a reasonable thing to check for. So it involves multiple organs but it does things for those organs. It’s not just Oh, crap and going up must be lupus no tg padding plus progeria, or if they have an anemia, but they have a GI bleed. It’s probably not lupus, you know, so it’s like unexplained anemia to kind of go down the rabbit hole of lupus but it’s a very easy thing to test for. So it gets tested pretty commonly,
right that the AMA, so we were talking about that earlier. Because like if I have a patient with a dry mouth, or burning tongue, or an unexplained perforation in their septum, I will order a battery of rheumatologic labs to make sure I’m not missing a sarcoid or a Wagner’s. And frequently those labs are a little bit out of the reference range and I’m not sure when to really look at the reason is no other symptoms, but I look up their nose, weed, sometimes it happens and the sound grows from just picking their nose. Yeah, like the big nose they get across, forms another crust it keeps picking, and they eventually eventually burrow or hold their nose or they had surgery or they you know, there was cocaine use. But if I have an unexplained perforation with no other symptoms and no sinus problems, you know, it still warrants some type of investigation as well as those other things right zero stoma with no clear cause or a burning tongue. So I’m going to want to order some rheumatologic Labs but If I have a patient that has an AMA, that’s maybe one point out of the reference range, how do I know what to do? How do I not convinced them to fly to Cleveland, knock down your door until they’re seen,
they absolutely need to knock on my door, I get to the bottom of this ama pronto. This is something good to know by ama is the longer you live, the higher the risk, you have a positive and a test. And up to 20% of population living in a given age will have a positive ama, but doesn’t mean anything. So what’s happening is your body’s making antibodies all the time, it’s making it to thousands of different things just to it’s just testing the waters right as making antibodies to life by saccharide. Every so often and then it hits its mark and antibody works that it continues to proliferate Dan about the polysaccharide. So your body is making antibodies to lots of different things all the time. So it’s not a surprise that it makes a and as a result Awesome. So any in any given time, you probably have a very low titer than a floating around in your blood sea of thousands and hundreds of thousands of antibodies floating around all the different things. So you have Na Na floating around, it’s your body’s job to recognize that, oh, the AMA is actually against my own body. So anti nuclear actually combined two components of my DNA actually cause inflammation that shouldn’t happen. So your body does not turn on the proliferate button for the antibody. So it doesn’t recognize it doesn’t like make it start producing all sorts of AV antibodies. So the point of what I’m trying to say is that everyone has some ama, okay, see, your body is constantly making random alibis, all sorts of things, but our supplies immune systems job to recognize when it shouldn’t be making those shouldn’t be like turning on the treadmill of man and turning those antibodies out. So everyone has a little bit. The longer you live the the higher the chance of having an A and A a one positive antibody myself is not As you can recognize not definitely diagnostic lupus because lots of people have a and it’s the titer is fairly useful. So we usually order Na Na by IFA, it’s called. And it’s usually positive ones one to 40. And then it doubles it goes one to 41 to 81 to 160. Ever rarely they get a patient with lupus, who has one to 80. It’s usually like 123 60 or one to 1280 it’s usually pretty high. And then when you have a patient with with those antibodies, and they have something have severe dry now, for example, they have some joint pain or not exactly sure if it’s the final or not. Or if they have anemia or low white count. That’s when we say okay, well let’s look further into this. And that’s when you say check, it’s called the extractable nuclear antigen, which is a panel till the end panel does it remember a na, na panel and the AMA has all the different other little lupus antibody tests. And these are not like usually like aha moments. It’s usually kind of just like another puzzle piece. So they have, let’s say Smith are an RMP plus the A and A plus maybe a little bit low white count, that really raise suspicion that something’s going on, but it’s usually autoimmune. So the N is kind of like a gateway blood test. Okay? If you have something going on and it’s positive, that can kind of lead down to further tests that can give you a more accurate diagnosis. But anyone can order the DNA and one way to do it at our facility is actually an A and A with reflex. So if the a is positive, and it has like a titer, greater than one to 40, that actually reflects to the NA right away, so it won’t do it and it’s negative, very small thing to do to not test everyone within DNA. But if the answer is positive and high enough, it automatically reflects any and it No, and again, those are much more informative. So if you have like a, any panels like a whole bunch of different what has chromatin Smith rmps, a SSP, which you probably know and love. And if again, if one of those are positive plus to an A plus something else, that looks like lupus, that kind To raise your suspicion a whole lot more. The two things to know about in terms of specificity like Oh, if you if these are positive, you have to convince me they don’t have lupus, and that’s going to be the Smith positivity and double stranded DNA positivity. So those are the two blood tests to know about that. If they have it. If they don’t have lupus, now they might get it in the future. Okay, so that’s like a, they have much higher specificity for the diagnosis of lupus than like say RMP and chroma 10 and SSI SSP. So the answer is yes, no, you don’t have to knock on anyone’s door for an AMA or an SSI SSP. That’s like the only the only time that’s a little more urgent is probably an anchor positivity, which could be more rapidly fatal than most of the other conditions that we treat. Oh, another quick caveat about ama, which I didn’t know about all the fellow is that they’re positive like eight to 10 years before disease develops. So if you have a high titer check for some reason, and there’s let’s say they have a At one to 1280, but nothing else. It’s kind of like I usually watch those patients like once a year, hey, let’s Why don’t you just check in and see how we’re doing every year? Because we know these antibodies are present? Well, well, well, well, well before the disease actually comes.
That’s interesting. I wonder how that would work is like a screening test, like, just, you know, getting my colonoscopy this year, should I get my nh act? And then?
Well, the thing is unclear if it would be a benefit? Probably not.
So they do. They’re doing some trials for rheumatoid arthritis right now have the blood test for rheumatoid arthritis but do not have clinical trials. And they’re giving those people very mild immunosuppressive medication to see if it actually delays the development of rheumatoid arthritis. And the answer is, I don’t know yet. Right now, the end of the year for rheumatoid arthritis. lupus is a little more straightforward of the diagnosis. If you have a blood test plus joint pain, you have a diagnosis but lupus is a lot more ambiguous.
We will check in on the ruminations
podcast. That’s right. I’ll keep you up to date on the ruminations podcast.
So you know, you keep giving us these these tidbits about, well, I didn’t know this until I was a fellow and I didn’t, you know, the more you move, the better it gets, as opposed to with osteoarthritis. The more you move, the worse it gets. Oh, is there anything else that you think that you learned either in med school or in residency, that you either became more solidified in your brain and fellowship? Or afterwards, or actually contradicted something that you had learned in med school? Like, for example, for me, something I hate is post nasal drip, right? Like one of the things I learned in med school was that post nasal drip was one of the most common causes of cough. Well, if your post nasal drip is causing you to cough, it means you’re aspirating it so you’ve got other problems to worry about post nasal drip doesn’t actually you swallow post nasal drip, it doesn’t. There’s nothing to do with cough. So is there anything like that that you experienced in fellowship that you found out? Wow, that actually wasn’t wasn’t correct, that you can clarify for us? Yeah, sure. Well,
probably not as good example, as you have, but I think that will Lucas Well I don’t want to keep I don’t want to keep harping on lupus because I think that people often told me about it. So if you don’t know what’s going on checking the lupus betting that’s a bit of a I think you’re to that overdose, diagnose, diagnose, over diagnose lupus if we do that.
syphilis, right i think syphilis falls into that. Yeah. Yeah,
I think I think syphilis and reckless are definitely things that that are reasonable but this dangers don’t see him as often. But lupus does like specific things it doesn’t just do everything so that’s kind of what I’m getting kind of annoys me is the cause inflammatory joint pain it causes legit site opinion is it causes like Maryland or fires with major proteinuria doesn’t just cause like crashing into bump every so often check for lupus you know, it’s like not everything. lupus can do everything it’s not really true does specific things, but there’s a lot of specific things a little bit more confusing, but nothing that I think that warrants more discussion of scouts, cuz you hear about God a lot and think when I was a fellow As a resident and as internal medicine resident and like in medical school, you kind of like blew off gout, right? It was like, Oh, just go, you know, it’s like not a big deal. Yeah, fixable, and joints, takes allopurinol go away. The Gulf actually, like, the most painful condition that I treat, but I didn’t really appreciate until I saw many, many patients for the gout. Like you have these like big buff guys were like I wanted to cut my foot off, like the pain is unbelievably intense, and it’s not really something to blow off. And I think that people don’t take it seriously enough to treat it seriously. And it could be like a pretty devastating disease, especially as it gets worse and worse. And with a little eastern United States levels, the numbers are going up and up habits it’s the most. It’s the most common type of inflammatory arthritis affecting about 5% of the population which is probably higher than that reality. Because I mean, the more alcohol we drink, the more fatty foods we eat, the higher the risk of getting gout and I think that it’s just like it’s something that I think we should take a little bit more seriously because it’s really painful for the seas. And we have a lot of great treatments for it. And the other thing, nother is I have a special place in my heart for gout is something that we kind of blow off, as I mentioned before, but it’s something we didn’t understand until 1962. So it’s like this condition that is known from the ages, right? The Greeks recognize gout. People talking about gout throughout time is actually kind of a sexy disease to have an 1800s because you’re rich. Yeah, exactly. Man, you’re rich. And then you’re like nobility and meant that you had enough money just to sit around and eat all day. For most people that not most people did not have that ability, right. So people who had that bad gout, were usually of nobility or like they were judges and they’re sitting around all day making laws, but we still understand where it came from. Now we call it karma. So the Knights of the crystals wasn’t discovered until 1962. So it’s just like it’s kind of unfolding. To me that we have this disease that we owe to scalp but it’s like, oh, actually, we had a little understanding what was causing it until 1962. So it was fairly recently in time in the history of medicine that actually recognized what it was doing and music, how rapidly we started to blow it off.
Like,
in terms like the seriousness of the condition,
and you would think with it affecting the richest of society, they would have put more funds towards research.
Yeah, you’re right. Yes, yes, actually, a few hundred to one. So people are getting an idea that uric acid was was the driver behind it. They didn’t really recognize how to do it means the technology with they had to figure out polarized light microscopy, they had to do a lot of things. The guy who actually figured out that when they figured out sorry, when they figured out that uric acid actually one of my favorite stories in medicine, when they figured out that uric acid was actually the sound and those joints, the way they proved, that gal actually triggered them started that uric acid trigger the inflammation was dumped Doctors in Pennsylvania University of Pennsylvania actually got a syringe full of uric acid and injected their knees. So a left knee with the uric acid and the right end of the inject was sailing as a control. My favorite part about this as a fellow and an attending who did this, a favorite part about this is in a row and then we went about the day of normal hospital day. So they went to work, like within three hours and then intact yet, they’re laying on the ground screaming like an agony because their knees just hugely blown up and swollen, that acute gout flare and their need for the first time. publish or perish, publish. And we’re talking about years later on a podcast, I guess it worked out for them. And then they’ll it’s been talked about as they want to see the normal progression of disease. Their original plan was not to do anything, no intervention, no painkillers, nothing. But within an hour of the man on the ground, they’re begging for like steroids and painkillers so it didn’t work out for them. Guys they plan they recognize how unbelievably painful gal is and they recognize that your gas actually triggers the gout flares. That’s how they did it they figured out a little injecting their needs with the crystal. So do you see it more commonly now that it’s popular for people to go on like the Atkins diet and keto and paleo where you’re eating all these high fat high protein foods are used more often and people that are doing these diets Yeah, we actually are thinking fairly high and like in high high meat take hi Sorry, I like red meat and take like Atkins things like that we’re seeing at younger people too. So yeah, you’re right we are it’s usually those usually kind of like in a 50 year old male kind of getting it but now we’re seeing in fairly younger age if you have a very very high protein diet it’s still it’s still not common in young people. But that is something that we see when the with those certain diets for sure. So maybe we should start referring to as the Gaucho genic diet got the ketogenic diet like that. Good.
So is there anything else That you think bears mentioning, we This was pretty comprehensive. So the answer is no, it’s totally reasonable. But is there anything else that you think that we should bring up today for our general medical audience?
Yeah. So if you’re interested in specialization, I think that trying to have a plugin for rheumatology, just because I think it’s a super interesting career that’s moving very rapidly. It’s like, every literally every year we have a new drug and have a new understanding of different pathways, which does lead against to discovering new diseases, you know, so it’s like some diseases come out that we didn’t know about five years ago. So it’s just like, it’s kind of a fascinating place to be to like, watch this. Watch a fairly rapidly moving field, that again, that patients used to be unbeliev suffer unbelievably from these diseases, and now we have treatment that can really make a huge difference people’s lives. So it’s very intellectually satisfying because we get called like in the hospital, for example, if something major is going on someone and they don’t know what it is they call rheumatology. You know, it’s like we have this like, it’s just like that. We have these weird diseases that do weird things and they see this stuff. So it’s kind of a fun, it’s a very fun, fun position to be in. Because I don’t think there’s a field like that. Again, it’s like a specialization that doesn’t really narrow, it kind of broadens out. And if you want to do the same thing every day, it’s not if you want to, like be extremely good at doing one thing. For you, it’s like it’s like a field that does a whole lot of different things. And every day is different. You’re not sure where you’re going to walk into when you walk into the clinic door. So it’s exciting field and I hope people pay attention to it. I was not exposed to it until fairly late in the game. So I like telling people to see if they can get exposure to it early on. I think you’ll like it.
Yeah, and that’s an excellent plug for this specialty. And also an excellent plug for not throwing away your otoscope and your your Tama scope and all the rest of the stuff that you bought in medical school that you thought you might not use because you guys have to use it all
we do we do we look at all the different body parts we look at MRIs brains, who look up people’s nostrils, look at people’s ears, I look at people’s capital letters. On a microscope, I look at all sorts of stuff. And I even I spend, I look at urine like a couple times a week looking at people who have been having Maryland or Florida. So it’s kind of a gamut of things that we look for. And you know, the fund is easy to learn about and like all the fun physical exam findings you learn about in medical school, I 80% of my room, that’s logic,
we find like cool stuff. Are you going to do a podcast at any point on the history of your analysis? Because I remember in medical school, we learned that smelling urine used to be part of the test, they would they would put in the results like, and it smells like until the until the lab techs discovered that that wasn’t actually used very often, and they could stop smelling.
I still taste and smell every year and
it’s part of being a good doctor. Okay. exam is the smell in the urine.
All right, well, I can tell you his podcast. He’s just as entertaining on his own podcast as he is on this podcast. So Adam monitor tell the audience about about ruminations which the name is near and dear to my heart. Because sometimes when I’m looking in patient’s ears, I find myself so ruminating was
terrible. But tell us tell us about your podcast.
Yes, that podcast is built out of my love of understanding where things come from. Like we were just talking before we started recording about the history of rheumatic fever. Right. So we have this disease that was those those groups a streptococcal pharyngitis, you know, they get rheumatic fever, but how do people figure that out? So that’s kind of my love when it drives me of understanding history of this stuff, and how it took five to six decades of multiple specialists working together to understand that association between Group A strep and eventual rheumatic fever. So is it a lot of work for a lot of people to understand that and that’s what kind of dry like a like learning the history of medicine, but I also love just going through interesting cases and talking to people who know more about this stuff than I do. So I think that like Part of that podcast is going through really fascinating cases. And then I interview people who know a lot about that disease. And they kind of walk us through it. They walk about how did that how the diagnosis was made, and walk about how what the things pathophysiology is within and walk us through what she knows now, what you may be in the future. So it’s just kind of a podcast built around a lot of different things, interviewing experts in rent and in the field about certain diseases, going through interesting cases and interviewing experts after that, or talking about history that I find really interesting, like the history of Gallup as your glucocorticoids, history, rheumatic fever, and I think it’s entertaining. I think that I think it’s pretty useful. Like I think it’s just like understanding this stuff and hearing these cases of these rare diseases. I think you learn a lot from it.
Where can people find it? So you can find it on
iTunes, Stitcher, I think you find it on Google, you can find it and I think most places I usually is Apple, but I but I think you can find that in both places.
And make sure you spell it correctly. It’s not ruminating like you normally
Right. It’s Rena ruminations room and the Navy clever. Pretty clever. Thank you.
All right. Well, Adam Brown, thank you so much for joining us today in the podcast. I definitely learned a lot and I will definitely be using my labs a lot more. A lot more wisely. So thank you for taking the time. Okay, good. It was
a pleasure being here. 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 to doctoring.
Transcribed by https://otter.ai

Facing Adverse Outcomes and Malpractice Litigation, Part 2

This is part two of the interview with Dr. Stacia Dearmin. She builds on the idea of the physician’s second victim status in bad outcome and potentially in litigation. The plaintiff’s attorney can weaponize our empathy against us after a bad outcome and she teaches us how to defend against that. She builds on ideas on how to recover that were discussed in the first episode.

She is a speaker, coach, consultant and blogger on the topic. She went to medical school at Case Western Reserve and has a masters in religion and ethics from Vanderbilt. She did her residency in pediatrics at Akron Children’s Hospital and worked as a general pediatrician for a few years. She has worked as a pediatric emergency medicine physician since 2004. After working at Case Western Rainbow Babies, she is back at Akron Children’s Hospital. She is the founder of thrivephysician.com, where she focuses exclusively on the well-being of physicians facing adverse outcomes and malpractice litigation. Her experience in practice raised her awareness of the deep pain and isolation that physicians experience after an adverse outcome or in the midst of a lawsuit. She alleviates that isolation and provides insight and support around some of the toughest experiences many physicians will face in their careers. She draws on her personal story to illuminate the experience for physicians and to educate about the needs of physician defendants.

She has created a course to help us at deposition. “Deposition Magic” is a new course designed to give physician-defendants exactly what they need to know to soar at their own deposition. In a series of brief, friendly videos, you’ll explore the nature and purpose of deposition, the goals and tactics of the opposing attorney, and most importantly, the high-integrity mindset and strategies that will serve you as a physician-defendant. Together, we’ll exchange confusion and anxiety for clarity and calm, and help you to level the playing field at deposition. Available to you online on-demand, “Deposition Magic” confers up to 3 hrs Category I CME.

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!!!

Facing Adverse Outcomes and Malpractice Litigation, Part 2

This is part two of the interview with Dr. Stacia Dearmin. She builds on the idea of the physician’s second victim status in bad outcome and potentially in litigation. The plaintiff’s attorney can weaponize our empathy against us after a bad outcome and she teaches us how to defend against that. She builds on ideas on how to recover that were discussed in the first episode.

She is a speaker, coach, consultant and blogger on the topic. She went to medical school at Case Western Reserve and has a masters in religion and ethics from Vanderbilt. She did her residency in pediatrics at Akron Children’s Hospital and worked as a general pediatrician for a few years. She has worked as a pediatric emergency medicine physician since 2004. After working at Case Western Rainbow Babies, she is back at Akron Children’s Hospital. She is the founder of thrivephysician.com, where she focuses exclusively on the well-being of physicians facing adverse outcomes and malpractice litigation. Her experience in practice raised her awareness of the deep pain and isolation that physicians experience after an adverse outcome or in the midst of a lawsuit. She alleviates that isolation and provides insight and support around some of the toughest experiences many physicians will face in their careers. She draws on her personal story to illuminate the experience for physicians and to educate about the needs of physician defendants.

She has created a course to help us at deposition. “Deposition Magic” is a new course designed to give physician-defendants exactly what they need to know to soar at their own deposition. In a series of brief, friendly videos, you’ll explore the nature and purpose of deposition, the goals and tactics of the opposing attorney, and most importantly, the high-integrity mindset and strategies that will serve you as a physician-defendant. Together, we’ll exchange confusion and anxiety for clarity and calm, and help you to level the playing field at deposition. Available to you online on-demand, “Deposition Magic” confers up to 3 hrs Category I CME.

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.

In the second part of Dr station demons interview, she builds on the idea of the physicians second victim status in a bad outcome, and potentially in litigation. We talked about how the plaintiff’s attorney can weaponize our feelings after a bad outcome against us, and how to defend against that. In the first interview, she had some suggestions for how to start to recover and she builds upon that in the second part. If you didn’t catch part one, be sure to listen to that first.
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. Station deerman. Thanks so much for being on the show again today.
Oh, My pleasure. We had fun last time. So it’s good to be back.
So last time we ended with the second victim, right? What would you classify that as, let’s say, you have a bad outcome, or rather one of your patients has a bad outcome that, again, makes you the second victim, because you’re going to be taking that personally and grappling with that, and we’re going to get to those thoughts in a second. But what’s the first thing someone should do even before they’ve been served or even thought of litigation? What steps can that physician take to maybe protect themselves?
So Well, I think the first thing you have to do, always, always, always, obviously, is do your best to continue to provide the patient with what they need. Right. So first, we’re going to lean into our highest ethical standards or highest values that work To ensure that the patient receives what they need, if the outcome is surprising enough or bad enough that the physician feels burdened by it, they may even want to involve colleagues and helping them to sort out how they’re going to continue to provide that care. They may need relief, they need a colleague step in. They’re really quite stunned by something happening. So there’s, there’s that piece you’re going to lean in to good pair. And you may need some guidance from a risk manager or people with legal knowledge or your division director someone have more years of experience, but you also want to be as truthful and transparent regarding what’s happened with the patient or their family as you can Important for ethical reasons. But also, it’s important to know that the sense that we are being forthright with patients and families, in and of itself, in many instances, Bill, prevent a potential lawsuit from taking root. families feel that we’re not being truthful with them, quite simply, that our anger and anger i think is at the basis of many lawsuits is faces from elastic. So it can be very difficult to feel like you have the words to tell people what you need to tell them or you’re feeling so spun yourself. You don’t know where to begin, if sometimes it can be helpful to involve colleagues and in sorting through that, but I think that’s the starting place there. If you think there’s any possibility at all. that a particular situation may result in litigation. Even if you think it’s a small possibility, then I think it’s prudent. And in many instances, your malpractice insurance policy requires that you make your malpractice carrier aware of what’s occurred. And it’s actually to your advantage to do so. Because they will start to collect information, collect records, and basically start to lay the foundation to support you in the best possible way if the claim arises. But you want to do that. Another tip I would throw out there that actually very useful to me, my own patient had a bad outcome is that you can even at that moment, within a day or two that something has occurred. Take the time to write down Everything you remember about the interaction and the situation, particularly with an eye towards capturing things that would never be captured in a medical record, like tone in the room or aspects of your conversation with the patient that weren’t captured in the record, write those down in the form of a letter addressed to my attorney may not even know who your attorney would be. You were sued, but address it to my attorney and then that letter becomes privileged, confidential attorney client communication, you can give it to your malpractice carrier. Give it to your hospitals Risk Manager, they’ll guard it for safekeeping for you. And at the time of the claim may arise that letter will go in To the hands of the attorney, sign to your face and provide them with details. You may not remember a year or two or more after the fact,
in all of the risk management reduction lectures that I’ve been to I’ve actually never heard that before. That is a that is a first that sounds like excellent advice and easy to do. And also therapeutic I’m sure in some ways.
Yeah, yeah, I think that’s true. I think that’s true. I think it is therapeutic. What you don’t want to do is create a shadow record that is not intended to be privileged communication with your attorney. In other words, you don’t keep a journal, a personal journal or personal diary or a personal set of notes that supplement the record if it’s not something that can legitimately be considered attorney client communication and it is Not privileged, and it will become discoverable. If a legal process begins meaning it will become a document that you will be forced to hand over to the legal process.
So how do we differentiate one from the other? Oh, by by making it addressed dear attorney, wherever you might descend, and then that’s what make it privileged. Interesting. Okay.
Exactly to my attorney.
Right. So let’s say you have this bad outcome.
And then it does go on to litigation. So you have a colleague who, you watch them get served, right? You watch all of the color leave their face, as it happens, and you happen to be right next to them. What do you see what is someone with your experience and your knowledge of this? What do you say to that physician? What do you say to that colleague?
What I would personally say as I I’m so sorry this is happening to you. I have been through it. And I am right here with you. And I am so sorry this is happening to you very much like I would say, I am so sorry to someone who’s lost a loved one because it’s so surprising to people and heartbreaking. The papers that your SIR when your serve suit, really, I think deliberately incorporate a harshest language while alleging wrongful death and willful neglect and just the very harshest language. So they’re very hard to read. And I think particularly if someone has never previously been sued, when we see those papers, really like the end of a chapter of their career in which they could hold out hope that they would never be sued. Does that make sense? You’re suddenly in a new chapter
and a very hard time and and we talked about that before the show, and I think it’s important for us to realize. So first, if you haven’t listened to the previous episode, please listen to the listen to the first episode where Dr. Dearman talks to us about the statistics of your likelihood of being sued. And as it turns out, most of us will not spend the lion’s share of us will not spend a career not getting sued at least once. And so, to hold out hope that you are going to be in this small minority of physicians where that never happens seems unrealistic. So I think it’s probably healthier to think it will eventually happen to me, so that when it does, you’re mentally prepared so that you don’t turn from the physician who’s never been sued to the physician who has been sued. You were a physician for both For you are still a physician, and it shouldn’t change your identity. And if you think that going into it, you will, you will come out the other side, the same person, you went in maybe a little bit wiser for it.
Right? I might even take a little bit larger view and look just at the adverse outcomes. And again, kind of going back to the second victim theme and say that the literature around who is at risk for becoming a second victim is says that there are two factors all second one having common the first factor being that they are doing, that they possess a deep commitment to humanity, and that there’s some type of professional doing work in the service of humanity will be commitment to humanity. And then the second piece being that they’re doing work of high complexity, often involving rapid fire decision making. And frequently in the face of significant unknowns. So that sounds very much like our work of medicine, right? deeply committed to serving humanity with compassion, and also significant unknowns and make complex decisions. Where those two factors intersect is the place where we are at risk of encountering that other person we’re trying to heal or protect, and countering their bad outcome and having an impact on us. So I would say that every day that you go into the situation of caring deeply for someone making difficult decisions, at some level, you’re in the line of fire. Now, is that a bad thing to be in the line of fire? No, it’s amazing work. We’re, I mean, we’re really of service. We’re a very deep service to our fellow human beings. But we have this baseline risk that we’re going to encounter these difficult situation. And similarly, in medicine in the United States, as we invest ourselves in caring for the members of our community, we’re always experiencing a certain baseline risk that a lawsuit will arise. Does that make it pleasant or acceptable to us? Really, it doesn’t. It is not a reflection on any one of us as an individual physician, out of reflection, our competence or compassion or our ability to establish rapport with patients, when one of these adverse outcomes or lawsuit arise, it’s a it’s actually a reflection of the fact out there, a root sets ending at the plate swinging the bat,
right? And I’ve heard you say that so if you take it a step further, reframing the situation, and that’s one of the things that helped you to heal. After your lawsuit, right? reframing what we do. So can you go into that for a second? Because I think it really is just a little niche further than what what you were just talking about.
So reframing it, in what sense to take me a little further with what you’re thinking so
so that we as physicians are willing to put ourselves in such situations that we’re constantly encountering in situations with incomplete information, and having to rapidly draw conclusions that could influence somebody’s health and well being every day, multiple times a day, it takes a certain type of person to put yourself in that situation. So the fact that you treat patients in acute situations, you have to be a certain kind of person in order to be able to handle that. And as such, you are putting yourself at risk for then being you know, being involved in a negative outcome and therefore named in a lawsuit?
Yeah, absolutely. I think really all second victims, all professions that run the risk of second victimhood. At some level, they’re doing heroic work. Right. And sort of the classical sense of the hero, the person who is really willing to get out there and take risks that may impinge even on their own well being in the interest of a higher good, right. We are out there taking those risks because we actually care about our fellow human beings. The fact that we actually care so deeply is why we get out there and do what we do. And it is also why it hurts so badly. Things don’t go
right. And the plaintiff’s attorney knows that and they use it to their advantage. Right? This is why the personal injury attorney is not invited back for brunch, because the second victim status, and they weaponize it against us. They take the fact that we feel for our patient, we feel badly for the fact that they they’re not doing as well as they could have. Whether or not we could have done anything differently. Even if we practice medicine, like a page out of the textbook and did everything we were supposed to if they had a negative outcome that people don’t sue for people sue for negative outcomes. If you didn’t have a negative outcome. You couldn’t you couldn’t bring a lawsuit. So, but the plaintiff’s attorney knows that we take it home with us knows that we feel guilty and responsible, even if we did everything right. And they’re gonna weaponize that against us. How do we steal ourselves? against that, how do we defend ourselves from falling into their traps?
Well, that’s a great question. I think there are probably two primary places that come to my mind that where our own emotions can be weaponized against us. One is that many, many physicians when a bad outcome arises that they didn’t foresee and potentially could not have even prevented, they will feel guilty. They’ll find themselves wondering if they could have prevented it and feel guilty in my particular patient’s case. Even after an autopsy, I don’t really understand why she died. It remains unclear why she arrested why she died. But the fact that I made the choice to discharge her home the day before she arrested left me feeling deep guilt over whether I had played some unexplained role in her death. So we have this feeling of guilt. I think we need to acknowledge to ourselves that it is normal to feel guilty under those circumstances that feeling guilty is not the same as actually being guilty or responsible for an outcome. But a good example a good analogy I would give as someone in the world of Pediatrics, I’m very aware that not uncommon Lee, after a woman has a miscarriage, right after a miscarriage in a desired pregnancy. Many mothers feel guilty and feel like they must have done something that causes miscarriage. Even people who are medical people who know better than an electrical Level feel guilty. So similar thing I think we feel guilty when these bad things happen. Now a plaintiff’s attorney can
use that feeling of guilt as a cool
tool to make the argument that we all are guilty and make it difficult for us to defend against that argument, because it aligns with how, how we feel, right. I think we have to really seek a lot of clarity around for one how the law defines what constitutes medical malpractice. And number two, with difference between our emotions and objective reality and work hard, oftentimes with the help of an outsider, to sort through those feelings. Particularly prior to any situation in which we would need to testify. Like. I think the other emotion that arises that can be, as you said weaponized against us, is the sensation of shame. It’s quite normal for second victims to feel very ashamed of the fact that they weren’t able to protect or prevent, to protect the person or prevent the injury that occurred, and that shame can be used against us. There’s a lot of literature. popular literature from people like me brown and scientific literature from people. Doing scientific research into the experience of the second victim, tells us that the way we heal shame is through connection to others who can hear our story and support a sense So I think that, in and of itself is an important piece of how we heal ourselves and then equip ourselves to deal with the legal process.
What was it that helped you heal most, after your lawsuit?
Wow, that’s a really good question. I think it was probably a lot of things along the way. I mean, I think the last time you and I spoke, we talked about the support that I received from a couple of colleagues, and from nurses and a social worker, other people who I worked with loved and respected me. But I think there was also a lot of inner work I had to do, examining my values around the value of human life. I mean, I think one of the core values of a, of an ethical physician is that every human life is as valuable as every other And there came a point in the course of my own suffering and healing, where I actually had to remind myself that my life is also valuable and as valuable as the life of the young lady who’s, whose death touched my life, and that it was imperative that I be able to heal and continue to do my work. So I think there’s that piece of it the internal work that we do, there certainly is a huge sense of loss that comes along with feeling like you weren’t able to do for your patient, what you would hope to do a sense of loss that many people experience along the lines that they’re not With physician they thought they were thought they would be if this has happened to them, and then of course that is amplified by litigation, but even just around the patients false many people feel that way. So, coming to terms with that sense of loss, acknowledging that it’s grief and allowing yourself to have that grief just like you would around, you know, the death of a loved one, I think with a piece of it, and then being very careful with what you choose to use to fill the vacuum that a sense of loss creates. So for example, there is a real risk for physicians after a bad patient outcome or in litigation, that they will feel this sort of vacuum of loss and attempt to fill it with things that don’t serve them. Well. classic examples would be alcohol or drugs, or other behaviors that put them at risk like gambling or other addictive things like pornography. But it’s also been shown that we who are very diligent will often fill that sense of vacuum by working more, and that predisposes to depression. So, being very careful to fill the sense of a vacuum with something that actually benefits you. And that might be for me, time in nature was absolutely healing. And I think for many people it is exercise if it’s not used in sort of an addictive way, but if it’s actually used as a means of promoting health and releasing all the healthy neurotransmitters that go along with exercise can be super healthy. digging a little deeper into relationships can be helpful. And many people need just need guidance of someone who’s been through it appear who’s been through it, or have psychologists or other kind of spiritual advisors.
That’s where the, the reframing also can be useful because you might be having thoughts like, my patient had this bad outcome. I don’t deserve to put myself in these situations doing these things that I enjoy. But I think the reframing comes in. I put my side for a living I put myself in a position where things like this can happen. Therefore, I deserve to have this time in nature this time exercising this time with my loved ones. I think that’s the that’s and I think I recall that that’s actually how you how you phrased it is is you know, is I I put myself in these situations, and therefore, I deserve to have these things.
That’s right. No, I think that’s exactly right, that we owe it to ourselves to attempt to put the one incident into the larger perspective of our lives, and also the larger perspective of the care that we provide, right. Another way that I sought healing was exactly that trying to see my patient in the context of my career. At one point, I sat down and did the math. I’ve been in practice for Let me think like about 14 years or so, when this happened with my patient. And when I sat down and did the math, I realized that I probably seen about 50,000 patients before I met Wow, wow, one in 50,000. It didn’t feel like 151 felt like she was the only one that mattered at that point. But I needed to remind myself that I had given something to 50,000 baby, children and teenagers. And if I could take care of myself and recover, I would yet attentionally if to another 50,000. Right. So I think that can be helpful as well. I view it really, and I like to encourage other physicians to view these experiences, not as a flaw as the result of a plot and meme, but rather as sort of an occupational injury, right? Like if someone’s working on scaffolding and some pieces of scaffolding this way and they fall several stories and somehow survive. Well, we certainly would want for them to get the best care possible in order for them to continue to live a full life. I think when these events are And frequently like we’ve fallen from the scaffolding, but the fact that we work on scaffolding is an important part of why we have potential.
It’s interesting that you draw that parallel because I’ve definitely heard other physicians refer to the workman’s comp system and how it would actually make sense for our medical malpractice system to work more like the workman’s comp system where you know, if a patient has has an adverse outcome, then they get compensated by the system, but at the same time, you know, that when something does happen, there, there is an opportunity for quality improvement, but still not this, you know, almost cannibalistic system where, where physicians are through what were put through.
Right, right. And you,
you said that it was your colleagues, your friends, your family that that really were part of the crux that helps you get through this, but For other physicians who are who are grappling with this, what are some other resources that you would recommend for them? Either books or blogs or websites? other podcasts?
Yeah. Well, I have a website, I blog regularly and I would invite everybody who’s interested to visit the blog at www. Fry physician calm. The focus of my blog is very much on issues surrounding litigation, and issues surrounding physician and other healers well being after adverse outcome. So that’s one resource that’s out there. And actually, I’m in the midst of developing my first online course on the subject of deposition and hope to develop an array of courses that people can pack them to, if and when they need them. So that is out there. Quite recently, another physician colleague practicing general Emergency Medicine named Dr. Geeta pensa started to create a podcast called The L Word l for litigation. And that you can find, I think, pretty much wherever podcasts are found she has maybe four or five episodes out now exploring litigation and how it impacts on us as physicians, what we experience is like, and trying to think what else there are a few books available, not as many as maybe we might like, but there’s one called when good doctors get sued. I can’t give the name of the author at the moment, but that is well worthwhile. And there’s lots of very interesting literature on the experience of the second victim written by a gentleman named Sidney Decker de Payton er, who is actually a pilot, who now specializes in safety science. And explores the experience of the second victim has written quite a lot about second victims in health care. So there’s some resources that come to the top of mind.
Well, I can definitely vouch for thrive physician as an excellent resource as well as Dr. penances podcasts. But both of those have been, you know, extra have been extremely helpful for me and very, very engaging as well. So I’m glad to hear that.
I’m glad to hear that any
any parting words for our audience?
I guess the last thing I would like to say in line with what you were alluding to, in regard to reframing experiences is that while this was one of the hardest experiences of my life, it has in common with all very other hard life experiences the potential to grow us and make us better people. And there again, the literature on second victims alludes to this theme After these hard experiences, some people drop out. Some just barely survive, and others thrive. And the one to thrive seems to be the one to find a way to take the very hard experience and extract something beautiful from people can read more about this on my website if it interests them. But I would simply like to say, anyone who’s going through this at all, it is very hard. But it need not be the end of your life may not be the end of your career, certainly not the end of your joy. It like many other hard life experiences, has the potential to become something you look back on as a place where you grew tremendously, and where you learned a lot about yourself as a person and about Life as a human being on this beautiful earth, so I want to encourage you to just hang in there and hold out hope in the very, very long run, you will be a better person or having been through what you’re going through.
Well, Dr. Station Gentlemen, I really appreciate you taking the time to talk to us on two episodes. And really, all of the work that you’re doing is going to help everyone that you touch to be a better physician and more prepared for these outcomes and your your gift from this is that it will make it much easier for us to get through these experiences. So thank you for your time and thank you for all the work that you’re doing.
Thank you so much. Thank you for giving me the chance to share it.
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

Facing Adverse Outcomes and Malpractice Litigation, Part 1

Dr. Stacia Dearmin can help us get through adverse patient outcomes and malpractice litigation. She has been through it herself. She is a speaker, coach, consultant and blogger on the topic. She went to medical school at Case Western Reserve and has a masters in religion and ethics from Vanderbilt. She did her residency in pediatrics at Akron Children’s Hospital and worked as a general pediatrician for a few years. She has worked as a pediatric emergency medicine physician since 2004. After working at Case Western Rainbow Babies, she is back at Akron Children’s Hospital. She is the founder of thrivephysician.com, where she focuses exclusively on the well-being of physicians facing adverse outcomes and malpractice litigation. Her experience in practice raised her awareness of the deep pain and isolation that physicians experience after an adverse outcome or in the midst of a lawsuit. She alleviates that isolation and provides insight and support around some of the toughest experiences many physicians will face in their careers. She draws on her personal story to illuminate the experience for physicians and to educate about the needs of physician defendants.

We start out discussing the statistics about how frequently physicians are sued and why we never talk to each other about it. Her own experience with an adverse outcome and lawsuit led to the creation of thrivephysician.com. We learn about the second victim and how being a second victim can take its toll on physicians especially amidst the isolation put upon us by the legal system. We learn how to start recovering.

She has created a course to help us at deposition. “Deposition Magic” is a new course designed to give physician-defendants exactly what they need to know to soar at their own deposition. In a series of brief, friendly videos, you’ll explore the nature and purpose of deposition, the goals and tactics of the opposing attorney, and most importantly, the high-integrity mindset and strategies that will serve you as a physician-defendant. Together, we’ll exchange confusion and anxiety for clarity and calm, and help you to level the playing field at deposition. Available to you online on-demand, “Deposition Magic” confers up to 3 hrs Category I CME.

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!!!

Facing Adverse Outcomes and Malpractice Litigation, Part 1

Dr. Stacia Dearmin can help us get through adverse patient outcomes and malpractice litigation. She has been through it herself. She is a speaker, coach, consultant and blogger on the topic. She went to medical school at Case Western Reserve and has a masters in religion and ethics from Vanderbilt. She did her residency in pediatrics at Akron Children’s Hospital and worked as a general pediatrician for a few years. She has worked as a pediatric emergency medicine physician since 2004. After working at Case Western Rainbow Babies, she is back at Akron Children’s Hospital. She is the founder of thrivephysician.com, where she focuses exclusively on the well-being of physicians facing adverse outcomes and malpractice litigation. Her experience in practice raised her awareness of the deep pain and isolation that physicians experience after an adverse outcome or in the midst of a lawsuit. She alleviates that isolation and provides insight and support around some of the toughest experiences many physicians will face in their careers. She draws on her personal story to illuminate the experience for physicians and to educate about the needs of physician defendants.

We start out discussing the statistics about how frequently physicians are sued and why we never talk to each other about it. Her own experience with an adverse outcome and lawsuit led to the creation of thrivephysician.com. We learn about the second victim and how being a second victim can take its toll on physicians especially amidst the isolation put upon us by the legal system. We learn how to start recovering.

She has created a course to help us at deposition. “Deposition Magic” is a new course designed to give physician-defendants exactly what they need to know to soar at their own deposition. In a series of brief, friendly videos, you’ll explore the nature and purpose of deposition, the goals and tactics of the opposing attorney, and most importantly, the high-integrity mindset and strategies that will serve you as a physician-defendant. Together, we’ll exchange confusion and anxiety for clarity and calm, and help you to level the playing field at deposition. Available to you online on-demand, “Deposition Magic” confers up to 3 hrs Category I CME.

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.

Dr. Stacy deerman Can you help us get through some unexpected patient outcomes and malpractice litigation. She’s been through it herself and is now a speaker, coach, consultant and blogger on the topic. Dr. Derman went to medical school at Case Western and has a master’s in religion and ethics from Vanderbilt and did her residency in pediatrics at Akron Children’s Hospital. She worked as a general pediatrician for a few years as worked as a pediatric emergency medicine physician since 2004. After working at Case Western rainbow babies, she’s now back at Akron Children’s Hospital. She’s the founder of Thrive a website where she focuses exclusively on the well being of physicians facing unexpected patient outcomes and malpractice litigation. Her experience in practice raised her awareness of the deep pain and isolation as physicians and other healers experience after an adverse outcome or in the midst of a lawsuit. She alleviates that isolation and provides insight and support around the toughest experiences many physicians will ever have. She draws on her personal story to illuminate the essence perience for professional healers, and to educate defense lawyers, risk managers and healthcare leaders regarding the needs of physician defendants. She blogs and can be reached at thrive physician calm. We were fortunate to have Dr. Dearman for a two segment special interview. In the first half. We started out talking about statistics and it is staggering how frequently physicians get sued. And if we’re getting sued that frequently why we never talked to each other about it. She gives us some details of her experience that led to her creating thrive physician, an online resource for physicians undergoing litigation. We’ll learn about the second victim and how being a second victim can take its toll on physicians especially admits the isolation put upon us by the legal system. And she helps us learn how to start recovering.
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 should have been learning while we were memorizing Krebs 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. setia deerman. Thanks so much for being on the show today.
Thank you for having me. I’m very happy to be here.
So this is a deep topic and, and it can be challenging to talk about. So I think it’s incredible that you’re actually able to discuss this as openly as you are. But to break the ice a little bit. We’re going to start with some humor. And this is a true story. I didn’t ask my wife for permission to tell this story. But I’m telling it anyway. So recently, my wife invited someone from my son’s class, my son’s preschool class over for brunch. So the kid from the class and his parents, but she warned me beforehand that the father is a personal injury attorney, and was so pleased about that.
I wouldn’t be there.
If you’re in my situation, what would you have done? The options being? Would you have let this person in your house to break bread allowed them in, but pretended you had something else to do. So you didn’t actually have to spend time with them or allowed them in, but glared silently the entire time. It would be maybe a more reasonable thing to do. But my my choices were really one of those three.
What would I do?
I think if my spouse had invited them, I would be too polite to just not show up. But I I would say this is a one time thing
for them, let them come back.
You get one I get the one wasn’t Yes.
would be hard. It was hard for me to hold in the glare, but I think I did a pretty good job of masking it. Good. I couldn’t rescind the invitation that would have been embarrassing. Yeah. Yeah. Yeah.
Your relationship with your spouse is definitely much more important.
Yeah, whatever, whatever it is that I’m trying to do by making this person uncomfortable, really just make myself uncomfortable, I guess. Okay. So So let’s talk about statistics. Okay, so for the, for the physicians out there, for the residents, maybe choosing a fellowship or the medical students choosing a residency because once we’re in our field, it’s not like we’re going to stop once we once we learn about the statistics, but maybe it’ll influence someone’s decision out there. So talk to us about our likelihood of getting sued overall. And then any particularly any particular specialties that are more vulnerable, either getting sued more frequently or when they do for larger sums of money. So who’s vulnerable?
Well, I don’t know that I would advise anybody to base their choice of specialty on this particular factor. But I would say that it would benefit all of us to have a better sense of what’s going on in different specialties. And particularly for a young person making a choice, what the frequency is and the specialty they’re choosing. So probably the best data we have around how often people get sued and how often they get sued in different medical specialties, actually comes from a study from the New England Journal of Medicine that was issued all the way back I think in 2011. So the study already is a little bit old, but there are not a whole lot of studies like this one out there. And in this particular study, they gathered data from a large medical malpractice insurance carrier, so and the value of gathering data from that kind of a source is that it’s going to give you data about claims that were opened and closed with out any settlement which the national practitioner data bank is not going to record. And this particular insurance carrier was so large, that the data covered something like 40,000 physicians practicing in all 50 states in all manner of specialties. So that’s very helpful that it’s such a diversity of physicians, geographically, as well as in terms of specialty. And with that particular study found was that approximately seven and a half percent of physicians in the US are named in a lawsuit every year. Some people say lawsuits Average a duration of one and a half years. Other sources say three to four years. In any case, it’s clear that it’s more than one year. So I would guess that that means that at least about 10%, maybe 12%, or maybe more of American physicians are in the middle of litigation at any one time. It’s quite a lot of us at any one time, even though most people cannot look around a large group of colleagues at their hospital or in their group practice and tell you who is in the middle of litigation or who has been litigated against. The other thing that that study did was looked at specialties and sort of ranked them according to the frequency with which they’re sued. They found that among what they called high risk specialties, according to their data, high risk 99% physicians will be sued by the age of 65. In what they called low risk specialties. 75% will be sued by the time they’re 65. So to me, that means nobody really is actually low risk, right? Pretty much in all specialties, you’re more likely to be sued at some point than not. And in those higher risk specialties, you also see people sued with greater frequency. So the one that comes immediately to my mind is neurosurgery. Where I think their data said that almost 20% like 19.6%, or something like that are named in a lawsuit every year. So if you figure 20% are named per year, then that says to me that on average, a neurosurgeon will be named in a lawsuit roughly every five years, some more, some less, probably all depending upon the environment that they practice in the A degree of litigiousness of the state where they live in practice, the complexity of the patients they’re seeing and any other
number of factors, I’m sure
you know, I wonder if there are program directors talking about this. Because if it’s happening so frequently, and it’s inevitable, then preparing your trainees for not just complications of surgery, but what could potentially come next and will come next, and how to grapple with that and continue seeing patients and doing surgeries while it’s happening. It seems like it should be a critical part of training.
I absolutely agree with you. I will say though, you know, I’ve been engaged in
learning about this issue, talking with people about this issue and working around this issue for a few years now. And I have yet to meet anyone who has said that oh, we were very well trained around this issue in my program. I think I meet people who say, I’ve been made aware that my specialty in my specialty, I’m very likely to be sued. And I think lots of people get some tips on minimizing the risk of lawsuits. But I’m not sure, really, that much of any program is doing the really thorough job we ought to be doing for young physicians and teaching them what to expect. How many of their colleagues have been through it, who they can turn to where they can turn for support? All the pieces and parts they’ll need to get through it. Right? I don’t know. Did you get any of that kind of training and you’re in the course of your education? I really
didn’t. The first thing the first time I ever heard a topic like this discussed was hearing you on another podcast. Oh, wow.
Yeah, that’s not very long ago. That’s like 15 months or a year ago.
Yes. So, so, no, it was not part of any of my, my training. And it’s not it hasn’t been part of any of the the CME that I’ve received from attending talks by lawyers about how to minimize your risk. Yeah, it’s all about preventing, while the education is about preventing, or possibly they might even get to what happens during a deposition. But yeah, they never really get into mentally preparing yourself for what what it’s like and and what it does to you. So all the more reason for us to be talking to you today.
Absolutely. It’s an important conversation because I think if the message is continually around, how to minimize the risk, if that’s the only message we hear, then if we get sued, or more likely when we get sued, we feel that we failed, right? Everybody taught me how To avoid this happening, now it’s happened, then I feel like I’m a failure. And that really doesn’t help. Because already the whole situation makes you feel like you’ve failed. So, you know, there, there are much better ways for us to be preparing people for this. And the plaintiff’s attorney is going to use that to their advantage.
But we’re gonna get to that later. So yes, I’m sorry, I took you I took you off track a little bit. We were talking about statistics. So you mentioned that, that neurosurgeons what was it, you said 99% of them end up getting sued, and the frequency with which they’re sued is, I think, what 20% of them at any given point, or in a year ago?
Well, probably more in litigation at any given point,
because I would imagine their suits drag on for a lot longer because of what they the type of things that they treat so badly, at the very least 20% of them are being sued at any given time, but probably significantly more. Yeah,
yeah. Yeah. So you also asked about like which specialties are more likely to be sued. Which are less definitely surgical specialties, the most high risk specialties, for the most part, our surgical specialties, vascular surgeons, neurosurgeons, etc. ob gyn we all know the practice of Obstetrics is high risk. And I sit, you know, my heart goes out to the OB GYN because as I think about this particular issue, I’m especially aware of the fact that if you’re practicing ob, every patient encounter, actually, you get two patients for the price of one or maybe even more, maybe you’ve got twins or triplets, right? You’ve got multiple patients sort of rolled into each patient encounter. Emergency Medicine is a high risk area. Some people say emergency physicians currently are sued every five to eight years. So that’s a high risk area. And it’s understandable because there’s Very high acuity in the emergency environment. And also, every almost everything that comes into an emergency department and I’m speaking from the perspective of someone who works in a pediatric emergency department is undifferentiated when it comes in most things are undifferentiated when they commit. So if I had somebody with abdominal pain really could run the entire gamut of causes for abdominal pain from a tourist testicle, to appendicitis to your bread and butter, constipation. So it makes sense that there’s a lot of risk in the practice of emergency medicine.
Also, in emergency medicine, you don’t have the advantage of having a prior relationship with the patient. And I think in some ways that that can protect you, right? If you’ve got a long history with this patient, and they end up having a complication it and we’ll get to this later. It’s not an impenetrable shield, but it does, it can decrease your risk of them. Turning to literary
right? That is certainly one of the challenges of emergency medicine that there’s no prior rapport. And prior rapport not only provides a, hopefully a ground or a foundation of warmth in the relationship and mutual respect, but also, I think when someone’s in an ongoing relationship with a patient and then that patient comes in looking a little different than they normally do, or complaining of pain in a way they normally would not. If you have that prior experience with that patient, your clinical meter for what’s going on with them is a little bit more sensitive, right a little more fine tuned. So at the other end of the spectrum specialties that are less frequently sued, would be pediatrics and family medicine. psychiatry is less frequently specialty that sued pathology luxurious, less frequently sued. But interestingly, pediatrics is one of the specialties that has the highest payouts when a payout occurs, probably for obvious reasons that the patient is young. And so there’s a, you know, added years of life ahead of that person,
which results in adequate added medical needs and also perhaps an added component of compassion on the part of a jury that could influence a payout. So the special teams that are the most frequently sued are not necessarily the ones with the highest payouts. So you practice emergency medicine or pediatric emergency medicine. So that’s a field so given the acuity, what you said about the frequency, so a high frequency but given that It’s a, it’s within the field of Pediatrics that also leads to higher payouts. That seems like a subset of physicians that are going to have, I guess, greater challenges in this in this
arena. I think that might be true. I don’t think we have crystal clear enough data in this domain for me to say that with any certainty and even what data we do have from that 2011 study, I think this is a constantly shifting domain. And I don’t think we have enough data, basically.
But I do I think also probably ours. There are there are some pediatricians that are in some of the ers working in the emergency department. There are some emergency medicine physicians who are probably treating children as well. So there’s probably a lot of overlap that would muddy the waters for statistics.
Absolutely. I think that’s absolutely right. Yeah.
So one thing you mentioned earlier was so many of us are being sued. But when you look around the room of your colleagues, you’re not able to identify anyone who has been sued. So how did we get there? And how do we get out of that situation?
Oh, wow, that is a great question and a huge one. How did we get there? Well, I think probably part of how we got there. I think there are multiple factors here. I think one piece of it is that any physician in the midst of litigation will be strongly encouraged by their defense lawyer, or by representatives of the hospital to keep talking with others about their case to an absolute minimum. The most common advice is something like don’t talk to anyone. So that is one piece prompts us to keep it to ourselves. But I think what’s, what’s the reason for that?
How come we’re not allowed to talk about it? So personally, just so the audience knows I’ve been sent. And so what I was told was, if you talk to anyone about it, they may need to be deposed. So, if I, if one of my patients has a complication, or even a perceived complication, and we go to litigation, and I get served, I’m told, so first, you’re what you’re told is immediately call your lawyer. Right? That’s the first thing you need to do. And, and then the Lord is going to tell you don’t talk to anyone about it, because if you do they meet, you know, the the plaintiff is, plaintiff’s lawyer is going to ask you, well, have you spoken to anyone about it? And if you do, that individual may need to be deposed for what? I can’t understand because whatever happened already took place. So it seems a strict strategy that works greatly to their advantage, because then they’re able to isolate. Right,
right. So I think let’s, let’s break that apart a little bit. I do think that is the advice people commonly hear. Don’t talk about. to anyone about it, but I would like to break that down a little bit and make sure that people know there are certain kinds of relationships that are protected. So there are some people that you can safely talk with, and they will not be deposed. And among them are your spouse, someone who is engaged with you in a professional relationship providing care to you. So that would be your own physician, a psychologist, you might see any any other type of counselor or you’re engaged in a professional, confidential relationship, clergy person or spiritual advisor, that is also a protective relationship, and certainly your defense. That’s a protective relationship. And then additionally, probably the risk manager at your hospital and the claim manager, whatever entity is providing your medical malpractice insurance coverage. Those are all protected settings. And the second piece would be to think about, well, what is it that someone would want to depose this person about? And what they want to depose them about is the details of the case, the medical details of the case and the events that occurred. They are not going to depose someone to talk with them about the fact that you told your best friend, that a lawsuit is in progress, and it’s deeply stressful to you and it’s breaking your heart and patient of yours was, you know, unexpectedly injured when you were performing surgery. That emotional content is not the details of the case. So if I’m a defendant and I’m deposed, that lawyer will ask School, who I discussed the case with. And what they’re talking about is the details, the medical details of the case, you want to be careful to be just twice full about to discuss those medical bills. Now, most hospitals today offer opportunities that are legally protected for discussing that very thing, the medical details of the case. And those legally protected situations are things like morbidity and mortality conference, peer review, a formal peer review, a formal root cause analysis, anything that really is formally under the umbrella of quality improvement is protected from legal discovery by a plaintiff’s attorney. So I think it’s hard after your patients had a bad outcome to Bring that to morbidity and mortality or to participate in that peer review conversation. But I think we should take advantage of it. I think it’s our opportunity to explore medical details and seek out answers to questions we have about whether the care we provided could have been provided differently or should have been provided differently. And then seeking emotional support is is another has an another objective or other and is not the same as discussing the medical being helpful. That makes sense.
Yes, I still still seems to me a little nefarious on the part of the plaintiff’s attorney that these are the rules. It seems it does seem to me strategic in order to isolate us but I think taking that into account, we should try to be within the confines of those rules as non an isolated if that’s a word as possible. And I think and we’re going to be in we’re going to be getting to that, because that’s that’s the theme of today’s talk right is, is is how to get there. So I think an incredible example of how to get through it is you’re right, I have so much admiration that you’re able to talk so openly about one of the most difficult experiences of your life. So if you could share that with us today, I really appreciate it.
Sure. So my particular case and the life experience that I had that brings me to working on this issue today is that I was working in pediatric emergency department in a community hospital different from the hospital where I practice today and saw a young woman on a Friday afternoon. She was a young woman with some underlying medical issues but generally doing pretty well and a contributing member of her family and her community, saw her over the course of several hours, ordered a number of tests, thought she looked well. And at the end of that period of maybe five or six hours, talked with her and her parents, and as a group, we decided that it made sense for her to go home and follow up with her doctor on Monday. So I discharged her home at the end of the day, like five or 6pm. On a Friday, I came back to work on Saturday, going to work an evening shift. So I came in at 5pm. And very shortly after I came on duty, I was approached by ear, nose and throat specialist who came the left We know that one of the patients I’d seen the day before was now in the ICU. And when I inquired further, he told me that this young lady who I discharged home the day prior and arrested that afternoon at home. Yeah, CMS responded, good not secure in their way. They transferred her to freestanding emergency department near her home, where skilled or on duty who still could not secure an airway and flew her to the ICU at the hospital where I worked with the CMT airway. You can imagine that was some time after she arrested quite a lot of time elapsed. So as soon as he told me that, I mmediately knew that her prognosis was not clear at all. And I really haven’t Say it was an experience that sort of left me feeling disoriented in the moment, sort of an out of body experience. That reminds me of times when I’ve gotten a phone call to tell me that someone I love inside. I felt really stunned, ashamed, guilty. I really felt terrible. And that was the beginning of a very long journey. Those feelings didn’t pass quickly. Someone’s I had a lot of questions about what if any role I had in her death and whether I could have prevented it. About a year after she died. I learned that I had been named in a lawsuit. I wasn’t surprised on probably about two and a half years after that. So three and a half years after she died, I went to trial and spent about three weeks in a courtroom as Defendant in a wrongful death case around her death. It was really one of the more complicated life experiences I’ve had. It was a marathon was draining and impacted on me personally, as well as professionally, in so many ways, I mean, I, I’m really
like most pediatricians, somebody who is in pediatrics because I love my own patients. So I felt her death very hard. And I interestingly, in the midst of my trial, I stumbled upon a TED talk on the subject of physician suicide. I had not previously been aware of how prevalent physician suicide is. And so it’s only when I got halfway into it, I realized what it was about. Immediately, I thought myself I don’t know what all the causes of physician suicide are, but I am absolutely certain that what I’m going through has to be one of them. So really, right in the middle of the trial that I started to realize that I felt a need to begin to break open the conversation to alleviate some of the isolation that we as physicians feel middle experience and to start just generating conversation and resources for going through it.
And that’s what I’ve been doing since that time and to this day,
when when you were in the middle of all of that, how did you how did you get up, start your day and see patients I just, I can’t imagine you know, going through this and then having to muster the confidence that it takes to continue doing what you do. Right. It’s such a it’s such a blow. How did you get through that? How did you get through that and continue being able to help people?
Wow, that is? That’s a good question. I think, Well,
for one, I was still paying off my student loans.
I know that wasn’t on our on our list of pre discussed questions, but as I’m listening to your story and trying to put myself in your shoes and thinking what what you’re thinking because it just having been sued myself for something, you know, that pales in comparison to something like that, you know, I did get up and see the patients the next day after learning that it was a blow to my confidence. And and thankfully, the first patient that I saw, you know, was one of my regular patients who was doing great nothing but thanks And, you know, that really helped helped me to get started. But But, you know, I just, I just can’t imagine having to continue working in that situation doing what what you do putting
one foot in front of the other, I think I cannot overstate the importance of the support of people who reached out to me in my workplace. So I certainly, you know, immediately after her death within a day or two, I reached out to my medical director, I was the assistant medical director of that department at the time. And I reached out to him because I wanted him partly to hear what it happened for me first, but also I needed to talk with people I respected about what had happened, whether they would have done anything differently. I had done for her no questions. We all have like, what did I miss here? I reached out to him. And I also reached out to someone who is really only a year or two older than I am, but has been in practice longer than I have a more direct route into medicine. And as someone whose clinical skills I really respect, so meet up with them to talk the case over with them, and just to reflect on it a little bit. And both of them offered important word support in terms of just reminding me that they viewed me view me as a gifted physician. So that was really important. I think also, you know, I’d been working in the department that I was in at the time for at least 10 years, I think, at the time when this happened, and had close relationships with a number of nurses and some social workers. So a tiny handful of those people saw that I was struggling. They had been on duty with me when we saw this young lady. And they reached out to me with words of support. They, they just, I think saw my demeanor that I was really taking it hard. One nurse in particular, this came to me at one point, she’s sort of a religious person. And she came up to me and said, You remember that you don’t get to choose who lives and dies. Right? And quite honestly, I did not remember that at that point. And those were very, very valuable words. I mean, obviously, I remember them now more than seven words after the fact. Another social worker who had transitioned from our department into the intensive care unit, where the shown patient came a patient came to me to check on me and she realized that A person taking care of her in the ER. So I think those things, those reminders that other people saw my commitment to my work and recognized that being a compassionate soul, I wouldn’t be hurting those things. Absolutely. essential to my survival
in that time. I think there are two lessons here. I think one is you’re going to be relying very heavily during this time on your social system for support. But at the same time, if you are not the person who is who’s being sued, if you know of someone who is recognize that they need you, and reach out to them, don’t wait for them to come to you. Talk to them with words of support and let them know how valuable you are. They are to the system and to their patients,
I think that’s really important. And this all what I’m describing these people reaching out to me that all transpired long before I was sued. So I think that’s the other piece that we have to remember. At, even though we know, let’s say that every surgery carries a risk of an adverse outcome or in the course of seeing people, we’re going to see adverse outcomes. Still, sometimes those adverse outcomes really hurt us. And just reach out to one another and check in after we’re exposed to those hard things because we invest ourselves in trying to ensure a better outcome, right? And standing outside it is somewhat objective outsider, you can say, Oh, well of course a baby with meningitis may or may not make it with a person who’s invested in caring for that baby and wants to see the baby make it
there may be some heartache potato.
Right? So the topic of this discussion is litigation, but at the same time, it’s any negative outcome in any situation like that when there’s a negative outcome of a patient, it’s going to be important to to heal. And I think that segues into one thing that I’ve heard you talk about, and that’s the second victim. So, tell us what is the second victim. So,
you know,
this really was a an important piece in my healing process that probably maybe 10 or 11 months after my patient died. I don’t even remember by what series of fortuitous events, I stumbled across a brief but very eloquent little essay, written by an internist at Johns Hopkins named blue in which He pointed out that when patients are harmed, his essay was referring to medical mistakes. But subsequent literature’s said medical mistakes or any other situation where a patient is harmed. When patients are harmed, we also experience an injury many times if we wonder whether we could have prevented that injury or wonder whether we had a hand in it, then we are also harmed. And so he really coined the use of the term, second victim to refer to that physician who is injured when their patient within burden some way. So in encountering that essay, I was touched, I was moved by it he describes very beautifully, how distressed a second victim can be. And when I read his description, I immediately recognized My own experience that was enormously helpful to me. Because at that point, I was almost a year out from the event. And I was still struggling feelings of grief and stuff out and wondering about whether I would ever feel really great about practicing medicine again, and starting to really beat myself up over the fact that I was not able to shake this off, is that really what we’re taught to do in medical school and residency somehow shake these bad outcomes off, and I wasn’t checking it off very well. So when I read this description, and I realized that I was not the only person to go through this, it was a huge relief to me. I started thinking, Oh, it’s not that I’m weak. It’s that I’m compassionate and I’m reflective, and so on suffering,
and ongoing. What I was thinking actually, as you were describing it, I thought, this is actually one Have her strengths as if your inability to shake it off speaks to your compassion and your empathy for your patients, how you carry them with with you, you know, long after they’ve they’ve left the emergency room, you’re know, even the ones that don’t have outcomes like this, I’m sure there are many times when you’re still thinking about them, which might interfere with your ability to carry on your day to day existence, because you’re thinking about your patients. And that doesn’t make you weak, it makes you strong, it makes you a better diet.
Right? I think that’s exactly right. And I think that’s part of what I learned that there are these vulnerabilities embedded in our strengths, right? There’s an array of strengths and classically we know are essential to an excellent position and among them are compassion and self reflection and diligence, right conscientiousness, with in those strengths are embedded these vulnerabilities, the more compassionate I am, the harder I’ll feel it when things don’t go well for my patient, the more diligent I am, the harder I’ll feel it if things taken an expected turn, or I feel like I’ve missed something along the way. So right, you’re exactly right. So then I became quite fascinated by this concept of the second victim, because it spoke to me so deeply and it was so healing for me that as I came out of my lawsuit with this newfound drive to teach other physicians what I had learned, I didn’t have experience. It started to explore the literature a little bit. And I learned that after Dr. Wu wrote this essay, which he did in the year 2000, long before my lawsuit, there was this whole explosion of research which took place which continues to this day into the experience of the second victim. It’s really fascinating. Literally insofar as it makes it clear at first of all that be physicians are not the only health care and health care givers are not the only second victims who exist pilots and aircraft controllers and all men are first responders, police, firefighters, etc. Members of the military, all are vulnerable to come second victim. And this somewhat earth shattering life experience that I had the emotional experience that I had is classic second victims in every domain. So it’s really not a doctor experience. It’s a human experience that I had. Right? Very complex human.
Well, I think for today’s episode, we’re going to stop here because I think you’ve covered extremely well. You know what happens with regards to who is likely to be sued? And what happened in your situation. And then, you know, this this concept of the second victim, but I think for the next episode, we’ll be covering how we can get through it. So you’re going to help us get from we’ve been served to walking us through what it’s like, and then how we can heal from that. So I really appreciate you taking the time to, to talk to us today and to really reveal so much of what you’ve been through again, I know I said it but I’ll say it again. I can’t imagine how challenging it must be to talk about such such a subject but you really have handled it with such grace and and you’re allowing your experience to help so many physicians, so thank you.
Thank you. My pleasure.
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.
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